Interstitial Cystitis/Painful Bladder Syndrome

Interstitial cystitis (IC), one of the chronic pelvic pain disorders, is a condition resulting in recurring discomfort or pain in the bladder and the surrounding pelvic region. The symptoms of IC vary from case to case and even in the same individual. People may experience mild discomfort, pressure, tenderness, or intense pain in the bladder and surrounding pelvic area.

Symptoms may include an urgent need to urinate (urgency), frequent need to urinate (frequency), or a combination of these symptoms. Pain may change in intensity as the bladder fills with urine or as it empties. Women's symptoms often get worse during menstruation. In IC, the bladder wall may be irritated and become scarred or stiff. Glomerulations (pinpoint bleeding caused by recurrent irritation) may appear on the bladder wall. Some people with IC find that their bladders cannot hold much urine, which increases the frequency of urination. Frequency, however, is not always specifically related to bladder size; many people with severe frequency have normal bladder capacity. People with severe cases of IC may urinate as many as 60 times a day.

Also, people with IC often experience pain during sexual intercourse. IC is far more common in women than in men. Of the more than 700,000 Americans estimated to have IC, 90 percent are women.

What Causes IC?

Some of the symptoms of IC resemble those of bacterial infection, but medical tests reveal no organisms in the urine of patients with IC. Furthermore, patients with IC do not respond to antibiotic therapy. Researchers are working to understand the causes of IC and to find effective treatments.

One theory being studied is that IC is an autoimmune response following a bladder infection. Another theory is that a bacterium may be present in bladder cells but not detectable through routine urine tests. Some scientists have suggested that certain substances in urine may be irritating to people with IC, but no substance unique to people with IC has as yet been isolated. Researchers are beginning to explore the possibility that heredity may play a part in some forms of IC. In a few cases, IC has affected a mother and a daughter or two sisters, but it does not commonly run in families. No gene has yet been implicated as a cause.

Are There Different Types of IC?

Because IC varies so much in symptoms and severity, most researchers believe that it is not one, but several, diseases. In the past, cases were mainly categorized as ulcerative IC or nonulcerative IC, based on whether ulcers had formed on the bladder wall. But many researchers and clinicians have questioned the usefulness of this classification, since the vast majority of cases do not involve ulcers, and their presence or absence does not influence treatment options as much as other factors do.

Factors that influence treatment options include whether bladder capacity under anesthesia is great or small, and whether mast cells are present in the tissue of the bladder wall, which may be a sign of an allergic or autoimmune reaction. In some cases, the success or failure of a treatment helps characterize the type of IC. For example, some cases respond to changes in diet while others do not.

How Is IC diagnosed?

Because symptoms are similar to those of other disorders of the urinary system and because there is no definitive test to identify IC, doctors must rule out other conditions before considering a diagnosis of IC. Among these disorders are urinary tract or vaginal infections, bladder cancer, bladder inflammation or infection caused by radiation to the pelvic area, eosinophilic and tuberculous cystitis, kidney stones,endometriosis, neurological disorders, sexually transmitted diseases, low-count bacteria in the urine, and, in men, chronic bacterial and nonbacterial prostatitis.

The diagnosis of IC in the general population is based on presence of urgency, frequency, or pelvic/bladder pain and cystoscopic evidence (under anesthesia) of bladder wall inflammation, including Hunner's ulcers or glomerulations (present in 90 percent of patients with IC).

Diagnostic tests that help identify other conditions include urinalysis, urine culture, cystoscopy, biopsy of the bladder wall, distention of the bladder under anesthesia, urine cytology, and, in men, laboratory examination of prostate secretions.

Urinalysis and Urine Culture

These tests can detect and identify the most common organisms that infect the urine and that may cause symptoms similar to IC. There are, however, organisms such as Chlamydia that cannot be detected with these tests, so a negative culture does not rule out all types of infection. A urine sample is obtained either by catheterization or by the "clean catch" method. For a clean catch, the patient washes the genital area before collecting urine "midstream" in a sterile container. White and red blood cells and bacteria in the urine may indicate an infection of the urinary tract, which can be treated with an antibiotic. If urine is sterile for weeks or months while symptoms persist, the doctor may consider a diagnosis of IC.

Cystoscopy Under Anesthesia with Bladder Distention

During cystoscopy, the doctor uses a cystoscope--an instrument made of a hollow tube about the diameter of a drinking straw with several lenses and a light--to see inside the bladder and urethra. The doctor will also distend or stretch the bladder to its capacity by filling it with a liquid or gas. Because bladder distention is painful in patients with IC, they must be given some form of anesthesia for the procedure. These tests can detect bladder wall inflammation; a thick, stiff bladder wall; and Hunner's ulcers. Glomerulations are usually seen only after the bladder has been stretched to capacity.

