FitSugar

New Birth Control Pill Means NO PERIOD!!!

FitSugar — Mon, 21 May 2007 17:15:00 -0700

See ya Aunt Flo. Adios cramps! Sayonara uncontrollable mood swings and chocolate cravings! Hello Lybrel! This new birth control pill, expected to be announced on Tuesday by the FDA, will help women avoid their periods altogether!

Allow me to throw a little background history your way. Before the wonderful invention of birth control, women spent most of their time pregnant or breast feeding, and endured only about 50 periods their entire lives. Now that we have a plethora of birth control options, women get as many as 450 periods! Dealing with your period is just as much fun as going to the gyno, so who wouldn't be excited about a safe and effective way to ditch your monthly period?

Lybrel is kind of like the pill Seasonale, where you take pills for 3 months straight, and then take 7 days of sugar pills (so you get your period). The difference is that Lybrel is taken continuously, with no sugar pill breaks - and that means no period.

Lybrel could change women's lives everywhere, but unfortunately testing has shown that it doesn't work as perfectly as planned. Although 59% of women who tried this new pill ended up with no periods after 6 months (wa-hoo!), 18% dropped out of the study because of annoying spotting and breakthrough bleeding. At this point if you switch to Lybrel, you may be trading in "scheduled bleeding" for "unscheduled bleeding," which many women won't be too psyched about.

For many women, getting no period at all is a brilliant concept. Even though Lybrel may not be the best option just yet, it's still a great first step towards making this happen.

Want to know if not getting your period is safe? Then read more

When a woman is not on the Pill, every month she gets her period to shed the unfertilized egg and the built up lining in her uterus that her body has made to prepare for getting pregnant.

When a woman is on the Pill, since she is not ovulating (producing an egg), the "period" she has is not actually a real period at all. It is a hormone withdrawal bleed, brought on simply from taking a break from the hormones. So whether you are having this fake period once a month, 4 times a year (with Seasonale), or not at all, it doesn't really make a difference since it's not a real menstrual period.

Source

Reduce Your Flow

FitSugar — Wed, 27 Dec 2006 11:57:08 -0800

The commercial for Seasonale, a birth control pill, raves about getting only 4 periods a year. So what's the deal? Is that safe?

Birth control pills can either be monophasic, where you get the same amount of hormones each day, or triphasic, where you get a different amount of hormones over 3 weeks.

Seasonale and other monophasic pills allow you to take them in any sequence you want. Each pill pack contains a 3 month supply, and each 4 week supply contains 3 weeks of hormones and one week of sugar pills. So if you want, you can get your period every month by taking the sugar pills after taking 3 weeks of hormones. Or you can get it every 3 months by taking all the hormone pills for 9 weeks and then one week of sugar pills, thus keeping Aunt Flo at bay for over 2 months.

When you're on any birth control pill, when you get your period, it isn't a real period, because you're not actually releasing an egg (the pill stops you from ovulating). It's called a "pill period," and it results as your body's reaction to withdrawing from the hormones. Having this kind of period once a month is just as safe as only having it 4 times a year.

Fit's Tips: Monophasic birth control might be right for you if you suffer from painful periods, excessive bleeding, or unbearable mood swings. Definitely ask your trusted DR about this if you have questions.

Levonorgestrel/ethinyl estradiol (By mouth)

admin — Thu, 04 Sep 2008 20:02:17 -0700

Overview

Introduction
Brand Name(s)
When This Medicine Should Not Be Used
How to Use This Medicine
How to Store and Dispose of This Medicine
Drugs and Foods to Avoid
Warnings While Using This Medicine
Possible Side Effects While Using This Medicine

HEALTH GUIDE REFERENCE FROM A.D.A.M

Introduction

Ethinyl Estradiol (ETH-in-il es-tra-DYE-ole), Levonorgestrel (LEE-voe-nor-jes-trel)

Prevents pregnancy. This medicine is an oral contraceptive (birth control pill).

Brand Name(s)

Aviane, Trivora-28, Levora-28, Lutera, Enpresse-28, Seasonale, Portia-28, Lessina 28, Levlite 28, Levlen, Nordette-28, Jolessa, Quasense, Sronyx, Seasonique

There may be other brand names for this medicine.

When This Medicine Should Not Be Used

You should not use this medicine if you have had an allergic reaction to hormone medicines. Do not use this medicine if you are pregnant, or if you have abnormal vaginal bleeding that has not been checked by a doctor. You should not use this medicine if you have a history of cancer of the breast, ovary, or uterus. Do not use this medicine if you have a history of heart attacks, stroke, or blood clots. You should not use this medicine if you have liver cancer, or a history of jaundice (yellow skin or eyes) caused by pregnancy or birth control pills.

How to Use This Medicine

Tablet

Your doctor will tell you how much of this medicine to use and how often. Do not use more medicine or use it more often than your doctor tells you to.
This medicine comes with patient instructions. Read and follow these instructions carefully. Ask your doctor or pharmacist if you have any questions.
Carefully follow your doctor's instructions about when to start taking your medicine. You may begin taking the pills on the first day of your menstrual period, or on the Sunday after your period begins.
You may need to use a second form of birth control when you first start using this medicine. Talk with your doctor about your individual situation. Some other forms of birth control include condoms, diaphragms, or contraceptive foams or jellies.
Take this medicine at the same time every day. Birth control pills work best when there is no more than 24 hours between doses. It is very important that you take this medicine on time every day.

If a dose is missed:

This medicine has specific patient instructions on what to do if you miss a dose. Read and follow these instructions carefully, and call your doctor if you have any questions
If you miss one pink pill, take it as soon as you can. Then take your next pill at the regular time. This means you may take two pills in one day.
If you miss two pink pills in a row during Week 1 or 2, take two pills as soon as you can. Take two more pills on the next day. Then go back to your regular schedule of taking one pill every day. Use a second form of birth control until you have been taking pink pills for seven days in a row.
If you started this medicine on Day 1 of your period and you miss two pink pills in a row during Week 3, throw out the rest of your pills and start a new pack the same day. If you miss three or more pink pills in a row during any week, throw out the rest of your pills and start a new pack the same day.
If you started this medicine on the Sunday after your period started and you miss two pink pills in a row during Week 3, keep taking one pill every day until the next Sunday. Then throw away the rest of your pills and start a new pack on that same Sunday.
If you started this medicine on the Sunday after your period started and you miss three or more pink pills in a row during any week, keep taking one pill every day until the next Sunday. Then throw away the rest of your pills and start a new pack on that same Sunday.
If you miss your pills and change your schedule, you may not have a period for that month. Make sure your doctor knows if you miss your period two months in a row, because you may be pregnant.
You could have light bleeding or spotting any time you do not take a pill on time. The more pills you miss, the more likely you are to have bleeding.
To prevent a pregnancy, you should use a second form of birth control for the next seven days after you miss a dose. Some other forms of birth control include condoms, diaphragms, or contraceptive foams or jellies.

How to Store and Dispose of This Medicine

Store the medicine in a closed container at room temperature, away from heat, moisture, and direct light.
Ask your pharmacist, doctor, or health caregiver about the best way to dispose of any outdated medicine or medicine no longer needed.
Keep all medicine away from children and never share your medicine with anyone.

Drugs and Foods to Avoid

Ask your doctor or pharmacist before using any other medicine, including over-the-counter medicines, vitamins, and herbal products.

Make sure your doctor knows if you are using phenylbutazone (Butazolidin®) or rifampin (Rifadin®, Rimactane®). Tell your doctor if you use seizure medicines such as phenobarbital or phenytoin (Dilantin®). Make sure your doctor knows if you are using any antibiotics such as ampicillin, griseofulvin, or tetracycline.

Warnings While Using This Medicine

Make sure your doctor knows if you are breast feeding, or have recently been pregnant. Tell your doctor if you have heart disease, high cholesterol, or high triglycerides (lipids). Tell your doctor if you have migraine headaches, diabetes, gallbladder disease, or a history of depression.
This medicine may increase your risk of certain heart or blood vessel problems. Tell your doctor if you have a history of heart attack, stroke, high blood pressure, congestive heart failure, blood clots, or circulation problems.
Your risk of heart disease or stroke from this medicine is higher if you smoke. Your risk is also increased if you have diabetes or high cholesterol, or if you are overweight. Talk with your doctor about ways to stop smoking. Keep your diabetes under control. Ask your doctor about diet and exercise to control your weight and blood cholesterol level.
This medicine may also increase your risk of certain types of cancer. Talk to your doctor if you have concerns about this risk.
You might have some light bleeding or spotting when you first start using this medicine. This is usually normal and should not last long. However, if you have heavy bleeding or the bleeding lasts more than seven days in a row, call your doctor's office. You should not have a "normal" menstrual period until you start taking the white pills. The white pills are the last seven pills in your package and do not contain hormones.
Call your doctor for a pregnancy test if your menstrual period does not start when you take the last seven white pills.
Make sure any doctor or dentist who treats you knows that you are using this medicine. This medicine may affect the results of certain medical tests.
Your doctor will need to check your progress at regular visits while you are using this medicine. Be sure to keep all appointments.
This medicine will not protect you from getting HIV, AIDS, or other sexually transmitted diseases. If this is a concern for you, talk with your doctor.

Possible Side Effects While Using This Medicine

Call your doctor right away if you notice any of these side effects:

Allergic reaction: Itching or hives, swelling in your face or hands, swelling or tingling in your mouth or throat, chest tightness, trouble breathing.
Breast changes or lumps.
Decrease in how much or how often you urinate.
Chest pain, or coughing up blood.
Lighter or heavier menstrual periods.
Numbness or weakness in your arm or leg, or on one side of your body.
Pain in your lower leg (calf).
Pain in your upper right stomach.
Shortness of breath, cold sweat, and bluish-colored skin.
Sudden or severe headache, problems with vision, speech, or walking.
Sweating, nausea or vomiting, pain in your chest, jaw, and left arm.
Swelling in your hands, ankles, or feet.
Unusual bleeding or bruising.
Yellowing of your skin or the whites of your eyes.

If you notice these less serious side effects, talk with your doctor:

Acne, increased non-scalp hair growth, or darkened skin on your face.
Breast pain, swelling, or tenderness.
Migraine headache, or a headache with vision changes or sensitivity to light.
Mood changes, depression, nervousness, or dizziness.
Nausea, vomiting, diarrhea, or upset stomach.
Pain or burning with urination.
Problems with vision, or trouble wearing contact lenses.
Vaginal itching or discharge.
Weight gain or loss, or appetite changes.

Review Date: 8/4/2008

A.D.A.M., Inc. is accredited by URAC, also known as the American Accreditation HealthCare Commission (www.urac.org). URAC's accreditation program is an independent audit to verify that A.D.A.M. follows rigorous standards of quality and accountability. A.D.A.M. is among the first to achieve this important distinction for online health information and services. Learn more about A.D.A.M.'s editorial policy, editorial process and privacy policy. A.D.A.M. is also a founding member of Hi-Ethics and subscribes to the principles of the Health on the Net Foundation (www.hon.ch).

A.D.A.M. Copyright

The information provided herein should not be used during any medical emergency or for the diagnosis or treatment of any medical condition. A licensed medical professional should be consulted for diagnosis and treatment of any and all medical conditions. Call 911 for all medical emergencies. Links to other sites are provided for information only -- they do not constitute endorsements of those other sites. © 1997-2009 A.D.A.M., Inc. Any duplication or distribution of the information contained herein is strictly prohibited.

adam.com

Source Doc: 45_4773

Birth control options for women

FitSugar — Wed, 08 Oct 2008 17:34:56 -0700

HEALTH GUIDE REFERENCE FROM A.D.A.M

Highlights

First "No-Period" Birth Control Pill Approved

In May 2007, the Food and Drug Administration approved Lybrel, the first birth control pill that completely eliminates monthly menstrual periods. Lybrel contains low doses of the estrogen estradiol and the progestin levonorgestrol. The active pills are taken 365 days a year with no inactive pill breaks. In clinical trials, 59% of women who took Lybrel completely stopped having menstrual periods by the end of the first year. Some women, however, continued to experience occasional unscheduled bleeding or spotting during the first 3 - 6 months of use.

Third-Generation Progestins Controversy

In February 2007, the consumer advocacy organization Public Citizen petitioned the Food and Drug Administration to ban the use of desogestrel in oral contraceptives. According to some studies, desogestrel has nearly double the risk for blood clots compared to older, second-generation progestins like levonorgestrel. (However, other studies have not found an increased risk.) Desogestrel is contained in birth control pills such as Mircette.

Oral Contraceptives and Heart Attack Risks

Low-dose oral contraceptives do not increase the risk of heart attack for women in their 30s and 40s, indicates a 2007 study in Fertility and Sterility.

Oral Contraceptives and Cancer Risks

Combination oral contraceptives may reduce the risk for uterine, ovarian, and colorectal cancer, but women who use them for more than 8 years have an increased risk for cervical, breast, and central nervous system cancers, according to a 2007 study in the British Medical Journal.

Birth Control Patch and Blood Clot Risk

Women who use the birth control patch (Ortho Evra) have double the risk for blood clots as women who use oral contraceptives, suggests a 2007 study in Obstetrics & Gynecology. Other studies have reported few differences in risks between the two types of contraceptives. Some experts are concerned that prolonged estrogen exposure with the birth control patch (and ring) increases the risks for blood clots.

Introduction

Contraceptives are devices or methods for preventing pregnancy, either by preventing the fertilization of the female egg by the male sperm or by preventing implantation of the fertilized egg. Contraceptives are not modern inventions. The first prescription for a contraceptive device described a tampon barrier device and was written on papyrus in 1550 BC.

Choosing the appropriate contraceptive varies from individual to individual. Contraceptive options include:

Hormonal contraceptives (oral contraceptives, skin patch, vaginal ring, implant, injection)
Intrauterine devices (IUDs), which contain either a hormone or copper
Barrier devices with or without spermicides (diaphragm, cervical cap, sponge, condom)
Natural family planning methods (basal body temperature, cervical mucus, symptothermal)
Female sterilization (tubal ligation, Essure)

The pill works in several ways to prevent pregnancy. The pill suppresses ovulation so that an egg is not released from the ovaries, and changes the cervical mucus, causing it to become thicker and making it more difficult for sperm to swim into the womb. The pill also does not allow the lining of the womb to develop enough to receive and nurture a fertilized egg. This method of birth control offers no protection against sexually-transmitted diseases.

Contraceptive effectiveness is characterized by "typical use" and "perfect use":

Typical use refers to real-life conditions, in which mistakes (such as forgetting to take a birth control pill at the right time) sometimes happen.
Perfect use refers to contraceptives that are used correctly each time intercourse occurs.

Research has shown that the four most effective standard female contraceptives are surgical sterilization, the intrauterine device (IUD), implants, and injections. They all have an estimated failure rate of less than 1% during the first year of normal (typical) use. Vasectomy (male surgical sterilization) is the only male contraceptive that is equally effective. By comparison, the estimated failure rate of the male latex condom used without spermicide is 14% with typical use and 3% with perfect use. To put these rates into perspective, a sexually active woman of reproductive age who does not use contraception faces an 85% likelihood of becoming pregnant in the course of a year.

Birth control is a controversial subject. In recent years, there has been a growing movement in the United States to restrict a woman's access to contraceptives. In addition to the political battles over non-prescription access to emergency contraception (Plan B), 18 states (as of 2006) are considering legislation that would allow pharmacists to refuse to dispense medications due to moral or religious objections. There have been hundreds of reports of pharmacists refusing to fill birth control prescriptions. In response to this trend, several members of Congress introduced in April 2005 the Access to Legal Pharmaceuticals Act, which would override any state legislation. The bill would require that pharmacies fill birth control prescriptions and would protect women’s legal right to purchase such products.

Oral Contraception

Oral contraceptives are available only by prescription and come in either a combination of estrogen and progestin or progestin alone. Many brands of each form are available. Although both are equally effective with typical use, the combined pill is more effective with perfect use, and most women choose this form.

Some women, however, experience severe headaches or high blood pressure from the estrogen in the combined pill and must take the progestin-only pill. Not all combined pills or progestin-only pills are alike, and brands differ in the amount of estrogen or progestin they contain. Many oral contraceptive combined brands now use lower estrogen doses than previous brands and are proving to be safe and effective while providing a better quality of life than earlier oral contraceptives.

For all oral contraceptive users, a check-up at least once a year is essential. It is also important for women to have their blood pressure checked 3 months after beginning the pill. Former pill users who want to bear children usually regain fertility in 3 - 6 months, but they may regain it even sooner.

Estrogen (Estradiol)

Estrogen is the major female hormone and is responsible for female characteristics. The estrogen compound used in most oral contraceptives is estradiol and is always used with a progestin.

