Can you give me some information on the new contraception option that eliminates menstrual periods as long as it is taken?

Wyeth Pharmaceuticals plans to release Lybrel, a contraceptive pill, and it is expected to be available in July. The idea that a woman can take a birth control pill for longer than a month and thereby reduce the number of menstrual periods has been marketed by other companies under Seasonale and Seasonique for a few years. These products are taken for about three months (rather than three weeks) and then the patient stops for a week to have a period. It is likely that Lybrel will be used the same way only for a year.

Many women may be concerned about not having a monthly, regular menstrual flow. Some feel it is not right or healthy or may cause illness. In reality, there is no evidence that a monthly menstrual flow is necessary for good health or a healthy reproductive life. This assumes, of course, that the absence of a period is not caused by some underlying problem. Gynecologists have, for decades, used the birth control pill in exactly this way to treat a variety of gynecologic conditions such as endometriosis, debilitating menstrual pain, or menstrual migraine. They have just used available oral contraceptives in a continuous manner rather than a cyclic manner.

Though we don’t have long-term information on safety, it is likely that this new pill will be as safe as other oral contraceptives and have similar cardiovascular risks (especially in smokers).

The real question is whether this pill offers anything new to women. The doses of the estrogen and progesterone component are comparable to current pills and therefore offers no new safety benefits. It may be appropriate for some women with the above mentioned problems, however. Some women may like the idea of not having a period, but many are unsure it is a good idea.

However, continuous hormonal therapy like this does increase the risk of break-through bleeding. This is bleeding when you’re not supposed to bleed. Break-through bleeding occurs in 2-5% of all oral contraceptive users. With this new pill, approximately 18% of women dropped out of the study because of unpredictable bleeding or spotting. This would be a drawback for many women. It will be up to women to decide for themselves if this new formulation offers any improvement in their current choices for contraception.

Since my early 40’s, I’ve noticed that my menstrual cycles are unpredictable and sometimes very heavy. Is this normal?

This is a very common question and concern! This is often (not always) a sign of hormonal transition. The female body produces three major hormones which regulate our cycles: estrogen, progesterone, and testosterone. During our peak reproductive years, these hormones work in balance with one another to produce (in most cases) cyclical and predictable menstrual cycles, with “normal” menstrual flow. During the “perimenopausal” years, or those transitional years leading up to menopause, the first change which occurs is typically a gradual drop in progesterone levels (with estrogen and testosterone levels remaining pretty constant). This has to do with the fact that during these later reproductive years, less of the egg follicles actually mature to the point of ovulation. Related to this, cycles become more irregular and heavy. With diminishing levels of progesterone, there is a relative excess of estrogen: More estrogen can cause our uterine lining (the endometrium) to become plumper than usual, leading to heavier flow with menses. This is a very common process that occurs in most women to some extent during the later reproductive years.

It is strongly advised that you seek consultation with your healthcare provider if you are experiencing significant changes in the pattern or flow of your menstrual cycles. In addition to hormonal changes, there are many other potential reasons for a woman to experience changes with menses in the perimenopausal years. An undiagnosed pregnancy, a thyroid condition, a blood disorder, an anatomical abnormality such as a uterine fibroid or endometrial polyp, or even uterine or cervical cancer are all examples of other possible causes for abnormal uterine bleeding. Based on your history and your clinical symptoms, your healthcare provider will help you to determine which types of evaluation and testing might be recommended in order to accurately determine the cause of your change in menstrual cycles.

Generally speaking, you are bleeding too much if you typically bleed for longer than one week, or if when you bleed you saturate a tampon or pad in less than one hour (in an ongoing way), OR if your bleeding interferes with your life either due to feeling depleted (some women will become anemic with heavy or frequent menses) or because of “flooding” which prevents you from being able to comfortably leave your home. When you are experiencing too much bleeding, there are many options in terms of treatment including, but not limited to, the use of NSAIDS, cauterization, hormones, surgery, and complementary therapies. Again, your healthcare provider can help you to determine which is the best method of treatment for you.

As for the interval between menses, we consider anything less than a 3-week interval (21 days from the start of one menses to the start of the next) to be abnormally short. If this type of pattern occurs in an ongoing way, it is advised that you seek care from a healthcare provider.