The doctor may also test the patient's maximum bladder capacity--the maximum amount of liquid or gas the bladder can hold. This must be done under anesthesia since the bladder capacity is limited by either pain or a severe urge to urinate. A small bladder capacity under anesthesia helps support the diagnosis of IC.

Biopsy

A biopsy is a tissue sample that is then examined under a microscope. Samples of the bladder and urethra may be removed during a cystoscopy and later examined with a microscope. A biopsy helps rule out bladder cancer.

What Are theTreatments for IC?

Scientists have not yet found a cure for IC, nor can they predict who will respond best to which treatment. Symptoms may disappear without explanation or coincide with an event such as a change in diet or treatment. Even when symptoms disappear, they may return after days, weeks, months, or years. Scientists do not know why. Because the causes of IC are unknown, current treatments are aimed at relieving symptoms. Most people are helped for variable periods by one or a combination of treatments. As researchers learn more about IC, the list of potential treatments will change, so patients should discuss their options with a doctor.

Bladder Distention

Because many patients have noted an improvement in symptoms after a bladder distention done to diagnose IC, the procedure is often thought of as one of the first treatment attempts. Researchers are not sure why distention helps, but some believe that it may increase capacity and interfere with pain signals transmitted by nerves in the bladder. Symptoms may temporarily worsen 24 to 48 hours after distention, but should return to predistention levels or improve after 2 to 4 weeks.

Bladder Instillation

During a bladder instillation, also called a bladder wash or bath, the bladder is filled with a solution that is held for varying periods of time, averaging 10 to 15 minutes, before being emptied. The only drug approved by the U.S. Food and Drug Administration (FDA) for bladder instillation is Dimethyl Sulfoxide (DMSO, RIMSO-50). DMSO treatment involves guiding a narrow tube called a catheter up the urethra into the bladder. A measured amount of DMSO is passed through the catheter into the bladder, where it is retained for about 15 minutes before being expelled. Treatments are given every week or two for 6 to 8 weeks and repeated as needed. Most people who respond to DMSO notice improvement 3 or 4 weeks after the first 6- to 8-week cycle of treatments. Highly motivated patients who are willing to catheterize themselves may, after consultation with their doctor, be able to have DMSO treatments at home. Self-administration is less expensive and more convenient than going to the doctor's office.

Doctors think DMSO works in several ways. Because it passes into the bladder wall, it may reach tissue more effectively to reduce inflammation and block pain. It may also prevent muscle contractions that cause pain, frequency, and urgency.

A bothersome but relatively insignificant side effect of DMSO treatments is a garlic-like taste and odor on the breath and skin that may last up to 72 hours after treatment. Long-term treatment has caused cataracts in animal studies, but this side effect has not appeared in humans. Blood tests, including a complete blood count and kidney and liver function tests, should be done about every 6 months.

Oral Drugs

Pentosan polysulfate sodium, the first oral drug developed for IC, was approved by the FDA in 1996. In clinical trials. This drug improved symptoms in 38 percent of patients treated. Doctors do not know exactly how it works, but one theory is that it may repair defects that might have developed in the lining of the bladder.

The FDA-recommended dosage is 100 mg, three times a day. Patients may not feel relief from IC pain for the first 2 to 4 months. A decrease in urinary frequency may take up to 6 months. Patients are urged to continue with therapy for at least 6 months to give it an adequate chance to relieve symptoms.

Side effects are limited primarily to minor gastrointestinal discomfort. A small minority of patients experienced some hair loss, but hair grew back when they stopped taking the drug. This drug may affect liver function, which should therefore be monitored by the doctor.

Other Oral Medications

Aspirin and ibuprofen are easy to obtain and may be a first line of defense against mild discomfort. Doctors may recommend other drugs to relieve pain.

Some patients have experienced improvement in their urinary symptoms by taking antidepressants or antihistamines. Antidepressants help reduce pain and may also help patients deal with the psychological stress that accompanies living with chronic pain. In patients with severe pain, narcotic analgesics such as acetaminophen with codeine or longer acting narcotics may be necessary.

Transcutaneous Electrical Nerve Stimulation

With transcutaneous electrical nerve stimulation (TENS), mild electric pulses enter the body for minutes to hours two or more times a day either through wires placed on the lower back or just above the pubic area, between the navel and the pubic hair, or through special devices inserted into the vagina in women or into the rectum in men. Although scientists do not know exactly how TENS works, it has been suggested that the electric pulses may increase blood flow to the bladder, strengthen pelvic muscles that help control the bladder, or trigger the release of substances that block pain.

TENS is relatively inexpensive and allows the patient to take an active part in treatment. Within some guidelines, the patient decides when, how long, and at what intensity TENS will be used. It has been most helpful in relieving pain and decreasing frequency in patients with Hunner's ulcers. Smokers do not respond as well as nonsmokers. If TENS is going to help, improvement is usually apparent in 3 to 4 months.