Effects on Reproduction. When used throughout a menstrual cycle with progesterone, estrogen suppresses the actions of other reproductive hormones (luteinizing hormone, or LH, and follicle stimulating hormone, or FSH) and prevents ovulation. Estrogen also changes the cellular structure of the lining of the uterus (the endometrium) and hinders implantation of a fertilized egg.

Side Effects of Estrogen. During the first 2 - 3 months of use of oral contraceptives, side effects from estrogen in the combined pill include:

Nausea and vomiting (can often be controlled by taking the pill during a meal or at bedtime)
Headaches (in women with a history of migraines, they may worsen)
Dizziness
Breast tenderness and enlargement

Progesterone (Progestin)

When used in contraception, progesterone is referred to by one of several names:

Progesterone is the name for the natural hormone.
Progestogen is a synthetic form.
Progestin is the term for any hormone, natural or synthetic, that causes progesterone effects; it is used as the general term in this report.

Progestins may be used alone or with estrogen in oral contraceptives. In addition, certain specific progestins are used in other kinds of contraceptives, such as etonogestrel in the Implanon implant and depo-medroxyprogesterone acetate in the injectable contraceptive Depo-Provera.

Progesterone can prevent pregnancy by itself in several ways:

Blocking luteinizing hormone (LH), one of the reproductive hormones important in ovulation
Maintaining a powerful barrier against the entry of sperm into the uterus by keeping the cervical mucus thick and sticky
Changing the lining of the uterus, making it more difficult for the fertilized egg to implant

Progestins used in contraceptives are referred to as:

Second generation (levonorgestrel, norethisterone).
Third generation (desogestrel, gestodene, norgestimate, drospirenone). The third-generation progestins tend to have fewer male-like side effects. Some studies suggest, however, they may pose a slightly higher risk for blood clots than the older progestins, although the risk is still small.

In 2007, the consumer advocacy group Public Citizen petitioned the Food and Drug Administration (FDA) to ban desogestrel-containing contraceptives, citing studies that indicated a nearly 2-fold increased risk for blood clots compared to second-generation oral contraceptives. Some experts, however, have criticized Public Citizen’s report for relying on older studies. The FDA has said that it will review Public Citizen’s petition.

Side Effects of Progestins. Side effects of progestin occur in both the combination oral contraceptives and any contraceptive that uses only progestin. Side effects may be less or more severe depending on the form and dosage of the contraceptive. Side effects may include:

Changes in uterine bleeding such as higher amounts during periods, spotting and bleeding between periods (called break-through bleeding), or absence of periods
Unexpected flow of breast milk (check with your doctor if this occurs to be sure other conditions are not causing it)
Abdominal pain or cramps
Diarrhea
Fatigue, unusual tiredness, weakness
Hot flashes
Decreased sex drive
Nausea
Trouble sleeping
Acne or skin rash (not all oral contraceptives have this side effect; low-dose oral contraceptives actually improve acne)
Depression, irritability, or other mood changes (although some oral contraceptives are helpful for women with premenstrual dysphoric syndrome)
Swelling in the face, ankles, or feet
Weight gain

Newer formulations of combination pills that use low-dose estrogen, and newer progestins, may reduce and even lower the risk of many of these side effects, including weight gain. Low-dose progestins used in non-oral contraceptives, such as the LNG-IUS IUD, also may not pose as high a risk for these side effects. If side effects continue or are severe, talk to your doctor. For many of those who do have side effects, their bodies eventually adjust.

Click the icon to see an image of a blood clot.

Oral contraceptives that contain both estrogen and progestin are the more common type of oral contraceptive. At least 10 million American women and 100 million women worldwide use combination oral contraceptives. When they were first marketed in the early 1960s, oral contraceptivescontained as much as 5 times the amount of estrogen and up to 10 times the amount of progestins currently used. After reports of severe complications (stroke, heart attack, and pulmonary embolisms) in young women, the hormone amounts were significantly reduced.

The estrogen compound used in most oral contraceptives is ethinyl estradiol (also called estradiol, or EE). Fifty micrograms of estradiol is considered high dose, 30 - 35 micrograms are considered average dose, and 20 micrograms or fewer is low-dose. (The high doses found in current oral contraceptives are still much lower than earlier forms of the pill.) Doctors recommend using the lowest possible progestin and estrogen doses. Estrogen doses should not exceed 50 micrograms, as higher doses increase the risk for complications.

Many different types of progestins are used in combination with estradiol. Some common types of progestin, and popular combination oral contraceptive brands, include:

Desogestrel is the progestrin used in Mircette. Approved in 1998, Mircette was the first oral contraceptive to offer a low estrogen dose and a new type of dosing regimen. Some studies suggest an increased risk for blood clots with desogesterel (see "Hormones Used in Contraceptives").
Drospirenone is used in Yasmin and Yaz. (Yaz contains a lower dose of estrogen than Yasmin.) Because drospirenone increases blood levels of potassium, women should not use Yasmin or Yaz if they have kidney, liver, or adrenal diseases.
Levonorgestrel is used in Seasonale and Seasonique, as well as many other oral and non-oral contraceptives.
Norethindrone is used in Loestrin and Loestrin 24 Fe (which adds iron supplements to the placebo pills).
Norgestrel is used in various generic and brand contraceptives.

Many types of medications and supplements (Tylenol, anti-seizure drugs, antibiotics, vitamin C, St. John's wort) can interact with progestin and reduce its effectiveness. Make sure your doctor is aware of any drugs, vitamins, and herbal supplements that you take.

Types of Regimens. Combination pills are sold in 21-day or 28-day packs:

Each pill in a 21-day pack contains estrogen and progestin. Women take 1 pill a day for 21 days, and then wait 7 days before starting a new 21-day pack.
28-day packs typically start with 21 hormone pills and add 7 placebo pills that do not contain hormones. After taking hormone pills for 21 days, a woman takes the inactive pills for 7 days. Some newer brands, like Yaz, use 24 days of active pills and 4 days of inactive pills. Mircette uses 21 days of low-dose progestin and estrogen, followed by 2 placebo days, and then 5 days of very low-dose estrogen. Loestrin 24 Fe uses 24 days of active pills followed by 4 days of iron-containing placebo pills.

Oral contraceptives may be taken in cycles that include pills of the same or different strengths. These are categorized as monophasic (one-phase), biphasic (two-phase), or triphasic (three-phase). Monophasic pills contain the same amount of hormones in each dose. Biphasic and triphasic pills contain different dosages of hormones within the pill packs. Because monophasic pills have a consistent amount of hormones, they tend to cause fewer hormone-fluctuating side effects than biphasic or triphasic pills. Several 2006 reviews found little difference in effectiveness between these three types of oral contraceptives. Many experts recommend monophasic pills as the best first-choice for birth control pills.

Taking the Pills. A woman usually takes the first pill either on the Sunday after her period starts or during the first 24 hours of her period. (The first pill can be started at any time during the menstrual cycle without affecting the bleeding patterns. Ovulation can occur that month, however.) The remaining pills are taken once a day, ideally at the same time of day, until the pack is used up. If a woman has a 21-day pack, she waits 7 days before starting a new pack. If she is on the 28-day pack, she takes the 7 inactive pills.

If you skip one or more pills, take the following precautions:

Missing the first pill in a new cycle. Take a tablet as soon as you remember and the next one at the usual time. Two tablets can be taken in one day. Use barrier contraception for 7 days after the missed dose. [See "Spermicidal and Barrier Contraception."]
Missing a pill 2 days in a row. Take 2 pills as soon as you remember and then 2 more the following day. Also use back-up barrier contraception until the next pill cycle.
Missing more than 2 days. Discard the pack, use a back-up birth control method, and begin a new cycle on the following Sunday, even if you have started bleeding.

Standard oral contraceptives come in a 28-pill pack that contains 21 active pills and 7 inactive pills. Newer "continuous-dosing" (also called "continuous-use") oral contraceptives aim to reduce -- or even eliminate -- monthly periods and thereby prevent the pain and discomfort that often accompanies menstruation. These oral contraceptives contain a combination of estradiol and the progesterone levonorgestrel, but use extending dosing of active pills.

Seasonale, the first continuous-dosing contraceptive, was approved in 2003. It contains 81 days of active pills followed by 7 days of inactive pills. Women who take Seasonale have on average a period every 3 months. Seasonique, a follow-up to Seasonale, was approved in 2006. As with Seasonale, it produces about 4 periods a year. With Seasonique, a women takes 84 days of levonorgestrol-estradiol pills followed by 7 days of pills that contain only low-dose estradiol.

In 2007, the Food and Drug Administration approved Lybrel, which supplies a daily low dose of levonorgestrol and estradiol with no inactive pills. Because Lybrel contains only active pills, which are taken 365 days a year, it completely eliminates monthly menstrual periods. In clinical trials, 59% of women who took Lybrel completely stopped menstrual periods by the end of the first year. Some women, however, experienced occasional unscheduled bleeding or spotting during the first 3 - 6 months. In clinical trials, women who took Lybrel experienced relief of premenstrual syndrome symptoms within a month of starting the drug.

Progestin-only pill brands include:

Levonorgestrel (Plan B)
Norethindrone (Micronor, Avgestin, Norlutin, Nor-QD). (This progestin is made from male hormones, so may cause more male side effects than others.)
Norgestrel (Ovrette)

Progestin-only pills, which only contain progestins, are always sold in 28-day packs and all the pills are active. (An exception is Plan B, which is emergency contraception.) Progestin-only pills must be taken at precisely the same time each day to maintain top effectiveness. If a woman deviates from her pill schedule by even 3 hours, she should call her doctor about using back-up contraception for the next 2 days. Progestin-only pill users will experience even lighter periods than those taking combination pills. Some may not have periods at all. These hormones should not be used by premenopausal women in their 40s, since they pose a higher risk for adverse effects in this group.

Oral contraceptives are the choice of most American women who use birth control, making them the most popular reversible contraceptives in the U.S. Oral contraceptives are among the most effective contraceptives. Failure rates are very low and are usually due to noncompliance. Some studies have suggested that women who are overweight may have a higher risk for failure. The risk for these women is also still very low, however.

Oral contraceptives also have the following advantages:

More sexual freedom. oral contraceptives do not interfere with intercourse, and in fact, many women report that sex is more pleasurable because they no longer have to worry about pregnancy.
Reduce menorrhagia (heavy bleeding) and, therefore, reduce the risk for anemia.
Reduction in dysmenorrhea (severe pain). High-dose oral contraceptives have been especially helpful, but they carry risks. Specific newer low-dose oral contraceptives that contain certain progestins, such as Yasmin (with drospirenone) and Mircette (with desogestrel), may reduce menstrual pain.
Possible reduction in premenstrual syndrome with specific oral contraceptives, notably Yaz (which was approved for treating premenstrual dysphoric disorder -- premenstrual depression -- in 2006.) Some oral contraceptives, however, are associated with worse emotional changes. Monophasic oral contraceptives may have a more beneficial effect on mood than triphasic oral contraceptives.
Reduction in endometriosis.

Endometriosis is the condition in which the tissue that normally lines the uterus (endometrium) grows on other areas of the body causing pain and irregular bleeding.

Possible protection against multiple sclerosis. Some studies have suggested that women who take oral contraceptives may be less likely to develop multiple sclerosis
Acne improvement with low-dose oral contraceptives. (Some low-dose contraceptives, such as Ortho Tri-Cyclen, have been specifically approved for acne reduction, although most low-dose oral contraceptives reduce testosterone levels and so help reduce acne.)
Possible protection against bone loss with low-dose oral contraceptives. The effect of contraceptives on bone density is unclear and may depend on the specific formulas and types of progestins used.

Common Side Effects. Estrogen and progesterone have different side effects. Women on the combined pill may experience different effects from those on the progestin-only pill. Symptoms of serious problems include severe abdominal pain, chest pain, unusual headaches, visual disturbances, or severe pain or swelling in the legs. In spite of some concerns, combination oral contraceptives do not generally cause weight gain.

[For specific side effects of estrogen and progestin, see "Hormones Used in Contraception."]

Serious Effects on Heart and Circulation. Combination birth control pills contain estrogen, which can increase the risk for stroke, heart attack, and blood clots in some women. The risk is highest for women who smoke or have a history of heart disease risk factors (such as high blood pressure) or cardiac events. Women who have certain metabolic disorders, such as polycystic ovary syndrome (PCOS), are also at higher risk for heart-related complications associated with these pills.

When birth control pills were first introduced, heart and circulatory risks were higher than they are now. Current brands of combination oral contraceptives contain much lower dosages of estrogen and are safer than those earlier pills. Some studies, however, including a 2005 review, suggest that even low-dose combination birth control pills have some cardiovascular risks. Other research, such as a 2007 study of older women ages 30 - 49, indicate that low-dose oral contraceptives do not increase heart attack risk.

All combination estrogen/progestin birth control products carry an increased risk for blood clots in the veins (venous thromboembolism). The risk is lower for oral contraceptives than for the birth control patch (Ortho Evra) or the ring (NuvaRing), which expose women to higher levels of estrogen than birth control pills. Women who smoke or who have other heart disease risk factors may want to consider using alternatives to combination oral contraceptives, such as progestin-only oral contraceptives ("mini-pills"), intrauterine devices, or barrier contraceptive methods. Discuss your lifestyle and health history with your doctor to determine if combination birth control pills are safe for you.

Click the icon to see an image of stroke.

Overall Cancer Risks. Combination oral contraceptives appear to increase the risk for some types of cancers (cervical) and reduce the risks for others (ovarian and uterine). For other types of cancer, such as breast cancer, the evidence is less clear. According to a 2007 study in the British Medical Journal, current users of high-dose (50 micrograms/day) combination oral contraceptives have a reduced risk for uterine, ovarian, and possibly colorectal cancer. However, women who use estrogen-containing oral contraceptives for more than 8 years have an increased risk for cervical, breast, and central nervous system cancers. Researchers found that once women stopped taking birth control pills, the risks for breast and cervical cancer returned to those of non-users within 10 years.

Breast Cancer. Studies have been conflicting about whether estrogen in oral contraception increases the chances for breast cancer, and if it does, which women are at risk. Some studies indicate that the risk may be higher for premenopausal breast cancer when women use oral contraceptives before their first pregnancy. The most definitive study to date -- the 2002 Women’s Contraceptive and Reproductive Experiences (CARE) study -- evaluated oral contraceptive use and breast cancer among women ages 35 - 64. The CARE study found that current or former oral contraceptive use did not increase the risk for breast cancer.

Cervical Cancer. Several studies have reported a strong association between cervical cancer and long-term use of oral contraception. Women who have taken oral contraceptives for more than 10 years have a much higher risk of human papilloma virus (HPV) infection (up to four times higher) than those who do not use oral contraceptives. Women taking oral contraceptives for less than 5 years have no significantly higher risk. The reasons for this risk from oral contraceptive use are not entirely clear. Women who use oral contraceptives may be less likely to use a diaphragm, condoms, or other methods that offer some protection against sexual transmitted diseases, including HPV. Some experts also suggest that the hormones in oral contraceptives might facilitate entry of the HPV virus in the genetic material of cervical cells. HPV is the main cause of cervical cancer, as well as genital warts.

Ovarian and Uterine Cancers. Evidence clearly indicates that oral contraceptives reduce the risk of ovarian cancer. The risk decreases by 10 - 12% after 1 year of use and by 50% after 5 years of use. Contraceptives with high levels of progestins may reduce ovarian cancer risk more than contraceptives with low levels of progestins. Oral contraceptives also reduce the risk of uterine (endometrial) cancer. The protective effect of oral contraceptives continues for many years after a woman stops taking the pills.

Click the icon to see an image of cervical cancer.

Other Complications. Other complications have been associated with the use of oral contraceptives:

Taking oral contraceptives containing certain progestins (desogestrel in one study) may increase the risk for periodontal disease. Other types of progestins do not pose a risk for gum disease.
There has been some debate over whether the progestin-only pill increases the risk for permanent type 2 diabetes in women who develop a temporary form of diabetes during pregnancy (called gestational diabetes). In any case, the low-dose combination pill does not appear to pose such a risk. Women with a history of gestational diabetes should discuss this controversy with their doctor.
Some evidence suggests that oral contraceptives may reduce lung capacity during exercise. There have been a few reports of worsening asthma symptoms with oral contraceptives, but this is not common.
The pill can affect the liver and, rarely, has been associated with liver tumors, gallstones, or jaundice. Women with a history of liver disease, such as hepatitis, should consider other contraceptive options.

Interactions with Other Medications. Oral contraceptives can interact with many other medications and herbal supplements.