Concerning a long space between menstrual cycles (and not related to a pregnancy or any other underlying medical condition) we generally feel that an interval of 3 months between menses should prompt a call or visit to your provider. This has to do with the fact that during these perimenopausal years in which a woman still produces plentiful levels of estrogen, it is sometimes necessary to “induce” a menstrual bleed in order to be sure of effective shedding of the endometrium. If the uterine lining is not effectively shedding, it is possible, over time, for a condition to develop called hyperplasia. This means an overgrowth or thickening of the tissue, and which could become a precursor to the development of endometrial or uterine cancer. Your provider can help you decide how to most safely and effectively monitor your cycles, while minimizing risks and keeping you as satisfied and comfortable as possible along the way!

Please keep in mind that the above discussion is in no way meant to be inclusive of the many possible other factors which can affect and alter menstrual cycles. For further direction on this topic we highly recommend that you make an appointment with your healthcare provider to discuss any questions that you might have.

What are some new trends in Oral Contraceptive use?

Continuous or extended contraception use is gaining popularity. “The pill” has typically been dispensed for birth control, however it has been found to help with other health risks such as decreasing incidence of cancer of the ovaries and uterus. It has also been helpful in reducing common menstrual complaints such as PMS, bloating, length and amount of bleeding, painful cramps, and ovarian cyst formation. We found that women with endometriosis or menstrual migraines (severe headaches that occur at the start of each period) could take the pill continuously for 3 months before stopping it to have a period. They were extremely happy to have their period 4 times each year.

This method of dosing has become extremely popular. In fact, 50% of women who take the pill this way have no medical problems and only do it for convenience. Scientific studies have been done over the past 15 years to test the safety and measure the satisfaction. There is one pill product that is now even packaged as three-tier rows of pills, taken daily, and the last week is a different color, for the period. Because “the pill” acts to stop ovulation, as when you are pregnant, it’s not necessary to have a period every 4 weeks.

We have found that the products “Nuva Ring” and the “Ortho Evra Patch” can be used in the same way. The Nuva Ring has a slow release of the hormones and lasts for 4 weeks. At the end of the 4 weeks the vaginal ring is removed and the new ring is inserted. This can be done for 3 months and at the end of the 3 months the ring is left out for a week to have her period. The patch lasts for 7 days. Used this way, the patch is changed for 12 weeks then left off for a week for a period. It is safe to use the pill, ring, or patch in this way, just as it is safe for a woman not to have a period when she is pregnant.

The studies show that bleeding rates for women on extended birth control are similar to rates of women taking it the typical 21 days on and 7 days off. As well, the contraceptive protection (pregnancy rates) were similar. If you have questions about this method of taking your pill, ring, or patch please talk with your provider. We want you to have access to new information and for you to have choices in your birth control method to fit your lifestyle.

I’m Exhausted & Why Can’t I Sleep??

In talking with women about the various aspects of their day-to-day lives, it is not uncommon to hear complaints about a lack of sleep. With this conversation comes talk about exhaustion, irritability, diminished concentration and memory. Sleep is essential in order to maintain physical and emotional well-being, but is frequently overlooked as one of the key elements in our quest for better health.

Women, in particular, are prone to sleep disorders for several reasons. Times of hormonal fluctuation (as in adolescence, pregnancy, menopause, or even the monthly cyclical changes) lead to a biological increase in the requirement for sleep. Ironically, hormonal changes are also often associated with an increase in sleep disturbances, making it all the more difficult to get the restorative sleep needed. Women experience frequent sleep interruptions with babies or children waking during the night, or in waiting for their teenager to get home at night. Women (or men) may have disturbances in sleep which relate to anxiety or depression, drug or alcohol use, sadness or grief, or an overly active mind – perhaps reflecting the over-extended lives we lead! Still, other causes of sleeplessness may include excessive caffeine intake, lack of exercise, smoking, an inconsistent sleep schedule (night shift workers), or even medical conditions such as sleep apnea or restless leg syndrome. Whatever the cause–while many of us will occasionally experience the irksome sleepless night, for some, sleeplessness will become a more chronic and troubling issue.

For those who unhappily experience chronic insomnia, a complete evaluation with a health care provider (and perhaps at a sleep disorders research lab) will be an important first step toward improving sleep. Sleep disorders that stem from a medical condition, depression or anxiety, or drug/alcohol use will necessitate help and treatment around that particular issue which is identified. For many, however, some or all of the following basic strategies may be useful in greatly improving one’s quantity and/or quality of sleep. This is frequently called “sleep hygiene”, and is considered the first line, and most successful form of treatment for most sleep disorders.