Diet

Patients find that certain foods may contribute to bladder irritation and inflammation. Refer to the list of dietary bladder irritants below. Some patients note that their symptoms worsen after consuming these products. Patients may try eliminating various products from their diet and reintroducing them one at a time to determine which affect symptoms. It is important, however, to maintain a varied, well-balanced diet. Click here to download IC Smart Diet.

Smoking:

Many patients feel that smoking makes their symptoms worse. Because smoking is the major known cause of bladder cancer, one of the best things smokers can do for their bladder is to quit.

Exercise

Many patients feel that gentle stretching exercises help relieve IC symptoms.

Bladder Training

People who have found adequate relief from pain may be able to reduce frequency by using bladder training techniques. Methods vary, but basically patients decide to void (that is, empty their bladder) at designated times and use relaxation techniques and distractions to keep to the schedule. Gradually, patients try to lengthen the time between scheduled voids. A diary that records voiding times is usually helpful in keeping track of progress.

Surgery

Many approaches and techniques are used, each of which has its own advantages and complications that should be discussed with a surgeon. Surgery should be considered only if all available treatments have failed and the pain is disabling. Most doctors are reluctant to operate because the outcome is unpredictable since some people still have symptoms after surgery.

Those considering surgery should discuss the potential risks and benefits, side effects, and long- and short-term complications with a surgeon and with their family, as well as with people who have already had the procedure. Surgery requires anesthesia, hospitalization, and weeks or months of recovery, and as the complexity of the procedure increases, so do the chances for complications and failure.

Two procedures--fulguration and resection of ulcers--can be done with instruments inserted through the urethra. Fulguration involves burning Hunner's ulcers with electricity or a laser. When the area heals, the dead tissue and the ulcer fall off, leaving new, healthy tissue behind. Resection involves cutting around and removing the ulcers. Both treatments are done under anesthesia and use special instruments inserted into the bladder through a cystoscope. Laser surgery in the urinary tract should be reserved for patients with Hunner's ulcers and should be done only by doctors who have had special training and have the expertise needed to perform the procedure.

Another surgical treatment is augmentation, which makes the bladder larger. In most procedures, scarred, ulcerated, and inflamed sections of the patient's bladder are removed, leaving only the base of the bladder and healthy tissue. A piece of the patient's bowel (large intestine) is then removed, reshaped, and attached to what remains of the bladder. After the incisions heal, the patient may void less frequently. The effect on pain varies greatly; IC can sometimes recur on the segment of bowel used to enlarge the bladder.

Even in carefully selected patients--those with small, contracted bladders--pain, frequency, and urgency may remain or return after surgery, and the patient may have additional problems with infections in the new bladder and difficulty absorbing nutrients from the shortened intestine. Some patients are incontinent, while others cannot void at all and must insert a catheter into the urethra to empty the bladder.

Bladder removal, called a cystectomy, is another surgical option. Once the bladder has been removed, different methods can be used to reroute urine. In most cases, ureters are attached to a piece of bowel that opens onto the skin of the abdomen;this procedure is called a urostomy, and the opening is called a stoma. Urine empties through the stoma into a bag outside the body. Some urologists are using a second technique that also requires a stoma but allows urine to be stored in a pouch inside the abdomen. At intervals throughout the day, the patient puts a catheter into the stoma and empties the pouch. Patients with either type of urostomy must be very careful to keep the area in and around the stoma clean to prevent infection. Serious potential complications may include kidney infection and small bowel obstruction.

A third method to reroute urine involves making a new bladder from a piece of the patient's bowel and attaching it to the urethra. After healing, the patient may be able to empty the newly formed bladder by voiding at scheduled times or by inserting a catheter into the urethra. Few surgeons have the special training and expertise needed to perform this procedure.

Even after total bladder removal, some patients still experience variable IC symptoms in the form of phantom pain. Therefore, the decision to undergo a cystectomy should be undertaken only after testing all alternative methods and after seriously considering the potential outcome.

A surgical variation of TENS, called saccral nerve root stimulation, involvespermanent implantation of electrodes and a unit emitting continuous electrical pulses.