New methods of administering the combination of progestin and estrogen are now available. Failure rates with perfect use (0.1 - 0.6%) are similar to those with combined oral contraceptives. The recommendations and side effects are the same as those for oral contraceptives. None of these methods protect against sexually transmitted diseases.

Skin Patches. Ortho Evra was approved in 2002 as the first birth control skin patch. It contains a progestin (norelgestromin) and estrogen. The patch is placed on the lower abdomen, buttocks, or upper body (but not on the breasts). Each patch is worn continuously for a week and reapplied on the same day of each week. After three weekly patches, the fourth week is patch-free, which allows menstruation. (The patch remains effective for 9 days, so being slightly late in changing it should not increase the risk for pregnancy.)

In 2005, the Food and Drug Administration warned that the Ortho patch exposes women to higher levels of estrogen than most birth control pills, and therefore may increase the risk for blood clots and other serious side effects. A 2007 study reported that women who use the patch have twice the risk of blood clots as women who use estrogen/norelgestromin oral contraceptives. In contrast, other studies in 2006 and 2007 suggested that the patch and oral contraceptives carry similar blood clot risks. Older women (over age 40) and women with risk factors for blood clots (such as cigarette smoking) may find other birth control products to be a safer choice. Discuss with your doctor whether the patch is appropriate for you.

Vaginal Ring. NuvaRing is a 2-inch flexible ring that contains both estrogen and progestin (etonogestrel). It is inserted into the vagina. Women can insert the ring by themselves once a month and take it out at the end of the third week to allow menstruation. It works well and may cause less irregular bleeding than oral contraceptives. Some women find it uncomfortable, and a few have reported vaginal irritation and discharge, but such problems rarely cause a woman to discontinue use. As with the patch, NuvaRing may put women who take it at higher risk for blood clots than oral contraceptives.

Implant Contraception

Implant contraception involves inserting a rod under the skin. The rod releases into the bloodstream tiny amounts of the hormone progestin.

The first implant was the Norplant system, which used six rods that contained levonorgestrel. Due in part to serious complications, Norplant was withdrawn from the U.S. market in 2002. The main complication was difficulty inserting and, in particular, removing the rods. (Many women experienced scarring.) In addition, some women who used Norplant experienced heavy irregular bleeding. A two-rod implant called Jadelle is sold in other countries, but not the United States.

In 2006, the Food and Drug Administration approved Implanon, a new implant contraceptive. In contrast to Norplant:

Implanon uses one rod, not six.
It is not inserted as deeply into the skin.
It uses etonogestrel, a different type of progestin than the levonorgestrel used in Norplant.
Only specially trained health care providers are allowed to insert and remove Implanon.

Implanon insertion takes about a minute and is performed with a local anesthetic in a doctor’s office. The rod remains in place for 3 years, although it can be removed at any time. (The removal procedure takes a few minutes longer than insertion.) After the rod is removed, a new one can be inserted.

Studies indicate that Implanon is safe. Irregular bleeding is the main side effect. However, some doctors are concerned that Implanon may have some of the same risks as Norplant.

Injected Contraception

Injected contraceptives are given once every 3 months. Most injectables are progestin-only. In the United States, depo-medroxyprogesterone acetate (Depo-Provera) is the only approved injected contraceptive. Depo-Provera (also called Depo, or DMPA) uses a progestin called medroxyprogesterone. Like other progestin contraceptives, Depo-Provera prevents pregnancy by halting ovulation, thickening the cervical mucus, and stopping the implantation of fertilized eggs in the uterine lining.

Depo-Provera is very effective in preventing pregnancies. About 3 in 100 women who use it become pregnant. However, Depo also carries the risk for many mild and serious side effects. The most serious side effect is loss of bone density (see "Disadvantages"). Because of this complication, Depo-Provera should not be used for more than 2 years.

Administering Injections:

A physical examination is necessary before beginning the injections.
Depo is injected into a muscle in the patient's arm or buttock. During months between injections, the hormone slowly diffuses out of the muscle into the bloodstream.
Depo requires an injection by the doctor once every 3 months.
If more than 2 weeks pass beyond the regular injection schedules, the woman should have a pregnancy test before receiving the next injection.

Because Depo-Provera does not contain estrogen, it is safe for many women who are not candidates for combination oral contraceptives, such as women smokers over age 35.

Depo-Provera should not be given to women who have a history of:

Current or past breast cancer
Stroke or blood clots
Liver disease
Epilepsy, migraine, asthma, heart failure, or kidney disease (due to the fact that the drug causes fluid retention)
Unexplained vaginal bleeding
Risk for osteoporosis

Because of the long lag time between ending treatments and restoration of fertility, Depo-Provera is not recommended for women who are thinking of becoming pregnant within 2 years.

Provides highly effective reversible protection against pregnancy without placing heavy demands on the user's time or memory.
Does not increase risk for breast, ovarian, or cervical cancer. May protect against endometrial cancer.
May be useful for women with painful periods, heavy bleeding (including heavy bleeding caused by fibroids), premenstrual syndrome, and endometriosis.

Weight gain. Most women gain an average of 5 - 8 pounds.
Other common side effects include menstrual irregularities (bleeding or cessation of periods), abdominal pain and discomfort, dizziness, headache, fatigue, nervousness.
Most users of Depo-Provera stop menstruating altogether after a year. Depo can cause persistent infertility for up to 22 months after the last injection, although the average is 10 months.
Long-term (more than 2 years) use of Depo-Provera can cause loss of bone density. In November 2004, the Food and Drug Administration (FDA) added a “black box” warning to the Depo-Provera label advising of this risk. The warning notes that the decline in bone density increases with duration of use and may not be completely reversible even after the drug is discontinued. Based on this information, the FDA recommends that Depo-Provera should not be used for longer than 2 years unless other birth control methods are inadequate. A 2005 study of young women (age 14 - 18 years) found that adolescents who stop taking Depo-Provera do regain bone density.
The injections do not provide protection against sexually transmitted diseases. According to a 2004 study, women who take Depo-Provera have three times the risk of acquiring chlamydia and gonorrhea as women who do not use a hormonal contraceptive. The reason for this increased risk is unclear. The same study found that oral contraceptive use, in comparison to non-hormonal contraceptives, was not associated with increased risk.

Intrauterine Devices (IUDs)

The intrauterine device (IUD) is a small plastic T-shaped device that is inserted into the uterus. An IUD's contraceptive action begins as soon as the device is placed in the uterus and stops as soon as it is removed. IUDs have an effectiveness rate of close to 100%. They are also a reversible form of contraception. Once the device is removed, a woman regains her fertility.

The intrauterine device (IUD) is one of the safest, least expensive, and most effective contraceptive devices available. In spite of its clear advantages and current safety record, only 1% of American women currently use the IUD. (Over 10% of European women have chosen the IUD.) This low use in America is mainly due to persisting and now unwarranted fears of serious infection and other complications. However, the evidence available today should reassure providers and patients about the following concerns:

Pelvic infections. What was thought to be an increased risk of pelvic inflammatory disease has proven not to be true. Large groups of patients have been evaluated, and their risk does not seem to be any greater than the risk in the general population The risk for infection may be increased around the time of insertion of the IUD, but routine screening before insertion is generally not recommended There is also no evidence that IUD usage increases the risk of HIV infection.
Infertility. IUDs were thought to cause infertility, mostly because of concerns about infections. However, studies have shown that women with a history of using an IUD are no more likely to be diagnosed with infertility than those who have not used IUDs. This seems to be true for women who have never been pregnant or women who have been pregnant previously.
Ectopic pregnancy. Another concern was a presumed increased risk for an ectopic pregnancy. In reality, women using IUDs have a significantly lower rate of ectopic pregnancies than women using no contraception at all. Even for women who have a history of ectopic pregnancies when not using contraception, the IUD is considered safe and may even lower their risk for another one.

The intrauterine device (IUD) shown uses copper as the active contraceptive, others use progesterone in a plastic device. IUDs are very effective at preventing pregnancy (less than 2% chance per year for the progesterone IUD, less than 1% chance per year for the copper IUD). IUDs come with increased risk of ectopic pregnancy and perforation of the uterus and do not protect against sexually transmitted disease. IUDs are prescribed and placed by health care providers.

Two types of intrauterine devices (IUDs) are available in the United States:

Copper-Releasing (ParaGard). This type of IUD can remain in the uterus for up to 10 years. Cooper ions released by the IUD are toxic to sperm, thus preventing fertilization.
Progestin-Releasing (Mirena). This type of IUD can remain in the uterus for up to 5 years. Mirena is also known as a levonorgestrel-releasing intrauterine system, or LNG-IUS. Levonorgestrel impairs sperm motility and viability, thus preventing fertilization. LNG-IUS is long-acting, safe, very effective in preventing heavy bleeding, and helps reduce cramps. In fact, some experts describe it as a nearly ideal contraceptive. This device is also proving beneficial for women with menstrual disorders, particularly heavy bleeding.

With some exceptions, an intrauterine device (IUD) can be inserted at any time, except during pregnancy or when an infection is present. It may be inserted immediately postpartum or after elective or spontaneous miscarriage. It is typically inserted in the following manner by a trained health professional:

A plastic tube containing the IUD (the inserter) is slid through the cervical canal into the uterus.
A plunger in the tube pushes the IUD into the uterus.
Attached to the base of the IUD are two thin but strong plastic strings. After the instruments are removed, the health care provider cuts the strings so that about an inch of each dangles outside the cervix within the vagina.

The strings have two purposes:

They enable the user or health care provider to check that the IUD is properly positioned. (Because the IUD has a higher rate of expulsion during menstruation, the woman should also check for the strings after each period, especially if she has heavy cramps.)
They are used for pulling the IUD out of the uterus when removal is warranted.

The insertion procedure can be painful and sometimes causes cramps, but for many women it is painless or only slightly uncomfortable. Patients are often advised to take an over-the-counter painkiller ahead of time. They can also ask for a local anesthetic to be applied to the cervix if they are sensitive to pain in that area. Occasionally a woman will feel dizzy or light-headed during insertion. Some women may have cramps and backaches for 1 - 2 days after insertion, and others may suffer cramps and backaches for weeks or months. Over-the-counter painkillers can usually moderate this discomfort.

Intrauterine devices are an excellent choice of contraception for women who are seeking a long-term and effective birth control method, particularly those wishing to avoid risks and side effects of contraceptive hormones. The LNG-IUS may be better suited for women with heavy or regular menstrual flow.

Around the time of insertion and shortly afterwards, women should be considered at low risk for sexually transmitted disease (mutually monogamous relationship, using condoms, or not sexually active).

Women with risk factors that preclude hormonal contraceptives should probably avoid progestin-releasing IUDs, although the progestin doses are much lower with LNG-IUS and probably do not pose the same risks.

Women with the following history or conditions may be poor candidates for IUDs:

Current or recent history of pelvic infection
History of menstrual disorders -- mostly for the copper-releasing IUDs, however
Current pregnancy
Abnormal Pap tests
Cervical or uterine cancer
A very large or very small uterus

IUDs have the following advantages:

The IUD is more effective than oral contraceptives at preventing pregnancy, and it is reversible. Once it is removed, fertility returns. (In spite of outdated concerns, studies have found no adverse effects on fertility with the current IUDs.)
Unlike the pill, there is no daily routine to follow.
Unlike the barrier methods (spermicides, diaphragm, cervical cap, and the male or female condom), there is no insertion procedure to cope with before or during sex.
Intercourse can resume at any time, and, as long as the IUD is properly positioned, neither the user nor her partner typically feels the IUD or its strings during sexual activity.
It is the least expensive form of contraception over the long term.

Additional advantages, depending on the specific IUD, include:

The progestin-releasing LNG-IUS (Mirena) is now considered to be one of the best options for treating menorrhagia (heavy menstrual bleeding). (However, irregular breakthrough bleeding can occur during the first 6 months.) It may even be appropriate and protective for women with uterine fibroids.
The copper-releasing IUDs do not have hormonal side effects and may help protect against endometrial (uterine) cancer.

Menstrual Bleeding. Both intrauterine device (IUD) forms have effects on menstruation, although they differ significantly by type:

Copper releasing IUDs can cause cramps, longer and heavier menstrual periods, and spotting between periods. Prescription medications are available to control the bleeding and pain, which, in any event, usually subside after a few months.
Progestin-releasing IUDs produce irregular bleeding and spotting during the first few months. Bleeding may disappear altogether. (This characteristic is a major advantage for women who suffer from heavy menstrual bleeding but may be perceived as a problem for others.)

Menstrual difficulties can be so troublesome with either IUD that, according to one study, they were responsible for a removal rate of 5 - 15% within a year of insertion.

Ovarian Cysts. The LNG-IUS may increase the risk for ovarian cysts, but such cysts usually do not cause symptoms and resolve on their own.

Expulsion. An estimated 2 - 8% of IUDs are expelled from the uterus within the first year. Expulsion is most likely to occur during the first 3 months after insertion. Expulsion rates may be higher than average if the IUD is inserted immediately after delivery of a child. In 1 in 5 cases, the woman fails to notice that the device is gone, and thus faces the risk of unintended pregnancy. The risk for expulsion is highest during menstruation, so women should be sure to check the strings to make sure the IUD is in place.

Effects on Pregnancy. None of the current IUDs increase the risk for infertility. In the very unlikely event that a woman conceives with an IUD in place, however, there is a higher risk of an ectopic pregnancy or miscarriage.

Click the icon to see an image of an ectopic pregnancy.

If the IUD is removed right after conception, the risk for miscarriage is close to average (about 20%). There is no evidence that the IUD in a pregnant woman increases the risk for birth defects in the infant.

Perforation. A potentially serious complication of the IUD is the accidental perforation of the uterus during insertion or later perforation if the IUD shifts position. Such an occurrence is very rare, and the risk is higher or lower depending on the skill of the doctor.

Spermicidal and Barrier Contraception

Barrier contraceptives are devices that provide a physical barrier between the sperm and the egg. Examples of barrier contraceptives include the male condom, female condom, diaphragm, cervical cap, and sponge. [For a description of the male condom, see "Male Condom."] Barrier devices are the only contraceptive methods that can help prevent sexually transmitted diseases (STDs).

Spermicides are sperm-killing substances available as foams, creams, or gels, and are often used in female contraception with barrier and other devices. Spermicides are usually available without a prescription or medical examination.

The active ingredient in U.S.-made spermicides is usually nonoxynol-9, which attacks the surface of the sperm cell. Nonoxynol-9, however, does not provide any additional protection against sexually-transmitted diseases. Research indicates that frequent use can cause vaginal irritation and abrasions and actually increase the risk for HIV transmission in women. In addition, use of a spermicide with a barrier device doubles or triples the risk for a urinary tract infection in women, regardless of whether the device is a condom or diaphragm. Spermicides are no longer recommended with male condoms. (Non-spermicidal lubricated condoms are safe to use.) Some experts think they are not necessary for use with diaphragms, but this issue is still under debate.

In general, spermicides may be an appropriate choice for women who have intercourse only once in a while, or need backup protection against pregnancy (for instance, if they forget to take their birth control pills). Spermicides should not be used alone as the primary method of birth control. Nor should they be used to prevent sexually transmitted diseases.

The diaphragm, which is generally used with a spermicidal cream, foam, or gel, is a small dome-shaped latex cup with a flexible ring that fits over the cervix. The cup acts as a physical barrier against the entry of sperm into the uterus. The spermicide provides added chemical protection but, as stated above, some doctors think they are not necessary for use with diaphragms.

The diaphragm is a flexible rubber cup that is filled with spermicide and self-inserted over the cervix prior to intercourse. The device is left in place several hours after intercourse. The diaphragm is a prescribed device fitted by a health care professional and is more expensive than other barrier methods, such as condoms.

There are three basic rim designs:

The Arcing Spring diaphragm applies strong pressure and easily flips into place. It is useful for women with weak vaginal muscles and for new users who are worried about incorrect placement.
The Coil Spring Rim is useful for women with strong vaginal muscles.
The Flat Spring Rim has a delicate rim and a gentle spring, and may be appropriate for women who have not had children.

Diaphragms come in different sizes and require a fitting by a trained health care provider. The health care provider also advises and prescribes the correct size of diaphragm for the user. Some women will need to be refitted with a different-sized diaphragm after pregnancy, abdominal or pelvic surgery, or weight loss or gain of 10 pounds or more. As a general rule, diaphragms should be replaced every 1 - 2 years.

Although the diaphragm has a relatively high failure rate, even with perfect use, it is considered a good choice for women whose health or lifestyle prevents them from using more effective hormonal contraceptives. Certain conditions of the vagina and uterus, a history of toxic shock syndrome, or a history of recurrent urinary tract infections, may disqualify a woman from using the device. The diaphragm should not be used if either partner is allergic to latex or spermicides.