  1. Get regular exercise. Exercise releases endorphins, a natural sleep aid. It is most beneficial to exercise late in the day, but not within 3 hours of sleep.
  2. Avoid caffeine entirely, or limit use. Stop consumption within 6 hours of bedtime.
  3. Avoid alcohol, or limit use. Alcohol affects quality of sleep by preventing the deep “delta” sleep which is so restorative and necessary to a “good night’s sleep”.
  4. Avoid smoking. Nicotine is a stimulant.
  5. Keep a regular sleep schedule, as much as is possible. Going to sleep and waking at consistent times leads to a consistent circadian rhythm, which helps the body to remember when to become drowsy and fall asleep, and when to wake up.
  6. Eliminate or decrease fluid intake in the evening, in order to avoid waking during the night with a full bladder.
  7. Complete the day’s activities prior to bedtime, allowing for pure relaxation time in the 2 hours prior to sleep. This should include making a list of the following day’s activities. Then, try reading, listening to music, or watching a non-stressful television program prior to bed.
  8. Try a light, carbohydrate snack in the 2 hours prior to bedtime. Carbohydrate intake leads to the production of serotonin, a natural chemical which increases restorative sleep.

Allow for some time and consistent practice with these techniques before determining whether or not these strategies are useful for you. If after a few weeks of committed effort you do not start to notice improvement in the quality of your sleep, seek the advice of your health care provider.
Occasionally a person may require sleep medication in order to break a cycle of poor sleep. This type of treatment should only be initiated under the care of an experienced health care provider, and should ideally be implemented only for short-term use. Medications used to help induce sleep can be habit-forming, can lose their effectiveness over time, can cause a grogginess or “hangover” effect following use, and can cause”rebound” insomnia with discontinuation. Therefore, the decision to use sleep medication bears careful consideration. Please talk with your provider if you feel that this form of treatment is a necessary part of a plan to help you get the rest you need.

Remember – sleep begets sleep! Start by taking simple steps as illustrated to improve your sleep habits. You may soon notice vast improvements in both your quality of sleep and your overall sense of well-being and health.

What does bone density testing entail?

Harbour Women’s Health has been providing on-site bone density tests for years, and in that time, determining bone density has become an integral part of the care regimen for peri- and post-menopausal women. If you are beginning to detect signs of menopause, the following questions and answers that we’ve collected from patients and our staff may help determine if it is time for you to schedule a bone density test with us.

How does it work? Is it an x-ray?

While there are various ways of measuring bone density, we have a GE Lunar machine that employs dual energy x-ray absorptiometry (DEXA) technology or an x-ray beam that splits into two. The x-rays pass through you, while you lie flat on a table, and are picked up by an arm extended over you called a receiver. The difference in the energy levels of the x-rays received is then used to compute bone mineralization, the most accurate approximation of bone density available.

How do I do it? Will it hurt? How long does it take? Will I be in a tube like this a CT scan?

There is no tube involved. The test is performed with you lying on a table so that the arm can extend over your whole body. Once you’re positioned on the table so that the machine can accurately measure locations in your spine and hips, the scan takes just a few seconds and is absolutely painless.

At what age should I have my first bone density test and how frequently after that?

Bone density is measured to try to estimate the risk of bone fracture and the potential need for treatment. There are no standardized guidelines as to who should be screened and how often but most of the national societies specializing in this area suggest that all women who would consider treatment for osteoporosis should have testing done. Because osteoporosis has no symptoms until a fracture occurs, testing is generally advised around the onset of menopause and at three to four year intervals thereafter. Testing is performed earlier if you are taking certain medications, have a family history of bone ailments or have been diagnosed with a bone condition that is being treated so that your response to treatment can be monitored.

If the results are abnormal, what will I have to do? Can bone density be improved?

There are several treatments available today, some of which slow the natural loss of bone that occurs with age, others that actively treat more advanced bone loss. Some treatments can increase bone density at any age and can substantially decrease the risk of bone fracture. As there are multiple factors to consider in this decision, such as personal risk factors, medications, family history and lifestyle, you should carefully explore your options with a care provider following an abnormal result.