DIETARY IRRITANTS TO THE URINARY TRACT

These may aggravate Bladder Control Problems

All alcoholic beverages
Apples, apple juice
Apricots
Avocados
BBQ Sauce
Bananas
Beer
Beets
Cabbage
Caffeine
Cantaloupes
Carbonated drinks
Cheese (except American, cottage, ricotta, cream)
Chicken livers
Chilies/spicy foods
Chocolate
Citrus fruits
Coffee (except no-acid type)
Cocktail Sauce
Cola
Corned beef
Cranberries
Cranberry juice and sauce
Grapefruit, grapefruit juice
Grapes, grape juice
Green Pepper
Guava
Honey
Hot Sauce
Jalapeno
Ketchup
Lemons, lemon juice
Lentils
Lima beans
Limes, lime juice
Mustard
Mayonnaise
Artificial sweetners
Nuts (almonds, peanuts and pine nuts are tolerable)
Onions
Oranges, orange juice
Peaches
Pickles (vinegar)
Pickled herring
Pineapple and pineapple juice
Pizza with tomato sauce
Plums
Prunes
Raisins
Red pepper
Relish
Rhubarb
Rye bread
Salad dressing
Salsa
Saccharine
Sauerkraut
Soda pop
Sour cream
Soy sauce
Spaghetti sauce
Steak Sauce
Strawberries
Sweet/Sour sauce
Tea
Tobacco
Tomatoes (except low-acid types)
Tomato juice, sauce and soup
Vinegar
Vitamins buffered with aspartate
Vitamin C and B complex
Watermelon
Yogurt

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Vaginal Yeast Infections

What is a vaginal yeast infection?

A vaginal yeast infection is irritation of the vagina and the area around it. Yeast is a type of fungus. In about 90% of cases yeast infections are caused by overgrowth of the fungus called Candida       Albicans. Small amounts of yeast are always in the vagina but when there is an overgrowth of yeast, you can get an infection. Yeast infections are very common. About 75 percent of women have one during their lives. And almost half of women have two or more vaginal yeast infections. If you are prone to yeast infections or have had four or more infections in one year you may have Recurrent Vulvovaginal Candidiasis. Women with recurrent vaginal yeast infections are more likely to suffer depression, have low self-esteem and to perceive their lives as stressful affecting sexual and emotional relationships. Please ask one of our doctors about more information if you are experiencing these symptoms. 

What are the signs of a vaginal yeast infection?

The most common symptom of a yeast infection is extreme itchiness in and around the vagina. Other symptoms include: burning, redness, swelling of the vagina and the vulva, pain when passing urine, pain during sex, soreness, a thick white vaginal discharge that looks like cottage cheese and does not have a bad smell, and a rash on the vagina. You may only have a few of these symptoms. They may be mild or severe.  

Should I call my doctor if I think I have a yeast infection?

Yes, you need to see the doctor to find out for sure if you have a yeast infection. The signs of a yeast infection are much like those of sexually transmitted diseases (STD), such as Chlamydia, Trichomonas, Herpes or Gonorrhea. In addition, skin changes such as vaginal eczema, vaginal warts, ulcers, a reaction to spermicidal condoms and even cancer may be underlying and would result in serious consequences if treated with antifungal medication. So, it’s hard to be sure you have a yeast infection and not something more serious. If you recognize your symptoms and you’ve had vaginal yeast infections before, talk to your doctor about acquiring over-the-counter medicines.

How is a vaginal yeast infection diagnosed?

Your doctor will do a pelvic exam to look for swelling and discharge, probing the affected region with a cotton bud to see what areas are sore. Your doctor may also use a swab to take a fluid sample from your vagina. A lab test, known as a fungal culture, will show if yeast is causing the problem.

What will my doctor be looking for during a physical exam?

To determine the manifestations of vaginitis in the affected area, a physical exam may be necessary. Your doctor will ask you about the nature, quantity and color of the discharge. Looking at physical symptoms, your doctor may ask, does the area feel like it’s itching, burning, or do you have dyspareunia (pain during intercourse). If the patient notes having an active sex life, a history into your past and recent sexual history will help your doctor reach the correct diagnosis.

Why did I get a yeast infection?

Many things can raise your risk of a vaginal yeast infection, such as: stress, lack of sleep, illness, poor eating habits, including eating extreme amounts of sugary foods, pregnancy, having your period, taking certain medicines, including birth control pills, antibiotics, and steroids. In addition, poor hygiene, lack of air flow to the region, not changing your underpants often enough, not changing out of sweaty clothes, damp clothing or underpants, not washing after sex, washing incorrectly can all cause yeast infection.

Some chronic sufferers may be especially vulnerable to yeast infections by virtue of vaginal immune system instability. Some exogenous factors may include diabetes, antibiotic use, systemic corticosteroids, or an infection correlated with human immunodeficiency virus.

How can I avoid getting another yeast infection?

To help prevent vaginal yeast infections avoid: douches, scented hygiene products like bubble bath, sprays, pads, and tampons. Change tampons and pads often during your period, avoid tight underwear or clothes made of synthetic fibers, wear cotton underwear and panty-hose with a cotton crotch, change out of wet swimsuits and exercise clothes as soon as you can, avoid hot tubs and very hot bath. If you keep getting yeast infections, be sure and talk with your doctor to avoid exaggerated symptoms.

What should I do if I get repeat yeast infections?

Call us, a diagnosis may need to be re-established. About 5 percent of women get four or more vaginal yeast infections in one year. This is called recurrent vulvovaginal candidiasis (RVVC). RVVC is more common in women with diabetes or weak immune systems. Doctors most often treat this problem with antifungal medicine for up to 6 months. However, this may not be the treatment plan for you. Many candidates who fail initial therapy have been successful using a combination of suppositories/oral medications and topical creams.