Using and Inserting the Diaphragm. The diaphragm can be placed in the vagina up to 1 hour before intercourse and can be used even when a woman is menstruating. The following are general guidelines for insertion:

Before or after each use, the woman should hold the diaphragm up to the light and fill it with water to check for holes, tears, or leaks.
A small amount of spermicide (about 1 tablespoon) is usually placed inside the cup, and some is smeared around the lip of the cup.
The device is then folded in half and inserted into the vagina by hand or with the assistance of a plastic inserter.
The diaphragm should fit over the cervix, blocking entry to the womb.
If more than 6 hours pass before repeat intercourse occurs, the diaphragm is left in place and extra spermicide is inserted into the vagina using an applicator.
The diaphragm must remain in the vagina for 6 - 8 hours after the final act of intercourse, and can safely stay there up to 24 hours after insertion.
The diaphragm should be washed with soap and warm water after each use and then dried and stored in its original container, which should be kept in a cool dry place.

Advantages of the Diaphragm. The diaphragm can be carried in a purse, can be inserted up to an hour before intercourse begins, and usually cannot be felt by either partner. It may protect against cervical gonorrhea, Chlamydia, and trichomoniasis, although more research is needed to confirm this. It does not provide protection against sexually-transmitted infections in areas other than the cervix.

Disadvantages and Complications of the Diaphragm. Some disadvantages or complications are as follows:

Failure rates are high, about 20% with typical use.
Some women dislike having to insert the device every time intercourse occurs or have trouble mastering the insertion and removal process.
Frequent urinary tract infections are a problem for some women. This difficulty can sometimes be resolved by a refitting, by urinating before inserting the device, or by urinating after intercourse.
Cases of toxic shock syndrome have been reported among diaphragm users, but it is very rare. To be safe, the diaphragm should not stay in place for more than 24 hours. (It is still important for pregnancy protection, however, to retain the diaphragm for 6 - 8 hours after intercourse.)
It provides protection against sexually transmitted disease only in the cervix, and women should not rely on it for protection against HIV.

The cervical cap (Prentif, FemCap) is a thimble-shaped latex cup that fits over the cervix. It is always used with a spermicidal cream or gel. It is similar to a diaphragm, but smaller, and is available in only four sizes. The cap is sold by prescription and requires a pelvic examination, Pap test, and fitting by a health care provider.

Insertion and Use of the Cervical Cap. After a small amount of spermicide is placed in the cap, the device is inserted by hand. As in diaphragm use, instruction and practice is required. The cap must be kept in the vagina for 8 hours after the final act of intercourse. Caps wear out and should be replaced every 1 - 2 years. A refitting may also be needed when a woman experiences certain changes in her health or physical status.

Click the icon to see an image of a cervical cap.

Candidacy for the Cervical Cap. Because of the restricted range of available sizes, about 1 in 5 woman will not be able to be fitted for the cap. The cap is not widely used, and some women, particularly those who live in sparsely populated areas, may not have access to health care professionals who are trained in fitting this device. Other conditions that can preclude cap use include:

An abnormal Pap test
A history of toxic shock syndrome
A sexually transmitted or reproductive tract infection
Inflammation of the cervix
The cap has little value for women who have had children, because the stretching of the vagina and cervix makes a proper fit more difficult and failure rates are high.

Advantages of the Cervical Cap. Among women who have never given birth, the cap's failure rate, at least with Prentif cervical cap, is similar to that of the diaphragm. (The FemCap appears to have a higher failure rate.) The cap in general is also similar to the diaphragm in terms of cost, ease of use, protection against sexually transmitted diseases (STDs), and also the potential for latex or spermicidal allergies. But unlike the diaphragm, the cap can safely remain in the vagina for up to 48 hours (twice the time limit for a diaphragm), so it can be inserted well in advance of intercourse. The cap is rarely associated with urinary tract infections, and no documented cases of toxic shock syndrome have been reported.

Disadvantages of the Cervical Cap. The following are disadvantages of the cervical cap:

Failure rate with any cap is high in women who have given birth (40%). In general, the FemCap has a higher risk for failure than either the diaphragm or the Prentif cap.
Unlike the diaphragm, the cap cannot be used during menstruation.
Use of the cervical cap (particularly the Prentif cap) poses a higher risk for abnormal cervical cell growth than with the diaphragm.

The female condom (Reality, Femidom) is a lubricated, loose-fitting pouch that lines the vagina. It is designed to create a physical barrier against sperm and sexually transmitted diseases by surrounding the penis during intercourse. The failure rate for the female condom is about the same as for the diaphragm and cervical cap. It is available without a prescription but may be hard to find.

Use and Insertion of the Female Condom. The female condom is about 3 inches wide and 6 - 7 inches long (larger than a male condom), with a flexible ring at both ends. Current products are made of polyurethane.

The ring at the closed end is used to insert the device into the vagina and hold it in place over the cervix.
The ring at the open end remains outside the vagina and partly covers the labia (lips).

The insertion process may seem difficult at first but becomes much easier with practice:

The female condom is inserted by hand into the vagina up to 8 hours before intercourse. (It should never be used in combination with a male condom.)
Although the female condom is prelubricated, extra lubricant is sometimes needed while inserting the device or during intercourse. (It is not made of latex, so oil lubricants will not harm it.)
During intercourse, the woman checks to be sure that the outer ring is lying flat against her labia and then guides her partner's penis into the ring.

The female condom should be removed in the following circumstances:

If it tears during insertion or use
If the outer ring is pushed inside
If it bunches up inside the vagina

The female condom may be the best option for women at risk for sexually transmitted diseases and who are not certain that their male partner will use a condom. There are virtually no obstacles against its use except a negative psychological perception. It is not completely fail-proof against pregnancy or sexually transmitted diseases.

Advantages of the Female Condom. In one study, 75% of the women preferred the female to the male condom. Many men also find it more appealing than the latex male condom. The female condom has a number of advantages over the male condom:

The female condom is an effective barrier to viruses, including HIV, and other sexually transmitted organism, particularly since it covers a large area, including external genitals. However, there are not enough clinical studies at this time to determine its protection against sexually transmitted diseases. No contraceptive device is foolproof.
The standard female condom is made of polyurethane, which is thin and soft but at the same time 40% stronger than the latex male condoms. Polyurethane is not damaged by lubricating oils, as latex is and is also less likely to cause an allergic reaction. It transmits body heat better than latex, providing a more "natural" sensation, and possibly enhancing the pleasure of the sexual act.
The man does not have to withdraw his penis immediately after ejaculation, as is the case with the male condom, but can, if he wishes, withdraw after he has lost his erection.

Disadvantages and Complications of the Female Condom. Compliance rates are low for many reasons. About 25% of women have difficulty on the first attempt at self-insertion. Some women are distressed by self-insertion. The inner ring may be uncomfortable for some women (in which case it can be removed). Some couples complain that the female condom is unpleasant to look at and can be noisy during intercourse. Without sufficient lubrication, it can also be pushed out of place by the penis. Using more lubricant can help keep the female condom in place and reduce the noise. Female condoms are also expensive, and some women wash them out and reuse them to save money. (In such cases, they should be disinfected first and then washed carefully.) Repeated washings can increase the risk for damage and holes. It is not known how many rewashings are safe.

The sponge (Today, Protectaid) is a disposable form of barrier contraception. It is made of soft polyurethane, is round in shape, and fits over the cervix like a diaphragm, but is smaller and easily portable. In 1994, the popular over-the-counter contraceptive was taken off the U.S. market because of problems at the company's manufacturing facility. A new company has since acquired the rights to manufacture the sponge, and has been selling it in Canada and online since 2003. In April 2005, the Food and Drug Administration granted re-approval for the Today sponge to return to the U.S. market.

Use and Insertion. To use the sponge, the woman first wets it with water, then inserts it into the vagina with a finger, using a cord loop attachment. It can be inserted up to 6 hours before intercourse and should be left in place for at least 6 hours following intercourse. The sponge provides protection for up to 12 hours. It should not be left in for more than 30 hours from time of insertion.

The sponge should not be used during menstruation, after childbirth, miscarriage, or termination of pregnancy, or by women with a history of toxic shock syndrome.

Advantages. Because the sponge is not felt during intercourse and can be inserted up to 6 hours before intercourse, it encourages spontaneity. It appears to protect against cervical gonorrhea and Chlamydia.

Disadvantages. Failure rates (about 10%) are higher than with the diaphragm. There is a very small risk for toxic shock using the sponge, as there is for other barrier methods of contraception. The sponge may increase the risk for candidiasis (yeast infection). People who are allergic to spermicides should not use the sponge. The sponge does not protect against HIV or sexually transmitted diseases outside the cervix. The Today sponge contains 10 times the amount of the spermicide nonoxynol-9 than other products, and there is some evidence that this spermicide may increase the risk for HIV. The Protectaid sponge, available in Canada, contains a mix of three spermicides (nonoxynol-9, sodium cholate and benzal konium chloride).

The Lea shield is made of silicone, and its cup-shaped bowl completely surrounds the cervix without resting on it. The shield does not need to be fitted, and is as effective as the diaphragm and cap when used with spermicide. Its advantages are:

One size fits all
Can be left for 48 hours after intercourse
Reusable for 6 months

The condom is still the only reversible form of male contraception currently available.

Pregnancy Protection. The condom should be put on before intercourse when the penis is erect, long before ejaculation, since the male can discharge sufficient semen to cause pregnancy before ejaculation occurs. The average rate of pregnancy for couples that rely only on condoms for protection is high -- about 12%. In adolescents the risk of pregnancy with condoms is even higher, 18%. Even for those who use a good-quality condom correctly, the annual risk for pregnancy is 3%.

Prevention of Sexually Transmitted Diseases. Condoms are important in the prevention of sexually transmitted disease in both male and female partners, but they have limitations. They are more protective in men against fluid-transmitted infections (gonorrhea, Chlamydia, trichomoniasis, and HIV) than in preventing infections transmitted by skin-to-skin contact (herpes simplex virus, human papilloma virus, syphilis, and chancroid). Male condoms, in fact, offer better protection against herpes for women than they do for men. (Men often shed the virus from the skin of the penis, which is covered by the condom. In women the virus is often shed from areas around their genitals, which can contact male skin outside the condom.)

Some condoms come pre-lubricated with the spermicide nonoxynol-9, which is no longer recommended with condoms because of a higher risk for HIV infection. Its use in male condoms also promotes yeast and urinary tract infections in women. Other condoms come pre-lubricated without spermicide. Lubricants can also be purchased and applied separately. Only water-based lubricants (K-Y Jelly, Astroglide, AquaLube, glycerin) should be used with latex condoms. Do not use petroleum jelly or other oil-based lubricant products as these can damage the condom. In general, it's best to use a pre-lubricated condom or to apply a water-based lubricant. Unlubricated condoms may injure vaginal tissue and make it vulnerable to infections.

Condom Materials.

Latex. Condoms made of latex rubber are the most common types. They are less likely to slip or break than those made of polyurethane, and they are contoured for a better fit that can provide fairly effective protection. Some people are allergic to latex, however, and in some cases the reaction can be very dangerous. The latex smell may also be unpleasant for some people.
Polyurethane. Polyurethane condoms (Avanti, eZ-on) are also available. It is hoped that eventually they will prove to be superior to latex in a number of ways, including strength, sensitivity, and durability. At this point, they have good acceptance by couples but have a higher breakage rate (6 - 7.2%) compared to the latex condom (1.1 - 2%). Other synthetic materials are under investigation.
Animal Membranes. Condoms made from animal membrane (such as lambskin) can prevent pregnancy, but they are permeable and do not protect against sexually transmitted infections.

Natural Family Planning Methods

Natural family planning contraceptive methods do not use medication, physical devices, or surgery to prevent pregnancy. Instead, these cycle-based fertility awareness methods rely on tracking the changes in the body that signal fertility. A woman is only fertile during part of her menstrual cycle. By monitoring certain changes in her body, a woman can more or less predict the fertile phase and abstain from sexual intercourse during that time. She can also use barrier methods if they are not prohibited by religious beliefs. The Roman Catholic Church, for example, generally approves of most natural family planning methods.

Natural family planning methods include:

Basal body temperature
Cervical mucus
Symptothermal
Lactational amenorrhea
Calendar

Basal Body Temperature Method. To determine the most likely time of ovulation and therefore the time of fertility, a woman is instructed to take her body temperature, called her basal body temperature. This is the body's temperature as it rises and falls in accord with hormonal fluctuations.

Each morning before rising, the woman takes her temperature with a specialized basal body thermometer and marks the result on a graph-paper chart.
She also notes the days of menstruation and sexual activity.
The so-called "fertile window" is 6 days long. It starts 5 days before ovulation and ends the day of ovulation.
The chances for fertility are considered to be highest between days 10 - 17 in the menstrual cycle (with day 1 being the first day of the period and ovulation occurring about 2 weeks later). However, one study reported that only 30% of women were fertile within that period of time. In the study, women had a 10% chance of ovulating on each day between day 6 and 21. The researchers suggested that each woman track the length of her cycle, which in the general population of women actually runs 19 - 60 days. A long cycle, for example, suggests a delayed ovulation date.
Immediately after ovulation, the body temperature increases sharply in about 80% of cases. (Some women can be ovulating normally yet not show this temperature pattern.)

By studying the temperature patterns over a few months, couples can begin to anticipate ovulation and plan their sexual activity accordingly. To avoid losing spontaneity, couples should try to avoid becoming fixated on the chart in scheduling their sexual activity.

Cervical Mucus Method. The cervical mucus method (also called the ovulation method) requires a woman to take a sample (by hand) of her cervical mucus every day for a least a month and to record its quantity, appearance, feel, and to note other physical signs connected with the reproductive system. Cervical mucus changes in predictable ways over the course of each menstrual cycle:

Six days before ovulation, mucus is affected by estrogen and becomes clear and elastic. Ovulation is likely to occur the last day that mucus has these properties.
Right after ovulation, mucus is affected by progesterone and is thick, sticky, and opaque.

Once a woman's individual pattern is understood, analyzing cervical mucus can provide a highly accurate guide to fertility.

Symptothermal Method. This method uses both the basal body temperature and cervical mucus methods. In addition, the woman tracks symptoms that may identify her fertile period. These symptoms include changes in the shape of the cervix, breast tenderness, and cramping pain.

Prolonged Breast-feeding (The Lactational Amenorrhea Method). Breast-feeding often delays the onset of ovulation and menstruation for about 6 months. A technique called the Lactational Amenorrhea Method (LAM) allows women to rely on breastfeeding for natural family planning. New mothers are candidates for LAM if their periods have not returned after delivery. They must be breastf-eeding the baby on demand, day and night, without regularly substituting other liquids or foods in the baby's diet.

The risk for pregnancy with this method is less than 2% in the early months, although by 6 months after birth it increases to over 5%. The return of menstruation indicates the return of fertility. Bleeding or spotting during the first 56 days is not considered menstruation. After that, 2 or more consecutive days of bleeding are usually an indicator that periods have returned. Ovulation can occur before menstruation resumes, although it is less likely within 6 months of delivery (particularly if the mother is intensively breast-feeding).

Calendar Method. The calendar (rhythm method) is considered the least reliable of natural family planning methods, with an effectiveness rate of about 87%. Women who have very irregular periods may have even less success with this method. In the calendar method, the woman first keeps a record of her menstrual periods for about 6 - 12 months. She then subtracts 18 days from the shortest and 11 days from the longest of the previous menstrual cycles. For example, if a woman's shortest cycle was 26 days and her longest cycle was 30 days, she must abstain from intercourse from day 8 through day 19 of each cycle.

Because of the high risk for pregnancy, natural family planning methods are recommended only for those whose strong religious beliefs prohibit standard contraceptive methods. Couples who are not guided by religious authority, but who simply want a more natural sexual life, should use a barrier contraceptive during the fertile phase and no contraception during the rest of the cycle. To be effective against pregnancy, cycle-based methods require not only training, commitment, discipline, and perseverance, but also the cooperation of the male partner. Cycle-based methods are not recommended for women unless they are in a stable, monogamous relationship, and can count on their partner's willing participation.

Many couples, especially older ones, who have used these methods for a while and are strongly motivated, are able to successfully incorporate fertility awareness into their lives. For those with strong religious beliefs, natural family planning allows them to have a fulfilling sexual life yet still adhere to the rules of their church.

Couples who adopt a cycle-based approach to pregnancy avoidance must often abstain from sex or substitute other kinds of sexual intimacy for vaginal intercourse. Some couples find this self-denial and the need for vigilant tracking of the cycle difficult and stressful for the relationship. Failure rates are high with natural family planning. The risk for sexually transmitted diseases is also of particular concern, because such methods offer no protection against infection and religious beliefs usually preclude barrier protection.

Emergency Contraception

Emergency contraception is available to prevent pregnancy:

After sexual assault
After consensual intercourse in which contraception is not used
When contraception is used but fails (for instance, when a condom breaks or a diaphragm dislodges)

Emergency contraception, also called the “morning after pill,” uses the hormones found in birth control pills to prevent either fertilization or the implantation of a fertilized egg in the uterine lining. The pill known as Plan B contains progestin. Emergency contraception is usually given as hormone pills within 72 hours of unprotected sex. It is not the same thing as the "abortion pill" [See "mifepristone," below]. Emergency contraception is also sometimes prescribed as an intrauterine device (IUD), which is inserted within 5 days of unprotected sex.

In 2006, the Food and Drug Administration approved the Plan B brand as the first over-the-counter emergency contraception. It is available without a prescription at pharmacies and health clinics for women over age 18. Women will need to present proof of age to purchase it. Girls younger than age 18 will still need a prescription from their doctors.

Emergency Oral Contraception. There is one form of emergency oral contraception:

Plan B uses two doses of the progestin levonorgestrel. In one large study, levonorgestrel prevented pregnancy in 85% of women requiring emergency contraception.

The woman takes her first pill or pills within 72 hours of intercourse and a second dose 12 hours later. The sooner the drug is taken, the more effective it is in preventing pregnancy. Some evidence suggests the pills may be effective up to 5 days after sex, although effectiveness is greater if used within 72 hours. Although these regimens are popularly called morning-after pills, they are actually the same oral contraceptives that users of oral contraceptives take regularly.

Side effects of emergency oral contraception include:

Nausea and vomiting
Fatigue
Headaches
Dizziness
Diarrhea
Breast tenderness
Fluid retention
Changes in the timing or flow of the woman's next menstrual period. A 2006 study found that emergency contraceptive pills (such as Plan B) that contain levonorgestrel may alter the menstrual cycle and the length of periods.

Immediate side effects typically subside within 1 - 2 days of taking the second dose. Family planning experts warn that emergency pill use should not be treated as a substitute for regular contraception.

Copper-Releasing Intrauterine Device. An alternative emergency contraception relies on insertion of a copper-releasing intrauterine device (IUD) within 6 days of intercourse. It can be removed after the woman's next period, or left in place to provide ongoing contraception. The copper IUD reduces the risk of pregnancy by 99.9%.

Female Sterilization

Female surgical sterilization (also called tubal sterilization, tubal ligation, and tubal occlusion) is a low-risk, highly effective one-time procedure that offers lifelong protection against pregnancy. About 700,000 women undergo this procedure each year in the United States.

Female surgical sterilization procedures block the fallopian tubes and thereby prevents sperm from reaching and fertilizing the eggs. The ovaries continue to function normally, but the eggs they release break up and are harmlessly absorbed by the body. Tubal sterilization is performed in a hospital or outpatient clinic under local or general anesthesia.

The uterus is a hollow muscular organ located in the female pelvis between the bladder and rectum. The ovaries produce the eggs that travel through the fallopian tubes. Once the egg has left the ovary it can be fertilized and implant itself in the lining of the uterus. The main function of the uterus is to nourish the developing fetus prior to birth.

Sterilization does not cause menopause. Menstruation continues as before, with usually very little difference in length, regularity, flow, or cramping. (One study suggested that women with a history of Cesarean section may experience slightly heavier bleeding.) Sterilization does not offer protection against sexually transmitted diseases.

Click the icon to see an image of tubal ligation.

Laparoscopy. Laparoscopy is the most common surgical approach for tubal sterilization:

The procedure begins with a tiny incision in the abdomen in or near the navel. The surgeon inserts a narrow viewing scope called a laparoscope through the incision.
A second small incision is made just above the pubic hairline, and a probe is inserted.
Once the tubes are found, the surgeon closes them using different methods: clips, tubal rings, or electrocoagulation (using an electric current to cauterize and destroy a portion of the tube).
Laparoscopy usually takes 20 - 30 minutes and causes minimal scarring. The patient is often able to go home the same day and can resume intercourse as soon as she feels ready.

Click the icon to see an illustrated series detailing tubal ligation.

Minilaparotomy. Minilaparotomy does not use a viewing instrument and requires an abdominal incision, but it is small -- about 2 inches long. The tubes are tied and cut. Generally speaking, minilaparotomy is preferred for women who choose to be sterilized right after childbirth, while laparoscopy is preferred at other times. Minilaparotomy usually takes approximately 30 minutes to perform. Women who undergo minilaparotomy typically need a few days to recover and can resume intercourse after consulting their doctor.

Laparotomy. Laparotomy, a less common approach, requires an extensive 2- to 5-inch incision in the abdomen. It is considered major surgery and can require a hospital stay of a few days followed by recovery at home for several weeks. Resumption of intercourse depends on how quickly one is able to recover.

Culdoscopy. Culdoscopy involves inserting a scope through the vagina and into the pelvic cavity. Although it is less invasive than laparoscopy, a major 2002 analysis reported that it has a higher complication rate than either laparoscopy or minilaparotomy.

Essure. Approved in 2002, the Essure method uses a small spiral-like device to block the fallopian tube. Unlike tubal ligation, the Essure procedure does not require incisions or general anesthesia. It can be performed in a doctor’s office and takes about 45 minutes. A specially trained doctor uses a viewing instrument called a hysteroscope to insert the device through the vagina and into the uterus, and then up into the fallopian tube. Once the device is in place, it expands inside the fallopian tubes. During the next 3 months, scar tissue forms around the device and blocks the tubes. This results in permanent sterilization.

Before undergoing sterilization, a woman must be sure that she no longer wants to bear children and will not want to bear children in the future, even if the circumstances of her life change drastically. She must also be aware of the many effective contraceptive choices available. Possible reasons for choosing female sterilization procedures over reversible forms of contraception include:

Not wanting children and being unable to use other methods of contraception
Health problems that make pregnancy unsafe
Genetic disorders

If married, both partners should completely agree that they no longer want to have children and should also have ruled out vasectomy for the man. Vasectomy is a simple procedure that has a lower failure rate than female surgical sterilization, carries fewer risks, and is less expensive. [See In-Depth Report #37: Vasectomy.]

Even if all these factors are present, a woman must consider her options carefully before proceeding. Studies report that over time, 14 - 25% of women eventually regret this choice. Women at highest risk for regretting sterilization include:

Women who are younger at the time of sterilization. In one long-term study, over 40% of women who had had tubal ligation between the ages of 18 - 24 regretted their choice. (Only about 4% of women over 35 had these regrets.)
Women who had the procedure immediately after a vaginal delivery.
Women who had the procedure within 7 years of having their youngest child.
Women in lower income groups.

If a woman changes her mind and wants to become pregnant, a reversal procedure is available, but it is very difficult to perform and requires an experienced surgeon. Subsequent pregnancy rates after reversal are between 20 - 84%, depending on the surgical skill, the age of the woman, and, to a lesser degree, her weight and the length of time between the tubal ligation and the reversal procedure. Not all insurance carriers cover the cost of reversal.

Women who choose sterilization no longer need to worry about pregnancy or cope with the distractions and possible side effects of contraceptives. Sterilization does not impair sexual desire or pleasure, and many people say that it actually enhances sex by removing the fear of unwanted pregnancy. There is some evidence it may help reduce the risk for ovarian cancer.

Failure is rare, but about 1 in 200 women become pregnant during the first year after sterilization, and failure rate can rise to 5% after 10 years. About a third of these pregnancies are ectopic, which require surgical treatment.
After any of the procedures, a woman may feel tired, dizzy, nauseous, bloated, or gassy, and may have minor abdominal and shoulder pain. In general, there is more postoperative pain with the tubal ring than with electrocoagulation.
Serious complications from female surgical sterilization are rare and are most likely to occur with abdominal procedures. They include bleeding, infection, or reaction to the anesthetic. On rare occasions the bowels or blood vessels are injured and require major surgical repair. The use of electrocoagulation poses a risk for burns in the small intestine and may increase the risk for menstrual disorders afterward.

Resources

www.nichd.nih.gov -- National Institute of Child Health and Human Development
www.plannedparenthood.org -- Planned Parenthood
www.engenderhealth.org -- EngenderHealth
http://ec.princeton.edu -- Emergency Contraception Website
www.acog.org -- American College of Obstetricians and Gynecologists
www.guttmacher.org -- The Alan Guttmacher Institute

References

Archer DF, Jensen JT, Johnson JV, Borisute H, Grubb GS, Constantine GD. Evaluation of a continuous regimen of levonorgestrel/ethinyl estradiol: phase 3 study results. Contraception. 2006 Dec;74(6):439-45. Epub 2006 Sep 18.

Cole JA, Norman H, Doherty M, Walker AM. Venous thromboembolism, myocardial infarction, and stroke among transdermal contraceptive system users. Obstet Gynecol. 2007 Feb;109(2 Pt 1):339-46.

Hannaford PC, Selvaraj S, Elliott AM, Angus V, Iversen L, Lee AJ. Cancer risk among users of oral contraceptives: cohort data from the Royal College of General Practitioner's oral contraception study. BMJ. 2007 Sep 11; [Epub ahead of print]

Jick S, Kaye JA, Li L, Jick H. Further results on the risk of nonfatal venous thromboembolism in users of the contraceptive transdermal patch compared to users of oral contraceptives containing norgestimate and 35 microg of ethinyl estradiol. Contraception. 2007 Jul;76(1):4-7. Epub 2007 May 11.

Jick SS, Kaye JA, Russmann S, Jick H. Risk of nonfatal venous thromboembolism in women using a contraceptive transdermal patch and oral contraceptives containing norgestimate and 35 microg of ethinyl estradiol. Contraception. 2006 Mar;73(3):223-8. Epub 2006 Jan 26.

Jick SS, Kaye JA, Russmann S, Jick H. Risk of nonfatal venous thromboembolism with oral contraceptives containing norgestimate or desogestrel compared with oral contraceptives containing levonorgestrel. Contraception. 2006 Jun;73(6):566-70. Epub 2006 Mar 29.

Kahlenborn C, Modugno F, Potter DM, Severs WB. Oral contraceptive use as a risk factor for premenopausal breast cancer: a meta-analysis. Mayo Clin Proc. 2006 Oct;81(10):1290-302.

MacIsaac L. Intrauterine contraception: the pendulum swings back. Obstet Gynecol Clin North Am. 2007 March;34(1):91-111, ix.

Margolis KL, Adami HO, Luo J, Ye W, Weiderpass E. A prospective study of oral contraceptive use and risk of myocardial infarction among Swedish women. Fertil Steril. 2007 Aug;88(2):310-6. Epub 2007 Jul 10.

Martinez F, Avecilla A. Combined hormonal contraception and venous thromboembolism. Eur J Contracept Reprod Health Care. 2007 Jun;12(2):97-106.

van Vliet HA, Grimes DA, Helmerhorst FM, Schulz KF. Biphasic versus monophasic oral contraceptives for contraception. Cochrane Database Syst Rev. 2006 Jul 19;3:CD002032.

van Vliet HA, Grimes DA, Lopez LM, Schulz KF, Helmerhorst FM. Triphasic versus monophasic oral contraceptives for contraception. Cochrane Database Syst Rev. 2006 Jul 19;3:CD003553.

Review Date:
3/11/2008
Reviewed By:
A.D.A.M. Editorial Team: David Zieve, MD, MHA, Greg Juhn, MTPW, David R. Eltz, Kelli A. Stacy, ELS. Previously reviewed by Harvey Simon, MD, Associate Professor of Medicine, Harvard Medical School; Physician, Massachusetts General Hospital (10/29/2007).

A.D.A.M. Copyright

adam.com

Menstrual disorders

FitSugar — Wed, 08 Oct 2008 17:34:59 -0700

In This Report

Highlights
Introduction
Menstrual Disorders
Causes
Risk Factors
Complications
Diagnosis
Treatment
Medications
Surgery
Resources
References

HEALTH GUIDE REFERENCE FROM A.D.A.M

Highlights

“No-Period” Pill Approved

In May 2007, the FDA approved Lybrel, the first birth control pill that completely eliminates monthly menstrual periods. Lybrel contains low doses of the estrogen estradiol and the progesterone levonorgestrol. The active pills are taken 365 days a year -- with no inactive pill breaks. In clinical trials, 59% of women who took Lybrel completely stopped menstrual periods by the end of the first year. Some women, however, continued to have occasional unscheduled bleeding or spotting during the first 3 - 6 months.

Other Options for Eliminating Menstrual Periods

In addition to Lybrel, women with menstrual problems have several other options for stopping periods:

Levonorgestrol-Releasing Intrauterine System (LNG-IUS). The LNG-IUS is an intrauterine device (IUD) that is placed in the uterus. The LNG-IUS releases levonorgestrol for up to 5 years. Over the course of the first year, it reduces menstrual bleeding. Many women find that their periods completely stop. Doctors often recommend this contraceptive device as a treatment for menorrhagia (heavy bleeding) and an alternative to hysterectomy. In the U.S., the LNG-IUS is marketed as Mirena.
Depo-Provera. Depo-Provera is an injectable progestin contraceptive. Most women who use Depo-Provera stop menstruating after a year. However, Depo-Provera is associated with serious side effects, including loss of bone density. Because of this risk, the FDA recommends that Depo-Provera should not be used for more than 2 years. Weight gain is also a common side effect.
Hysterectomy. Hysterectomy, the surgical removal of the uterus, is a permanent cure for menorrhagia, but it is an invasive procedure that also ends fertility.

Menstruation in Girls and Adolescents

According to a 2006 report from the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists:

Most girls begin to menstruate when they are between 12 - 13 years old.
Menstruation usually starts 2 - 3 years after initial breast development.
Girls who have not begun menstruation by the age of 15 should see a doctor for an evaluation.

Introduction

The Primary Organs and Structures in the Reproductive System.

The uterus is a pear-shaped organ located between the bladder and lower intestine. It consists of two parts, the body and the cervix.
When a woman is not pregnant the body of the uterus is about the size of a fist, with its walls collapsed and flattened against each other. During pregnancy, the walls of the uterus are pushed apart as the fetus grows.
The cervix is the lower portion of the uterus. It has a canal opening into the vagina with an opening called the os, which allows menstrual blood to flow out of the uterus into the vagina.
Leading off each side of the body of the uterus are two tubes known as the fallopian tubes. Near the end of each tube is an ovary.
Ovaries are egg-producing organs that hold 200,000 - 400,000 follicles (from folliculus, meaning "sack" in Latin). These cellular sacks contain the materials needed to produce ripened eggs, or ova.
The inner lining of the uterus is called the endometrium, and during pregnancy it thickens and becomes enriched with blood vessels to house and support the growing fetus. If pregnancy does not occur, the endometrium is shed and a woman starts her menstrual flow (or "period"). Menstrual flow also consists of blood and mucus from the cervix and vagina.

Reproductive Hormones. The hypothalamus (an area in the brain) and the pituitary gland control the reproductive hormones. In women, six hormones help regulate the reproductive system:

Click the icon to see an image of the hypothalamus and pituitary gland.

Gonadotropin-releasing hormone (GnRH) is released by the hypothalamus.
GnRH stimulates the pituitary gland to produce follicle-stimulating hormone (FSH) and luteinizing hormone (LH).
Estrogen, progesterone, and the male hormone testosterone are secreted by the ovaries at the command of FSH and LH.

Click the icon to see an image of the pituitary gland.

Ovulation. The process leading to fertility is very intricate. It depends on the healthy interaction of two sets of organs and hormone systems in both the male and female. In addition, reproduction is limited by the phases of female fertility. Nevertheless, this astonishing process results in conception within a year for about 80% of couples. Only 15% conceive within a month of their first attempts, however, and about 60% succeed after 6 months.

A woman's ability to produce children occurs after she enters puberty and begins to menstruate. The process to conception is complex:

With the start of each menstrual cycle, FSH stimulates several follicles to mature over a two-week period until their eggs nearly triple in size. Only one follicle becomes dominant, however, during a cycle.
FSH signals this dominant follicle to produce estrogen, which enters the bloodstream and reaches the uterus. There, estrogen stimulates the cells in the uterine lining to reproduce, therefore thickening the walls.
Estrogen levels reach their peak around the 14th day of the cycle (counting days beginning with the first day of a period). At that time, they trigger a surge of LH.