What are common therapy regimes used to treat yeast infections?

Over the counter medications:

Gyne-Lotrimin or Mycelex (clotrimazole)

Gynezol or Femstat (butoconazole)

Monistat (miconazole nitrate)

Vagistat (tioconazole)

Terazol (terconazole)

Prescription oral medications:

Fluconazole (Diflucan)

Itraconazole (Sporanox)

Other treatment options may include:

Boric acid suppositories

Tea tree oil

Probiotics

What are common home- therapies used to treat yeast infections?

Dietary changes can be particularly beneficial in preventing yeast flora from growing. Refined sugar, alcohol, and carbohydrates all feed yeast, thus allowing the food for an infection to thrive. Using natural sweeteners like honey, date syrup or agave syrup in small quantities may be a good way to combat sugar cravings.  Many women have found cutting out caffeine can also be effective, as blood sugar levels are kept more constant. Because protein balances blood sugar levels, fish, eggs, white meat and beans should be eaten sparingly.

There are some products which may help. These include: Antifungals (walnut, olive leaf, garlic, grapefruit seeds), Probiotics (Acidophilus) and Enzymatic Products. Vegetables such as: asparagus, avocado, broccoli, brussels sprouts, eggplant, kale, cabbage, cauliflower, celery, cucumber, onions, peppers, radish, spinach, Swiss chard, tomatoes, turnip may be beneficial. In addition, look for fruit and herbal teas known for their high antioxidant properties. Avoid wine, beer, and hard liquor. These will all make candida worse. Exercise Every Day. Drink Lots of Water. Stress-Less, get more sleep, do yoga, breathing and meditation.

Remember, hydration is the key to minimizing all symptoms and will bring about a faster recovery.

Lastly, some hygiene dos and don’ts.

Your vagina is self-cleaning but it is vitally important that you shower daily. Do not use harsh (non-pH balanced soaps) internally, and if a mild soap is used, wash it out completely. Change your clothes daily. Don’t wear clothes that are too tight or that are made with irritating materials; cotton is preferred. Avoid wearing soiled or sweaty underwear. Try to sleep without underwear and keep your vaginal area at all times. Always wipe/wash from front to back after using the toilet. Fold and wet toilet paper with water and wipe front to back until clean after bowel movements. And lastly, if you are sexually active, remember to wash after sex and to ask your partner about their sexual past before genital contact.

This guide will help you avoid exaggerated or prolonged symptoms of vaginitis and fight against disease for long term vaginal health.

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Polycystic Ovary Syndrome (PCOS)

What is polycystic ovary syndrome (PCOS)?

Polycystic (pah-lee-SIS-tik) ovary syndrome (PCOS) is a health problem that can affect a woman's:

• Menstrual cycle
• Ability to have children
• Hormones
• Heart
• Blood vessels
• Appearance

With PCOS, women typically have:

• High levels of androgens (AN-druh-junz). These are sometimes called male hormones, though females also make them.
• Missed or irregular periods (monthly bleeding)
• Many small cysts (sists) (fluid-filled sacs) in their ovaries

How many women have PCOS?

Between 1 in 10 and 1 in 20 women of childbearing age has PCOS. As many as 5 million women in the United States may be affected. It can occur in girls as young as 11 years old.

What causes PCOS?

The cause of PCOS is unknown. But most experts think that several factors, including genetics, could play a role. Women with PCOS are more likely to have a mother or sister with PCOS.

A main underlying problem with PCOS is a hormonal imbalance. In women with PCOS, the ovaries make more androgens than normal. Androgens are male hormones that females also make. High levels of these hormones affect the development and release of eggs during ovulation.

Researchers also think insulin may be linked to PCOS. Insulin is a hormone that controls the change of sugar, starches, and other food into energy for the body to use or store. Many women with PCOS have too much insulin in their bodies because they have problems using it. Excess insulin appears to increase production of androgen. High androgen levels can lead to:

• Acne
• Excessive hair growth
• Weight gain
• Problems with ovulation

What are the symptoms of PCOS?

The symptoms of PCOS can vary from woman to woman. Some of the symptoms of PCOS include:

• Infertility (not able to get pregnant) because of not ovulating. In fact, PCOS is the most common cause of female infertility.
• Infrequent, absent, and/or irregular menstrual periods
• Hirsutism (HER-suh-tiz-um) — increased hair growth on the face, chest, stomach, back, thumbs, or toes
• Cysts on the ovaries
• Acne, oily skin, or dandruff
• Weight gain or obesity, usually with extra weight around the waist
• Male-pattern baldness or thinning hair
• Patches of skin on the neck, arms, breasts, or thighs that are thick and dark brown or black
• Skin tags — excess flaps of skin in the armpits or neck area
• Pelvic pain
• Anxiety or depression
• Sleep apnea — when breathing stops for short periods of time while asleep

Why do women with PCOS have trouble with their menstrual cycle and fertility?