LH serves two important roles:

First, the LH surge around the 14th cycle day stimulates ovulation. It does this by causing the dominant follicle to burst and release its egg into one of the two fallopian tubes. Once in the fallopian tube, the egg is in place for fertilization.
Next, LH causes the ruptured follicle to develop into the corpus luteum. The corpus luteum provides a source of estrogen and progesterone during pregnancy.

Fertilization. The so-called "fertile window" is 6 days long and starts 5 days before ovulation and ends the day of ovulation. Fertilization occurs as follows:

The sperm can survive for up to 3 days once it enters the fallopian tube. The egg survives 12 - 24 hours unless it is fertilized by a sperm.
If the egg is fertilized, it moves about 2 - 4 days later from the fallopian tube into the uterus where it is implanted in the uterine lining and begins its nine-month incubation.
The placenta forms at the site of the implantation. The placenta is a thick blanket of blood vessels that nourishes the fertilized egg as it develops.
The corpus luteum (the yellow tissue formed from the ruptured follicle) continues to produce estrogen and progesterone during pregnancy.

Click the icon to see an image of the placenta.

Click the icon to see an image of the corpus luteum.

If the egg is not fertilized, the corpus luteum degenerates into a form called the corpus albicans, and estrogen and progesterone levels drop. Finally, the endometrial lining sloughs off and is shed during menstruation.


Menstrual Phases	Typical No. of Days	Hormonal Actions
Follicular (Proliferative) Phase	Cycle Days 1 through 6: Beginning of menstruation to end of blood flow.	Estrogen and progesterone start out at their lowest levels. FSH levels rise to stimulate maturity of follicles. Ovaries start producing estrogen and levels rise, while progesterone remains low.
	Cycle Days 7 - 13: The endometrium thickens to prepare for the egg implantation.
Ovulation	Cycle Day 14:	Surge in LH. Largest follicle bursts and releases egg into fallopian tube.
Luteal (Secretory) Phase, also known as the Premenstrual Phase	Cycle Days 15 - 28:	Ruptured follicle develops into corpus luteum, which produces progesterone. Progesterone and estrogen stimulate blanket of blood vessels to prepare for egg implantation.
	If fertilization occurs:	Fertilized egg attaches to blanket of blood vessels that supplies nutrients for the developing placenta. Corpus luteum continues to produce estrogen and progesterone.
	If fertilization does not occur:	Corpus luteum deteriorates. Estrogen and progesterone levels drop. The blood vessel lining sloughs off and menstruation begins.

Click the icon to see an animation about the menstrual cycle.

What is Menstruation? Menstruation, also called a "period," is the cyclical flow of blood from the uterus in women between the ages of puberty and menopause.

Onset of Menstruation (Menarche). The onset of menstruation, called the menarche, typically begins between the ages of 12 - 13 years. Menarche generally occurs 2 - 3 years after initial breast development (breast budding). African-American and Hispanic girls tend to mature slightly earlier than Caucasian girls. A higher body mass index (BMI) during childhood is associated with an earlier onset of puberty. Environmental factors and nutrition may also affect menarche timing.

Length of Monthly Cycle. The menstrual cycle can be very irregular during the first 1 - 2 years, ranging from 21 - 45 days. The length then generally stabilizes to an average of 28 days, although the cycle length may range from 21 - 34 days and still be considered normal. A variation of 10 days or more -- either more or fewer days -- may have an impact on fertility, however. The cycle lengthens when a woman is in her 40s, reaching an average of 31 days by age 49. A number of factors can affect cycle length at any age.


Shorter Cycles	Longer Cycles
Regular alcohol use.	Being under 21 and over 44.
Stressful jobs.	Being very thin (also at risk for short bleeding periods).
	Competitive athletics (also at risk for short bleeding periods).

Length of Periods. Periods average 6.6 days in adolescent girls. By the age of 21, menstrual bleeding averages 6 days until women approach menopause. However, about 5% of healthy women menstruate fewer than 4 days and 5% menstruate more than 8 days.

Normal Absence of Menstruation. Normal absence of periods can occur in any woman under the following circumstances:

Menstruation stops during the duration of pregnancy. Some women continue to have irregular bleeding during the first trimester. This bleeding may indicate a threatened miscarriage and requires immediate attention by the doctor.
When women breastfeed they are unlikely to ovulate. After that time, menstruation usually resumes and they are fertile again.
Perimenopause starts when the intervals between periods begin to lengthen, and it ends with menopause itself (the complete cessation of menstruation). Menopause usually occurs at about age 51, although smokers often go through menopause earlier.

Menstrual Disorders

There are a number of different menstrual disorders. Problems can range from heavy, painful periods to no period at all.

Dysmenorrhea is severe, frequent cramping during menstruation. Pain occurs in the lower abdomen but can spread to the lower back and thighs. Dysmenorrhea is usually referred to as primary or secondary.

Primary dysmenorrhea. Cramps occur from contractions in the uterus. These contractions are a normal part of the menstrual process. With primary dysmenorrhea, cramping pain is directly related to and caused by menstruation. About half of menstruating women experience primary dysmenorrhea. It usually begins 2 - 3 years after a women begins to menstruate. The pain typically develops when the bleeding starts and continues for 32 - 48 hours. Cramps are generally most severe during heavy bleeding.

Secondary dysmenorrhea. Secondary dysmenorrhea is menstrually related pain that accompanies another medical or physical condition, such as endometriosis or uterine fibroids.

During a normal menstrual cycle, the average woman loses about 1 ounce (30 mL) of blood. Most women change their tampons or pads around 3 - 6 times per day. Menorrhagia is the medical term for significantly heavier bleeding. Menorrhagia occurs in 9 - 14% of all women and can be caused by a number of factors. Women often overestimate the amount of blood lost during their periods. Clot formation is fairly common during heavy bleeding and is not a cause for concern. However, women should consult their doctor if any of the following occurs:

Soaking through at least one pad or tampon every 1 - 2 hours for several hours
Heavy periods that regularly last 10 or more days
Bleeding between periods or during pregnancy. Spotting or light bleeding between periods is common in girls just starting menstruation and sometimes during ovulation in young adult women, but it is still a good idea to speak with a doctor.

Amenorrhea is the absence of menstruation. There are two categories: primary amenorrhea and secondary amenorrhea. These terms refer to the time when menstruation stops:

Primary amenorrhea occurs when a girl does not begin to menstruate. Girls who show no signs of sexual development (breast development and pubic hair) by age 13 should be evaluated by a doctor. Any girl who does not have her period by age 15 should be evaluated for primary amenorrhea.
Secondary amenorrhea occurs when periods that were previously regular become absent for at least three cycles.

Oligomenorrhea is a condition in which menstrual cycles are infrequent. It is very common in early puberty and does not usually indicate a medical problem. When girls first menstruate they often do not have regular cycles for a couple of years. Even healthy cycles in adult women can vary by a few days from month to month. In some women, periods may occur every 3 weeks and in others, every 5 weeks. Flow also varies and can be heavy or light. Skipping a period and then having a heavy flow may occur; this is most likely due to missed ovulation rather than a miscarriage. Women should be concerned when periods come less than 21 days or more than 3 months apart, or if they last more than 10 days. Such events may indicate ovulation problems.

Premenstrual syndrome (PMS) is a set of physical, emotional, and behavioral symptoms that occur during the last week of the luteal phase (a week before menstruation) in most cycles. The symptoms typically do not start until at least day 13 in the cycle, and resolve within 4 days after bleeding begins. Women may begin to experience premenstrual syndrome symptoms at any time during their reproductive years. Once established, the symptoms tend to remain fairly constant until menopause, although they can vary from cycle to cycle. About 100 symptoms have been identified with the premenstrual phase. [See In-Depth Report #79: Premenstrual syndrome.]

Causes

Menstrual disorders can be triggered by a number of different factors, such as hormone imbalances, genetic factors, clotting disorders, and pelvic diseases.

Contraction-Causing Chemicals. Powerful chemicals known as prostaglandins and arachidonic acid can induce uterine muscle contractions. Prostaglandins also play a large role in the heavy bleeding that causes dysmenorrhea.
Abnormal Nervous System Response. Some women with primary dysmenorrhea may have autonomic nervous systems that are overly sensitive to menstrual cycle changes. The autonomic nervous system regulates heart rate and blood pressure, and it contains the pain receptors in nerve fibers in the uterus and pelvic area. As a result, women with autonomic nervous system abnormalities may have a more intense response to pain.
Abnormalities in the Arteries in the Uterus.Impaired blood flow through the arteries in the uterus may cause severe dysmenorrhea for some women.
Genetic Factors. Genetic factors may play an important role in over half of primary dysmenorrhea cases.
Endometriosis. Endometriosis is a chronic and often progressive disease that develops when the tissue that lines the uterus (endometrium) grows onto other areas, such as the ovaries, bowels, or bladder. [See In-Depth Report #74: Endometriosis.]

Endometriosis is the condition in which the tissue that normally lines the uterus (endometrium) grows on other areas of the body causing pain and irregular bleeding.

Uterine Fibroids. Fibroids are noncancerous growths that grow on the walls of the uterus. They can cause heavy bleeding during menstruation and cramping pain. [See In-Depth Report #73: Uterine fibroids.]
Other Causes. Pelvic inflammatory disease, ovarian cysts, and ectopic pregnancy. The intrauterine device (IUD) contraceptive can also cause dysmenorrhea.

Hormonal imbalances and uterine fibroids are the most common causes of menorrhagia. Other causes of menorrhagia include:

Dysfunctional Uterine Bleeding (DUB). DUB is a general term for abnormal bleeding. It is usually caused by hormonal problems and is one of the primary causes of menorrhagia. DUB usually occurs either when girls begin to menstruate or when women approach menopause, but it can occur at any time in during a woman's reproductive life. About 90% of DUB events occur when ovulation is not occurring (anovulatory DUB). In such cases, women do not properly develop and release a mature egg. When this happens, the corpus luteum does not form. As a result, estrogen is produced continuously, causing an overgrowth of the uterus lining. The period is delayed in such cases, and when it occurs menstruation can be very heavy and prolonged. The other 10% of DUB cases occur in women who are ovulating (ovulatory DUB), but progesterone secretion is prolonged because estrogen levels are low. This causes irregular shedding of the uterine lining and break-through bleeding.
Von Willebrand Disease and Other Bleeding Disorders. Bleeding disorders that stop blood from clotting can cause heavy menstrual bleeding. Most of these disorders have a genetic basis. Von Willebrand disease is the most common of these bleeding disorders and may be underdiagnosed in many women with unexplained menorrhagia.
Abnormal Blood Vessel Growth. Every month, blood vessels regrow in the uterus to replace the blood-rich uterine lining lost during menstruation. Abnormalities in this growth process (called arteriogenesis or angiogenesis) may occur in some women with menorrhagia.
Abnormalities in the Uterus. Structural problems or other abnormalities in the uterus may cause bleeding. They include uterine polyps (small benign growths in the uterus), uterine fibroids, endometriosis, adenomyosis, and miscarriage. Infections or inflammation in the vagina or pelvic area can also cause heavy bleeding.
Medications. Certain drugs, including anticoagulants and anti-inflammatory medications, can cause heavy bleeding.
Cancer. Uterine, ovarian, and cervical cancer can cause excessive bleeding but these are rare causes.
Other Medical Conditions. Systemic lupus erythematosus, diabetes, pelvic inflammatory disorder, and thyroid disorders can cause heavy bleeding. Women who have migraine headaches may be more likely to experience menorrhagia and endometriosis.

Fibroid tumors may not need to be removed if they are not causing pain, bleeding excessively, or growing rapidly.

Normal causes of skipped or irregular periods include pregnancy, breastfeeding, hormonal contraception, and perimenopause. Skipped periods are also common during adolescence, when it may take a while before ovulation occurs regularly. Consistently absent periods may be due to the following factors:

Delayed Puberty. The most common cause of primary amenorrhea is delayed puberty due to some genetic factor that delays physical development.
Weight Loss and Eating Disorders. Extreme weight loss and reduced fat stores lead to hormonal changes that include low thyroid levels (hypothyroidism) and elevated stress hormone levels (hypercortisolism). These changes produce a reduction in reproductive hormones. A syndrome known as the female athlete triad is associated with hormonal changes that occur with eating disorders in young women who excessively exercise. It comprises anorexia (severe weight loss), amenorrhea, and osteoporosis (decrease in bone density).
Polycystic Ovarian Syndrome (PCOS). PCOS is a condition in which the ovaries produce high amounts of androgens (male hormones), particularly testosterone. PCOS occurs in about 6% of women, and amenorrhea or oligomenorrhea (infrequent menses) is quite common. According to some studies, nearly 30% of obese women with PCOS have amenorrhea.
Elevated Prolactin Levels (Hyperprolactinemia). Prolactin is a hormone produced in the pituitary gland that stimulates breast development and milk production in association with pregnancy. High levels of prolactin (hyperprolactinemia) in women who are not pregnant or nursing can reduce gonadotropin hormones and inhibit ovulation, thus causing amenorrhea. It is the cause of between 10 - 40% of cases of secondary amenorrhea.
Premature Ovarian Failure (POF). POF is the early depletion of follicles before age 40. In most cases it leads to premature menopause. POF is a significant cause of infertility.
Structural Problems. In some cases, structure problems or scarring in the uterus may prevent menstrual flow. Inborn genital tract abnormalities may also cause primary amenorrhea. A specific malformation called Mullerian agenesis, in which no vagina or uterus develops, is rare but still causes about 16% of primary amenorrhea cases.
Stress. Physical and emotional stress may block the release of luteinizing hormone, causing temporary amenorrhea
Other Medical Conditions. Epilepsy, thyroid problems, celiac sprue, metabolic syndrome, and Cushing's disease are associated with amenorrhea.

If the ovaries produce too much androgen (hormones such as testosterone) a woman may develop male characteristics. This ovarian imbalance can be caused by tumors in the ovaries or adrenal glands, or polycystic ovarian disease. Virilization may include growth of excess body and facial hair, amenorrhea (loss of menstrual period) and changes in body contour.

Risk Factors

Age plays a key role in menstrual disorders. Girls who start menstruating at age 11 or younger are at higher risk for severe pain, longer periods, and longer menstrual cycles. Between 20 - 90% of teenage girls report menstrual pain and about 15% report that it is severe. Adolescents may experience amenorrhea before their ovulating cycles become regular.

Women who are approaching menopause (perimenopause) may also skip periods. Occasional episodes of heavy bleeding are also common as women approach menopause.

Other risk factors include:

Weight. Being either excessively overweight or underweight can increase the risk for dysmenorrhea and amenorrhea.
Smoking and Alcohol Use. Smokers have a 50% higher risk than nonsmokers for menstrual pain. Alcohol does not cause menstrual pain, but in women with existing dysmenorrhea, alcohol consumption may prolong the pain.
Stress. Physical and emotional stress may block the release of luteinizing hormone, causing temporary amenorrhea. Emotional problems, including history of sexual abuse, may predispose to dysmenorrhea.
Menstrual Cycles and Flow. Longer and heavier menstrual cycles can cause dysmenorrhea.
Pregnancy History. Women who have had a higher number of pregnancies are at increased risk for menorrhagia. Women who have never given birth are at increased risk of dysmenorrhea, while women who first gave birth at a young age are at lower risk.
Chronic Pelvic Pain. Many women experience chronic pain in the pelvic area. This pain can be due to gynecologic reasons (fibroids, endometriosis, pelvic inflammatory disease) or non-gynecologic causes (irritable bowel syndrome, interstitial cystitis, diverticulitis).

Exercise and oral contraceptive use may help protect against dysmenorrhea.

Complications

An estimated 10 - 15% of all women in their reproductive years have chronic gynecologic problems. Nearly 30% of women reporting such problems spend one or more days in bed per year because of them. In fact, menstrual pain is the primary cause of short-term absences in school age girls. In adult women, who have not received treatment, it is an important cause of reduced work productivity.

Menorrhagia is the most common cause of anemia in premenopausal women. A blood loss of more than 80mL per menstrual cycle can trigger anemia. According to one report, 10% of women in their reproductive years have iron deficiencies, and between 2 - 5% have iron levels low enough to cause anemia. Although poor diets play a role in many cases, the problem is compounded in women who have heavy periods.

Most cases of anemia are mild. Nevertheless, even mild anemia can reduce oxygen transport in the blood, causing fatigue and a diminished physical capacity. (Some studies indicate that even iron deficiency without anemia can produce a subtle but still lower capacity for exercise.) Moderate-to-severe iron-deficiency anemia is known to reduce endurance.