The ovaries, where a woman’s eggs are produced, have tiny fluid-filled sacs called follicles or cysts. As the egg grows, the follicle builds up fluid. When the egg matures, the follicle breaks open, the egg is released, and the egg travels through the fallopian tube to the uterus (womb) for fertilization. This is called ovulation.

In women with PCOS, the ovary doesn't make all of the hormones it needs for an egg to fully mature. The follicles may start to grow and build up fluid but ovulation does not occur. Instead, some follicles may remain as cysts. For these reasons, ovulation does not occur and the hormone progesterone is not made. Without progesterone, a woman's menstrual cycle is irregular or absent. Plus, the ovaries make male hormones, which also prevent ovulation.

Does PCOS change at menopause?

Yes and no. PCOS affects many systems in the body. So, many symptoms may persist even though ovarian function and hormone levels change as a woman nears menopause. For instance, excessive hair growth continues, and male-pattern baldness or thinning hair gets worse after menopause. Also, the risks of complications (health problems) from PCOS, such as heart attack, stroke, and diabetes, increase as a woman gets older.

How do I know if I have PCOS?

There is no single test to diagnose PCOS. Your doctor will take the following steps to find out if you have PCOS or if something else is causing your symptoms.

Medical history. Your doctor will ask about your menstrual periods, weight changes, and other symptoms.

Physical exam. Your doctor will want to measure your blood pressure, body mass index (BMI), and waist size. He or she also will check the areas of increased hair growth. You should try to allow the natural hair to grow for a few days before the visit.

Pelvic exam. Your doctor might want to check to see if your ovaries are enlarged or swollen by the increased number of small cysts.

Blood tests. Your doctor may check the androgen hormone and glucose (sugar) levels in your blood.

Vaginal ultrasound (sonogram). Your doctor may perform a test that uses sound waves to take pictures of the pelvic area. It might be used to examine your ovaries for cysts and check the endometrium (en-do-MEE-tree-uhm) (lining of the womb). This lining may become thicker if your periods are not regular.

How is PCOS treated?

Because there is no cure for PCOS, it needs to be managed to prevent problems. Treatment goals are based on your symptoms, whether or not you want to become pregnant, and lowering your chances of getting heart disease and diabetes. Many women will need a combination of treatments to meet these goals. Some treatments for PCOS include:

Lifestyle modification. Many women with PCOS are overweight or obese, which can cause health problems. You can help manage your PCOS by eating healthy and exercising to keep your weight at a healthy level. Healthy eating tips include:

• Limiting processed foods and foods with added sugars
• Adding more whole-grain products, fruits, vegetables, and lean meats to your diet

This helps to lower blood glucose (sugar) levels, improve the body's use of insulin, and normalize hormone levels in your body. Even a 10 percent loss in body weight can restore a normal period and make your cycle more regular.

Birth control pills. For women who don't want to get pregnant, birth control pills can:

• Control menstrual cycles
• Reduce male hormone levels
• Help to clear acne

Keep in mind that the menstrual cycle will become abnormal again if the pill is stopped. Women may also think about taking a pill that only has progesterone (proh-JES-tuh-rohn), like Provera, to control the menstrual cycle and reduce the risk of endometrial cancer. But, progesterone alone does not help reduce acne and hair growth.

Diabetes medications. The medicine metformin (Glucophage) is used to treat type 2 diabetes. It has also been found to help with PCOS symptoms, though it isn’t approved by the U.S Food and Drug Administration (FDA) for this use. Metformin affects the way insulin controls blood glucose (sugar) and lowers testosterone production. It slows the growth of abnormal hair and, after a few months of use, may help ovulation to return. Recent research has shown metformin to have other positive effects, such as decreased body mass and improved cholesterol levels. Metformin will not cause a person to become diabetic.

Fertility medications. Lack of ovulation is usually the reason for fertility problems in women with PCOS. Several medications that stimulate ovulation can help women with PCOS become pregnant. Even so, other reasons for infertility in both the woman and man should be ruled out before fertility medications are used. Also, some fertility medications increase the risk for multiple births (twins, triplets). Treatment options include:

• Clomiphene (KLOHM-uh-feen) (Clomid, Serophene) — the first choice therapy to stimulate ovulation for most patients.
• Metformin taken with clomiphene — may be tried if clomiphene alone fails. The combination may help women with PCOS ovulate on lower doses of medication.
• Gonadotropins (goe-NAD-oh-troe-pins) — given as shots, but are more expensive and raise the risk of multiple births compared to clomiphene.