Moderate-to-severe anemia can also cause shortness of breath, rapid heart rate, lightheadedness, headaches, ringing in the ears (tinnitus), irritability, pale skin, restless legs syndrome, and mental confusion. Heart problems can occur in prolonged and severe anemia that is not treated. Pregnant women who are anemic, particularly in the first trimester, have an increased risk for a poor pregnancy outcome. [See In-Depth Report #57: Anemia.]

Amenorrhea caused by reduced estrogen levels increases the risk for osteoporosis (loss of bone density). Conditions that are associated with low estrogen levels include eating disorders, the female-athlete triad (excessive exercise and weight loss), pituitary tumors, and premature ovarian failure. Because bone growth is at its peak in adolescence and young adulthood, losing bone density at that time is very dangerous, and early diagnosis and treatment is essential for long-term health. [See In-Depth Report #18: Osteoporosis.]

Osteoporosis is a condition characterized by progressive loss of bone density, thinning of bone tissue, and increased vulnerability to fractures. Osteoporosis may result from disease, dietary or hormonal deficiency, or advanced age. Regular exercise and vitamin and mineral supplements can reduce and even reverse loss of bone density.

Some conditions associated with heavy bleeding, such as ovulation abnormalities, fibroids, or endometriosis, are important contributors to infertility. Many conditions that cause amenorrhea, such as ovulation abnormalities and polycystic ovary syndrome, can also cause infertility. Irregular periods from any cause may make it more difficult to conceive. In some cases treating the underlying condition can restore fertility. In other cases, specific fertility treatments that use assisted reproductive technologies may be beneficial. [See In-Depth Report #22: Infertility in women.]

Diagnosis

A doctor needs to have a complete history of any medical or personal conditions that might be causing menstrual disorders. This information can help determine whether a menstrual problem is caused by another medical condition. For example, non-menstrual conditions that may cause abdominal pain include appendicitis, urinary tract infections, ectopic pregnancy, and irritable bowel syndrome. Endometriosis and fibroids may cause heavy bleeding and pain. Doctors may ask questions concerning:

Menstrual cycle patterns -- length of time between periods, number of days that periods last, number of days of heavy or light bleeding
The presence or history of any medical conditions that might be causing menstrual problems
Any family history of menstrual problems
History of pelvic pain
Regular use of any medications (including vitamins and over-the-counter drugs)
Diet history, including caffeine and alcohol intake
Past or present contraceptive use
Any recent stressful events
Sexual history (it is very important that patients trust their doctor enough to describe any sexual activity that might be risky)

Menstrual Diary. A menstrual diary is a helpful way to keep track of changes in menstrual cycles. Patients can record when their period starts, how long it lasts, and the amount of bleeding and pain that occurs during the course of menstruation.

Pelvic Examination. A pelvic exam is a standard part of diagnosis. A Pap test may be done during this exam.

Blood tests can help rule out other conditions that cause menstrual disorders. For example, a doctor may test thyroid function to make sure that low thyroid (hypothyroidism) is not present. Blood tests can also check follicle-stimulating hormone, estrogen, and prolactin levels. Patients who have menorrhagia may get tests for bleeding disorders. If patients are losing a lot of blood, they should also get tested for anemia.

Patients who have amenorrhea may need to receive special hormonal tests. The progestational challenge test uses oral or injected progesterone to test for a functional uterine lining (endometrium):

Bleeding that occurs up to 3 weeks after the progesterone dose suggests that the woman has normal estrogen levels but is not ovulating, particularly if thyroid and prolactin levels are normal. In such cases, the doctor will check for stress, recent weight loss, and any medications. Such results could also suggest polycystic ovaries or stress.
A failure to bleed could indicate an abnormal uterus that prevents outflow or insufficient estrogen. In such cases, the next step may be to administer estrogen followed by progestin. If bleeding occurs after that, then the cause of amenorrhea is related to low estrogen levels. The doctor will then check for ovarian failure, anorexia, or other causes of low estrogen. If bleeding does not occur, then the doctor would check for obstructions that are preventing outflow of menstruation.

Imaging techniques are often used to detect certain conditions that may be causing menstrual disorders. Imaging can help diagnose fibroids, endometriosis, or structural abnormalities of the reproductive organs.

Ultrasound and Sonohysterography. Ultrasound is the standard imaging technique for evaluating the uterus and ovaries, detecting fibroids, ovarian cysts and tumors, and finding obstructions in the urinary tract. It uses sound waves to produce an image of the organs. Ultrasound carries no risk and causes very little discomfort.

Transvaginal sonohysterography uses ultrasound along with saline injected into the uterus to enhance the visualization of the uterus.

Hysteroscopy. Hysteroscopy is a procedure that may be used to detect the presence of fibroids, polyps, or other causes of bleeding. It may miss cases of uterine cancer, however, and is not a substitute for more invasive procedures, such as D&C or endometrial biopsy, if cancer is suspected.

It is done in the office setting and requires no incisions. The procedure uses a long flexible or rigid tube called a hysteroscope, which is inserted into the vagina and through the cervix to reach the uterus. A fiber optic light source and a tiny camera in the tube allow the doctor to view the cavity. The uterus is filled with saline or carbon dioxide to inflate the cavity and provide better viewing. This can cause cramping.

Hysteroscopy is non-invasive, but 30% of women report severe pain with the procedure. The use of an anesthetic spray such as lidocaine may be highly effective in preventing pain from this procedure. Other complications include excessive fluid absorption, infection, and uterine perforation. Hysteroscopy is also performed as part of surgical procedures.

Laparoscopy. Diagnostic laparoscopy, an invasive surgical procedure, is currently the only definitive method for diagnosing endometriosis. Laparoscopy normally requires a general anesthetic, although the patient can go home the same day. The procedure is as follows:

Click the icon to see an image of laparoscopy.

The surgeon makes tiny abdominal incisions through which a fiber optic tube, equipped with small camera lenses, is inserted. The doctor uses these devices to view the uterus, ovaries, tubes, and peritoneum (lining of the pelvis) on a video monitor.
Carbon dioxide gas is injected into the abdomen, distending it and pushing the bowel away so that the doctor has a wider view.
A blue dye may be flushed through the fallopian tubes to determine blockage; if there is an obstruction, the dye will not flow through the tube.
If the surgeon needs to remove small endometrial cysts or other lesions during the procedure (operative laparoscopy), tiny surgical instruments are passed through a tube.

The procedure is used for detecting and staging endometriosis to determine its severity. In some cases, the procedure itself will restore fertility in women with endometriosis.

Transvaginal Hydrolaparoscopy. Transvaginal hydrolaparoscopy is a new and less invasive approach than laparoscopy, since the instruments are inserted through the vagina, not through incisions in the abdomen. It requires only sedation, does not use CO2 to distend the abdomen, and has a much shorter and easier recovery than with standard laparoscopy. When used by a skilled professional, it is as accurate as laparoscopy, but is not yet widely available.

Endometrial Biopsy With or Without Dilation and Curettage (D&C). When heavy or abnormal bleeding occurs, an endometrial (uterine) biopsy can be performed in the office along with an ultrasound. It is usually used with a procedure called dilation and curettage (D&C), which is particularly important to rule out uterine (endometrial) cancer. A D&C is a somewhat invasive procedure:

A D&C is usually done in an outpatient setting so that the patient can return home the same day, but it sometimes requires a general anesthetic. It may need to be performed in the operating room to rule out serious conditions or treat some minor ones that may be causing the bleeding.
The cervix (the neck of the uterus) is dilated (opened).
The surgeon scrapes the inside lining of the uterus and cervix.

The procedure is used to take samples of the tissue and to relieve heavy bleeding in some instances. D&C can also be effective in scraping off small endometrial polyps, but it is not very useful for most fibroids, which tend to be larger and more firmly attached.

Click the icon to see an image of a D&C.

Treatment

Making dietary adjustments starting about 14 days before a period may help some women with certain mild menstrual disorders, such as cramping. The general guidelines for a healthy diet apply to everyone; they include eating plenty of whole grains, fresh fruits and vegetables, and avoiding saturated fats and commercial junk foods.

Dietary Fats. A 2000 study reported that women who followed a low-fat vegetarian diet for two menstrual cycles experienced less pain and bloating and a shorter duration of premenstrual symptoms than those who ate meat. Women who are losing too much blood, however, may need meat to help maintain iron levels. Choosing more fish and eggs may be a helpful alternative.

More than one study has reported less menstrual pain with a higher intake of omega 3 fatty acids (fat compounds found in oily fish, such as salmon and tuna). In one study, supplements of fish oil also appeared to reduce heavy bleeding in adolescent girls.

Salt Restriction. Limiting salt may help bloating.

Reducing Caffeine, Sugar, and Alcohol. Reducing caffeine, sugar, and alcohol intake may be beneficial. The effects of alcohol are mixed. One study found that women who drank less wine had less menstrual pain than those who drank more wine. Another reported that regular consumption of alcohol lowered the risk for developing cramps, but it actually increased the length of cramping time in certain women. In any case, alcohol is certainly not recommended for relieving menstrual disorders.

Forms of Iron. Women who have heavy menstrual bleeding can sometimes become anemic. Eating iron-rich foods can help prevent anemia. Iron found in foods is either in the form of heme or non-heme iron. Heme iron is better absorbed than non-heme iron.

Foods containing heme iron are the best for increasing or maintaining healthy iron levels. Such foods include (in order of iron-richness) clams, oysters, organ meats, beef, pork, poultry, and fish.
Non-heme iron is less well absorbed. About 60% of iron in meat in non-heme (although meat itself helps absorb non-heme iron). Eggs, dairy products, and iron-containing vegetables only have the non-heme form. Such vegetable products include dried beans and peas, iron-fortified cereals, bread, and pasta products, dark green leafy vegetables (chard, spinach, mustard greens, kale), dried fruits, nuts, and seeds.

The absorption of non-heme iron often depends on the food balances in meals. The following are foods that enhance absorption of non-heme iron:

Meat and fish not only contain heme iron, the best form for maintaining stores, but they also help absorb non-heme iron.
Increasing intake of vitamin C rich foods can enhance absorption of non-heme iron during a single meal. In any case, vitamin C rich foods are healthful and include broccoli, cabbage, citrus fruits, melon, tomatoes, and strawberries. One orange or six ounces of orange juice can double the amount of iron the body absorbs from plant foods. (Taking vitamin C supplements does not appear to have any significant effect on iron stores.)

Exercise may help reduce menstrual pain. It is not clear, however, how intense the exercise should be to reduce dysmenorrhea. For example young female athletes in a 2001 study were only half as likely to suffer from dysmenorrhea as their non-active peers. However, they were also three times more likely to experience an absence of periods. Exercise may be very helpful for women with menstrual pain due to endometriosis. It relieves stress and tension and may reduce hormonal levels that could contribute to endometrial growth.

Sexual Activity. There have been reports that orgasm reduces the severity of menstrual cramps.

Applying Heat. One study found that continuously applying a heated abdominal pad for 12 hours 2 days in a row was as effective in reducing menstrual cramps as ibuprofen (Advil). A warm bath may also be helpful.

Menstrual Hygiene. Tampons should be changed every 4 - 6 hours. Scented pads and tampons should be avoided; feminine deodorants can irritate the genital area. Women should not douche during or between periods. Women who douche on a weekly basis are more likely to contract cervical cancer than those who do not. Douching may destroy the natural bacteria normally present in the vagina. Bathing regularly is sufficient.

Acupuncture and Acupressure. Some studies, including a small well-conducted trial, have reported relief from pelvic pain after acupuncture or acupressure, a technique that applies small pins or pressure to specific points on the body. Some women report relief with reflexology, an acupuncture technique that uses manual pressure on acupuncture points on the ears, hands, and feet.

Yoga and Meditative Techniques. Yoga and meditative techniques that promote relaxation may help relieve menstrual cramps.

Chiropractic. Some women with primary dysmenorrhea have sought help from chiropractors trained in spinal manipulation. One study compared a high-force spinal manipulation technique with a low-force maneuver used as a placebo technique. Both showed lower scores on tests that measure pain, perhaps indicating that a simple back rub by a sympathetic partner or friend may be helpful.

Herbs and Supplements. Studies have not generally found herbal or natural remedies to be any more effective than placebos for reducing menstrual disorders. Natural remedies for menstrual symptoms include:

Evening primrose oil. Evening primrose oil contains a polyunsaturated fatty acid known as gamma linolenic acid. This compound seems to block the release of cytokines and prostaglandins, immune system factors that are manufactured by the endometrium. These factors are involved in uterine muscle contraction and cramping. Foods that contain gamma linolenic acid include black currant oil and cold-water fish.
Omega-3 fatty acids. There is some evidence that the fatty acids found in fish oil have anti-inflammatory properties that may help relieve menstrual cramps. Omega-3 fatty acids are available in supplement pill form, but diets that include cold-water fish (tuna, salmon, mackerel) provide the best source for these nutrients.
Ginger. Ginger tea or capsules may help to relieve nausea and bloating.
Aromatherapy. Aromatherapy with topically-applied lavender, sage, and rose oils may help ease menstrual cramps, according to a small 2006 study.
Pycnogenol. Pycnogenol, an extract from the bark of the French maritime pine tree, may help reduce menstrual pain and discomfort, according to some small studies.

Generally, manufacturers of herbal remedies and dietary supplements do not need FDA approval to sell their products. Just like with drugs, herbs and supplements can affect the body's chemistry, and therefore have the potential to produce side effects that may be harmful. There have been a number of reported cases of serious and even lethal side effects from herbal products. Patients should check with their doctor before using any herbal remedies or dietary supplements.

The following are special concerns for people taking natural remedies for menstrual disorders:

Valerian has been used by some women for menstrual cramps. This herb is listed on the FDA's list of generally safe products. However, its calming effects can be dangerously increased if it is used with sedative drugs. Other interactions and long-term side effects are unknown.
Black cohosh (also known as Cimicifuga racemosa or squawroot) contains a plant estrogen and is the most studied herbal remedy for treating menopausal symptoms, although a 2006 study indicated it is ineffective. Some women also use it for dysmenorrhea. Black cohosh has been used for decades in Germany and appears to be safe, but because its actions resemble estrogen more clinical studies are needed to confirm both long-term safety and effectiveness. Headaches and gastrointestinal problems are common side effects. At this time, experts do not recommend taking it for more than 6 months.

Medications

There are a number of different medicines prescribed for menstrual disorders.

Nonsteroidal Anti-inflammatory Drugs (NSAIDs). Nonsteroidal anti-inflammatory drugs (NSAIDs) block prostaglandins, the substances that increase uterine contractions. They are effective painkillers that also help control the inflammatory factors that may be responsible for heavy menstrual bleeding. Aspirin is the most common NSAID, but there are dozens of others available over the counter or by prescription.

Among the most effective NSAIDs for menstrual disorders are ibuprofen (Advil, Motrin, Midol PMS), naproxen (Aleve, Naprosyn, Naprelan, Anaprox), and mefenamic acid (Ponstel). In a comparison study of ibuprofen and naproxen, both were effective, but the effects of naproxen lasted longer. Naproxen, however, may carry a higher risk for gastrointestinal (GI) effects than ibuprofen. Long-term use of any NSAID can increase the risk for GI bleeding and ulcers. Long-term NSAID use can also increase the risk for heart attack and stroke.

An ulcer is a crater-like lesion on the skin or mucous membrane caused by an inflammatory, infectious, or malignant condition. To avoid irritating an ulcer a person can try eliminating certain substances from their diet such as caffeine, alcohol, aspirin, and avoid smoking. Patients can take certain medicines to suppress the acid in the stomach causing the erosion of the stomach lining. Endoscopic therapy can be used to stop bleeding from the ulcer.

Acetaminophen. Some evidence suggests that acetaminophen (Tylenol) reduces levels of female hormones (gonadotropins and estradiol, an estrogen), which may have some beneficial effect on menstrual disorders. A combination of acetaminophen and pamabrom (Women's Tylenol Menstrual Relief) is specifically aimed at treating menstrual pain and bloating. (Pamabrom is a diuretic, a drug used to reduce fluid build-up and bloating.) One study indicated that acetaminophen is less effective than NSAIDs for dysmenorrhea, but does not have the same potentially harmful effects on the gastrointestinal tract.

Oral contraceptives (OCs), commonly called "the Pill" collectively, contain combinations of an estrogen and a progestin (either a natural progesterone or the synthetic form called progestogen). The estrogen compound used in most combination OCs is estradiol. There are many different progestins, but commonly used types include levonorgestrol, drospirenone, norgestrol, norethindrone, and desogestrel. (Combination contraceptives are also available in other forms, including patches and vaginal rings, but they may increase the risk for menstrual cramping and bleeding.)

Click the icon to see an image of hormone-based contraceptives.