Another option is in vitro fertilization (IVF). IVF offers the best chance of becoming pregnant in any given cycle. It also gives doctors better control over the chance of multiple births. But, IVF is very costly.

Surgery. "Ovarian drilling" is a surgery that may increase the chance of ovulation. It’s sometimes used when a woman does not respond to fertility medicines. The doctor makes a very small cut above or below the navel (belly button) and inserts a small tool that acts like a telescope into the abdomen (stomach). This is called laparoscopy (lap-uh-RAHS-kuh-pee). The doctor then punctures the ovary with a small needle carrying an electric current to destroy a small portion of the ovary. This procedure carries a risk of developing scar tissue on the ovary. This surgery can lower male hormone levels and help with ovulation. But, these effects may only last a few months. This treatment doesn't help with loss of scalp hair or increased hair growth on other parts of the body.

Medicine for increased hair growth or extra male hormones. Medicines called anti-androgens may reduce hair growth and clear acne. Spironolactone (speer-on-oh-LAK-tone) (Aldactone), first used to treat high blood pressure, has been shown to reduce the impact of male hormones on hair growth in women. Finasteride (fin-AST-uhr-yd) (Propecia), a medicine taken by men for hair loss, has the same effect. Anti-androgens are often combined with birth control pills.  These medications should not be taken if you are trying to become pregnant.

Before taking Aldactone, tell your doctor if you are pregnant or plan to become pregnant. Do not breastfeed while taking this medicine. Women who may become pregnant should not handle Propecia.

Other options include:

• Vaniqa (van-ik-uh) cream to reduce facial hair
• Laser hair removal or electrolysis to remove hair
• Hormonal treatment to keep new hair from growing

Other treatments. Some research has shown that bariatric (weight loss) surgery may be effective in resolving PCOS in morbidly obese women. Morbid obesity means having a BMI of more than 40, or a BMI of 35 to 40 with an obesity-related disease. The drug troglitazone (troh-GLIT-uh-zohn) was shown to help women with PCOS. But, it was taken off the market because it caused liver problems. Similar drugs without the same side effect are being tested in small trials.

How does PCOS affect a woman while pregnant?

Women with PCOS appear to have higher rates of:

• Miscarriage
• Gestational diabetes
• Pregnancy-induced high blood pressure (preeclampsia)
• Premature delivery

Babies born to women with PCOS have a higher risk of spending time in a neonatal intensive care unit or of dying before, during, or shortly after birth. Most of the time, these problems occur in multiple-birth babies (twins, triplets).

Researchers are studying whether the diabetes medicine metformin can prevent or reduce the chances of having problems while pregnant. Metformin also lowers male hormone levels and limits weight gain in women who are obese when they get pregnant.

Metformin is an FDA pregnancy category B drug. It does not appear to cause major birth defects or other problems in pregnant women. But, there have only been a few studies of metformin use in pregnant women to confirm its safety. Talk to your doctor about taking metformin if you are pregnant or are trying to become pregnant. Also, metformin is passed through breast milk. Talk with your doctor about metformin use if you are a nursing mother.

Does PCOS put women at risk for other health problems?

Women with PCOS have greater chances of developing several serious health conditions, including life-threatening diseases. Recent studies found that:

• More than 50 percent of women with PCOS will have diabetes or pre-diabetes (impaired glucose tolerance) before the age of 40.
• The risk of heart attack is 4 to 7 times higher in women with PCOS than women of the same age without PCOS.
• Women with PCOS are at greater risk of having high blood pressure.
• Women with PCOS have high levels of LDL (bad) cholesterol and low levels of HDL (good) cholesterol.
• Women with PCOS can develop sleep apnea. This is when breathing stops for short periods of time during sleep.

Women with PCOS may also develop anxiety and depression. It is important to talk to your doctor about treatment for these mental health conditions.

Women with PCOS are also at risk for endometrial cancer. Irregular menstrual periods and the lack of ovulation cause women to produce the hormone estrogen, but not the hormone progesterone. Progesterone causes the endometrium (lining of the womb) to shed each month as a menstrual period. Without progesterone, the endometrium becomes thick, which can cause heavy or irregular bleeding. Over time, this can lead to endometrial hyperplasia, when the lining grows too much, and cancer.

I have PCOS. What can I do to prevent complications?

If you have PCOS, get your symptoms under control at an earlier age to help reduce your chances of having complications like diabetes and heart disease. Talk to your doctor about treating all your symptoms, rather than focusing on just one aspect of your PCOS, such as problems getting pregnant. Also, talk to your doctor about getting tested for diabetes regularly. Other steps you can take to lower your chances of health problems include:

• Eating right
• Exercising
• Not smoking

How can I cope with the emotional effects of PCOS?

Having PCOS can be difficult. You may feel:

• Embarrassed by your appearance
• Worried about being able to get pregnant
• Depressed

Getting treatment for PCOS can help with these concerns and help boost your self-esteem. You may also want to look for support groups in your area or online to help you deal with the emotional effects of PCOS. You are not alone and there are resources available for women with PCOS.

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Back Pain in Pregnancy

What are the reasons for back pain during pregnancy?

• Pregnancy can cause you to gain as much as a quarter of your body weight, adding stress to the back and other weight-bearing structures.

• Center of gravity changes during pregnancy. This change in your center of gravity creates muscular imbalances and muscle fatigue that strains weight-bearing structures in the body and causes poor posture and/makes poor posture even worse.
• Abdominal muscles become increasingly lax in order to accommodate a growing uterus, back muscles compensate by working much harder.
• As your breasts become fuller, added weight in the chest area can pull at your upper spine, creating painful, pinching pressure.
• As your belly gets bigger throughout your pregnancy, your lower back curves more than usual to accommodate the load, resulting in strained muscles and, you guessed it, pain.
• Malfunction in the hip joint is the most common cause of back pain in pregnancy.
• Activities that create unbalanced, uneven weight-bearing of the spine, pelvis, and hips causes back pain during pregnancy, which includes walking and running, rolling over in bed, bending forward, twisting, lifting and navigating stairs.
• Increased level of the hormone relaxin  that is released during pregnancy allow ligaments in the pelvic area to soften and the joints to become looser in preparation for the birthing process of your baby; this shift in joints and loosening of ligaments may affect the support your back normally experiences.
• Poor posture, excessive standing, lifting, twisting, navigating the stairs and bending over can trigger or escalate the pain you experience in your back
• Stress usually finds the weak spot in the body, and because of the changes in your pelvic area, you may experience an increase in back pain during stressful periods of your pregnancy

What helps?

• Good posture. Standing up straight allows muscles to naturally lengthen and stretch, making good posture one of the easiest “exercises” for easing lower back pain. Good posture also means sitting with care.
• Lower back stretching. Lower back extensions safely strengthen back muscles during pregnancy, making their tough work a little easier (and less painful for you).
• Prenatal yoga. Prenatal yoga is a relaxing way to tone parts of the body most affected by pregnancy, including the back.
• Pelvic tilts. Pelvic tilts (also called “pelvic rocking”) strengthen abdominal muscles, relieve backache, and help improve posture.
• Swimming/water exercise. Water supports your weight, swimming and prenatal water aerobics classes relieve pressure from your back and joints while still giving you a great whole-body workout.
• Acupuncture. Acupuncture places thin, sterile needles at specific “energy points” in order to activate the body’s own natural pain relief system.
• Chiropractic care. Chiropractors adjust misaligned joints, especially in the spine, to relieve nerve stress and promote healing throughout the body. This is effective in treating pregnancy-related back pain
• Lumbar support pillows. Keep your head and shoulders in line and use a lumbar support pillow (a small pillow specially designed to fit the lower back) to keep your back properly positioned and pain-free.
• Supportive sleep environment. Sleeping on your side and using strategically placed pillows for support can provide relief from aches and pains, and help you get some much-needed rest. Make sure your mattress is firm.  A body pillow (at least 5 feet long) can also help you find stress-minimizing sleeping positions.
• Crisscross support sling is designed specifically for a pregnant figure, which will help take the burden of your belly’s weight off your lower back.
• Maternity support belt. These are thick elastic bands worn around the hips and under the belly cradle and support lax abdominal muscles.
• Footrest. Use a footrest to elevate your feet slightly, and don’t cross your legs; that can cause your pelvis to tilt forward, exacerbating those strained back muscles.
• Regular physical activity. Take breaks by walking or standing and stretching at least once an hour. Sitting too long can make your back hurt even more.
• Lift properly. Avoid lifting heavy loads, but if you must, do it slowly.
• Keep your weight gain where it should be (extra weight is extra hard on any back).
• Wear the right shoes. Experts recommend a 2-inch heel to keep your body in proper alignment. You might also consider orthotics, orthopedic shoe inserts designed for muscle support.
• No reaching for the stars — or the cookies on the top shelf. Use a low, stable, step stool to get items from high places and you’ll avoid additional strain. (Better still, leave the cookies where they are.)
• Think good thoughts. A calm mind leads to a looser back.
• Warm and cold compresses. Soothe sore muscles by applying cold compresses, then warm compresses in 15-minute intervals. Rubbing your back might also help.
• Warm bath. Take a warm bath (ask your partner to draw it for you). Or turn the shower head to pulsating and enjoy the back massage.
• Body massage. Talking about massages, go get one (after the first trimester and with a masseuse who knows you’re pregnant and is trained in the art of prenatal massage).
• Medications. Over the counter pain medication such as Tylenol is generally safe during pregnancy. Talk to your healthcare provider before taking any medication.
• Sacral belt.
• Learn relaxation techniques to cope with the discomfort and back pain during bed time.

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