OCs are often used to regulate periods in women with menstrual disorders, including menorrhagia (heavy bleeding), dysmenorrhea (severe pain), and amenorrhea (absence of periods). Oral contraceptives are as effective for treating pain from endometriosis as the more potent gonadotropin releasing hormone agonists. They also protect against ovarian and endometrial cancers.

High-dose OCs have been specifically helpful for adolescents with severe dysmenorrhea. Studies with low-dose OCs have also shown they can reduce menstrual pain for adolescents and adults.

OCs may be taken in cycles that include pills of the same or different strengths. These are categorized as monophasic (one-phase), biphasic (two-phase), or triphasic (three-phase). Monophasic pills contain the same amount of hormones in each dose. Biphasic and triphasic pills contain different dosages of hormones with the pill packs. The monophasic regimen is the most studied regimen and is usually recommended for dysmenorrhea as well as premenstrual symptoms.

Continuous-Dosing OCs. Standard OCs usually come in a 28-pill pack with 21 days of “active” (hormone) pills and 7 days of “inactive” (placebo) pills. Newer “continuous-dosing” (also called “continuous-use”) oral contraceptives aim to reduce -- or even eliminate -- monthly menstrual periods. These OCs contain a combination of estradiol and the progesterone levonorgestrel, but use extending dosing of active pills.

Seasonale, the first continuous-dosing contraceptive, was approved in 2003. It contains 81 days of active pills followed by 7 days of inactive pills. Women who take Seasonale have on average a period every 3 months. Seasonique, a follow-up to Seasonale, was approved in 2006. As with Seasonale, it produces about 4 periods a year. With Seasonique, a woman takes 84 days of levonorgestrol-estradiol pills followed by 7 days of pills that contain only low-dose estradiol.

In 2007, the FDA approved Lybrel, which supplies a daily low dose of levonorgestrol and estradiol with no inactive pills. Because Lybrel contains only active pills, which are taken 365 days a year, it completely eliminates monthly menstrual periods. In clinical trials, 59% of women who took Lybrel completely stopped menstrual periods by the end of the first year. Some women, however, experienced occasional unscheduled bleeding or spotting during the first 3 - 6 months.

Side effects. Common side effects of combination OCs include headache, nausea, bloating, breast tenderness, and bleeding between periods. The estrogen component in combination OCs is usually responsible for these side effects. In general, today’s OCs are much safer than OCs of the past because they contain much lower dosages of estrogen.

However, all OCs can increase the risk for migraine, stroke, heart attack, and blood clots. The risk is highest for women who smoke or who have a history of heart disease risk factors (such as high blood pressure or diabetes) or past cardiac events. Women who have certain metabolic disorders, such as polycystic ovary syndrome (PCOS), are also at higher risk for the heart-related complications associated with these pills.

Progestins (either natural progesterone or synthetic progestogen) are used by women with irregular or skipped periods to restore regular cycles. Because of this, they may also help menstrual pain. They also reduce heavy bleeding and may protect against uterine and ovarian cancers. Progestin-only contraceptives may be a good option for women who are not candidates for estrogen-containing OCs, such as women smokers over the age of 35.

Progestins can be delivered in various forms:

Levonorgestrel-Releasing Intrauterine System (LNG-IUS). An intrauterine device (IUD) that releases progestin can be very beneficial for menstrual disorders, regardless of its contraceptive effects. In the United States, a levonorgestrel-releasing intrauterine system, also called an LNG-IUS, is sold under the brand name Mirena. The LNG-IUS has been proven to reduce heavy bleeding and pain in many women who suffer from menorrhagia and dysmenorrhea. In a 3-year study, the proportion of women with dysmenorrhea using the LNG-IUS dropped from 60% to about 30%. Some studies suggest that the LNG-IUS is more effective than oral contraceptives for controlling heavy menstrual bleeding.

Many experts now recommend the LNG-IUS as a first-line treatment for menorrhagia, particularly for women who may face hysterectomy (removal of uterus), conservative surgery such as endometrial resection (removal of endometrial lining), or endometrial ablation (destruction of endometrial lining). Studies report that about 60% of women with menorrhagia who use the LNG-IUS are able to avoid hysterectomy. Some clinical trials suggest that endometrial resection or ablation may be better at reducing menstrual bleeding than the LNG-IUS. Other studies report that the device is as effective as conservative surgery. Research also indicates that women who choose the LNG-IUS are as satisfied with their quality of life as those who choose surgery.

The LNG-IUS remains in place in the uterus and releases the progestin levonorgestrel for up to 5 years. Progestin released by an IUD mainly affects the uterus and cervix, and so it causes fewer widespread side effects than progestin pills do. (However, the other major IUD -- the Copper T -- may increase bleeding.)

After the LNG-IUS is inserted, heaver periods may occur during the first 3 - 6 months as the lining of the uterus is shed. This shedding may also cause irregular periods and light bleeding (“spotting”) between menstrual cycles. Eventually, the LNG-IUS results in a shorter period, with little or no blood flow. For many women, the LNG-IUS completely stops menstrual periods.

Common side effects include cramping, acne, back pain, breast tenderness, headache, mood changes, and nausea. The LNG-IUS may increase the risk for ovarian cysts, but such cysts usually cause no symptoms and resolve on their own. Women who have a history of pelvic inflammatory disease or who have had a serious pelvic infection should not use the LNG-IUS.

Injections (Depo-Provera). Depo-Provera uses a progestin called medroxyprogesterone. Most women who use Depo-Provera stop menstruating altogether after a year. Depo-Provera may be beneficial for women with heavy bleeding, severe cramps, or both. Women who eventually want to have children should be aware that Depo-Provera can cause persistent infertility for up to 22 months after the last injection, although the average is 10 months.

Weight gain can be a problem, particularly in women who are already overweight. Women should not use Depo-Provera if they have a history of liver disease, blood clots, stroke, or cancer of the reproductive organs.

Long-term (more than 2 years) use of Depo-Provera can cause loss of bone density. In 2004, the FDA added a “black box” warning to the Depo-Provera label advising of this risk. The warning notes that the decline in bone density increases with duration of use and may not be completely reversible even after the drug is discontinued. Based on this information, the FDA recommends that Depo-Provera should not be used for longer than 2 years unless other birth control methods are inadequate. [See In-Depth Report #91: Birth control options for women.]

Gonadotropin releasing hormone (GnRH) agonists are sometimes used to treat menorrhagia. GnRH agonists block the release of the reproductive hormones LH (luteinizing hormone) and FSH (follicular-stimulating hormone). As a result, the ovaries stop ovulating and no longer produce estrogen. GnRH agonists include goserelin (Zoladex), buserelin, a monthly injection of leuprolide (depot Lupron), and a nasal spray, Nafarelin (Synarel). Such drugs may be used alone or in preparation for procedures used to destroy the uterine lining. They are not generally suitable for long-term use.

Commonly reported side effects, which can be severe in some women, include menopausal-like symptoms. These symptoms include hot flashes, night sweats, changes in the vagina, weight change, and depression. The side effects vary in intensity depending on the GnRH agonist. They may be more intense with leuprolide and persist after the drug has been stopped.

The most important concern is possible osteoporosis from estrogen loss. Women ordinarily should not take these drugs for more than 6 months. Certain approaches may preserve enough estrogen to protect bones and still effectively relieve endometriosis symptoms:

Add-back therapy, which provides doses of estrogen and progestin that are high enough to maintain bone density, but are too low to offset the beneficial effects of the GnRH agonist.
Intermittent leuprolide, which uses repeated 6-month courses of GnRH agonists followed by an average of 9 months of symptom control only.
Taking GnRH agonists in very low doses is an alternate approach, but is still largely untested.
Adding a bone-protective drug called a bisphosphonate (alendronate or etidronate) may be helpful.
Other drugs are being tested in combination with a GnRH agonist to preserve bone. They include parathyroid hormone or selective estrogen-receptor modulators (SERMs).

GnRH treatments used alone do not prevent pregnancy. Furthermore, if a woman becomes pregnant during their use, there is some risk for birth defects. Women who are taking GnRH agonists should use non-hormonal birth control methods, such as the diaphragm, cervical cap, or condoms while on the treatments.

Danazol (Danocrine) is a synthetic substance that resembles a male hormone. It suppresses estrogen, and therefore menstruation, and is used (sometimes in combination with an oral contraceptive), to help prevent heavy bleeding. It may also improve surgical success rates in women with menorrhagia when used before ablation or resection to destroy the uterine lining. It is not suitable for long-term use.

Adverse side effects include facial hair, deepening of the voice, weight gain, acne, and dandruff. It may also increase the risk for unhealthy cholesterol levels. Pregnant women or those trying to become pregnant should not take this drug because it may cause birth defects. [See In-Depth Report #74: Endometriosis or In-Depth Report #63: Uterine fibroids.]

Surgery

Women with heavy menstrual bleeding, dysmenorrhea, or both have medical and surgical options available to them. Most procedures eliminate the possibility for childbearing, however. Hysterectomy removes the entire uterus while ablation and resection destroy most or all of uterine lining.

For some women, an intrauterine device (IUD) that releases hormones is proving to be a good medical alternative to surgery. The levonorgestrel-releasing intrauterine system, or LNG-IUS (Mirena), is increasingly being used to treat menorrhagia. Many experts recommend it as a first-line treatment for heavy bleeding. Studies have found the LNG-IUS to work just as well as ablation and resection. Women should be sure to ask their doctors about all medical options before undergoing surgical procedures.

In either standard endometrial resection or ablation, the entire lining of the uterus (the endometrium) is removed or destroyed. The standard endometrial ablation and resection techniques are equally effective in reducing bleeding. In general, either one reduces bleeding by about half. About 15% of women require a hysterectomy later on. Some recent studies report that microwave endometrial ablation may work better than resection, and considerably reduce the need for future hysterectomy. Women should discuss with their surgeon which procedure may be best for them.

Hormonal Pretreatment. Hormonal drugs, such as GnRH analogs or danazol, are sometimes used before the procedures to help prepare the uterus by thinning the endometrial lining. However, a 2005 study suggested that drug preparation may not be required before microwave endometrial ablation.

Postoperative Effects of Endometrial Ablation or Resection Procedures. Postoperative effects of either procedure include the following:

Anesthesia may cause nausea and even vomiting for a few hours following the operation.
Cramping and pain occurs but can usually be relieved using over-the-counter painkillers.
Patients may experience frequent urination for the first day after the procedure and blood-tinged, watery vaginal discharge for more than a month.

Complications of Endometrial Ablation or Resection Procedures. Complications from either procedure may include perforation of the uterus, injury to the intestine, hemorrhage, or infection.

In standard resection and ablation, the uterine cavity is expanded by filling it with fluid. In rare instances, excess glycine from the fluid instilled in the uterus builds up in the bloodstream and causes an abnormal drop in sodium levels. This can be a serious event resulting in mental confusion, convulsions, and, very rarely, death. General anesthesia may pose a lower risk for this complication than local. Some of the newer ablation procedures do not require fluid instillation.

In a 2002 study, 10% of patients who were given standard ablation using the roller ball technique experienced blockage or blood build-up in the fallopian tubes that require a follow-up procedure or a hysterectomy later on.

Resection procedures benefit those women who have very heavy menstrual bleeding but do not have any other underlying uterine problems, such as polyps, hyperplasia of the endometrium, or cancer. Resection also seems to have a higher success rate in reducing bleeding and relieving pain in older women than younger women.

Resection procedures typically involve the following:

The patients are given a local or general anesthesia.
The surgeon dilates (widens) the cervix and fills the uterine cavity with fluid to improve visualization.
The surgeon then removes the uterine lining.

Endometrial ablation involves the destruction of the uterine lining using a number of approaches that include heat, electricity, laser energy, and other methods. The standard ablation approach uses hysteroscopy to allow the doctor to view the uterus.

A typical procedure uses the following approach:

The doctor uses hysteroscopy to view the uterine cavity. This is a fiber optic light source inside a long flexible or rigid tube, which is inserted into the uterus in order to view the cavity. The image of the uterine cavity is transmitted by camera lenses to a video screen.
The uterine cavity is filled with fluid for better visualization. A special substance such as glycine, sorbitol, or mannitol may be added to the fluid so that it does not conduct electricity. This process prevents accidental burns.
With ablation, uterine tissue is usually vaporized using a thin powerful laser beam or high electric voltage. One ablation technique, known as electrocautery with roller ball diathermy, uses a device that looks like a tiny steamroller. This device applies heat and destroys endometrial tissue as it rolls across the uterine lining.
The procedure typically takes 15 - 45 minutes. Although a general anesthetic is usually required, the patient can go home the same day.

It takes about 3 months to determine whether the procedure has been effective. There should be a follow-up appointment about 2 weeks after the procedure. One study revealed 80% of the women were satisfied with ablation. However, this was lower than the 89% satisfaction rate reported by women who had hysterectomy. About 30% of women who have this procedure still require additional surgeries, including hysterectomies, within 5 years. The risk is higher in younger women. The risk for complications increases with repeat ablations.

Newer endometrial ablation techniques (described below) do not use the hysteroscopy. These “second-generation” procedures are technically easier to perform than standard ablation and may be less dependent on the skill of the surgeon. A 2005 review found that second-generation procedures reduce surgery time. Women who had the newer procedures were less likely to experience fluid buildup, perforation of the uterus, cervical cuts and tears, or accumulation of blood in the uterus. However, women did experience more nausea, vomiting, and cramping.

Balloon Endometrial Ablation. Balloon ablation (ThermaChoice in the U.S., Cavaterm in Europe) is proving to be very effective:

A balloon at the tip of a catheter tube is filled with fluid and inflated until it conforms to the walls of the uterus.
A probe in the balloon heats the fluid to destroy the endometrial lining.
After 8 minutes the fluid is drained out and the balloon is removed.

Studies show that bleeding is controlled in 70 - 90% of patients for at least 5 years. It is fast, simple to perform, and comparison studies suggest that it is as effective as resection and standard ablation.

Treatment is less likely to succeed in younger women, those with a tipped uterus, when the uterine lining is 4 mm or thicker, and when menstrual bleeding is prolonged. Pregnancy is possible if some of the lining is maintained, but generally women should not depend on it to preserve fertility.

Electric Wand Ablation. This approach involves inserting a slender wand up through the cervix (the NovaSure System). A triangular mesh-like device is then passed through the wand and expands to fit the uterus. Electrical energy is passed through it for about 90 seconds and the mesh and wand are then withdrawn. As with many other second-generation ablation techniques, it is quick, effective, and does not require pretreatment to expand the uterus. In a 2003 study, it achieved significantly lower bleeding rates than balloon ablation.

Freezing (Cryoablation). With cryoablation (Her Option Uterine Cryoablation Therapy System), the uterine tissue is frozen, which destroys the lining. The procedure takes about 10 minutes to destroy the lining, and it requires no fluid to expand the uterus and little anesthetic. Ultrasound is used to guide the procedure so that the surgeon can view the depth of the ablation. In a 2003 study, cryoablation was slightly less successful than a standard ablation procedure. However, bleeding still declined by 92% with the freezing technique, and quality of life significantly improved.

Hot Saline. Another recently approved technique [Hydro-Therm-Ablator (HTA) system] uses hot saline (salt water) to destroy the lining. It takes about 10 minutes to do this. This is not a "blind" procedure but uses hysteroscopy so that the surgeon can view the uterus.

Laser Ablation. Endometrial laser intrauterine thermotherapy (ELITT) is an ablation technique that does not require either fluid or devices for expanding the uterus or direct contact with the endometrium. This appears to be a very effective approach.

Microwave Endometrial Ablation. Microwave endometrial ablation applies very low-power microwaves to the uterus, which limits tissue destruction only to the lining without causing any unnecessary harm to other tissues. It takes about 3 minutes. Studies report success rates equal to standard ablation and resection procedures.

Until recently, hysterectomy was the only surgical option for uterine fibroids. Other procedures, however, are now available:

Myomectomy. Myomectomy is the surgical removal of only one or more fibroids. Myomectomy usually involves a laparotomy (a procedure that uses a wide abdominal incision) or less invasive surgical techniques, such as laparoscopy and hysteroscopy. In such cases, unlike with hysterectomy, this technique may preserve fertility.
Uterine Artery Embolization (UAE). UAE, also called uterine fibroid embolization (UFE), is a non-surgical radiology procedure. An interventional radiologist injects small plastic particles through a catheter placed in the uterine artery. The particles block the blood supply to the fibroids and cause them to shrink.
Other Procedures. Endometrial ablation (destruction of the lining of the uterus) may be useful in women with small fibroids and heavy bleeding. Myolysis is another procedure best suited for women with specific types of small fibroids. Magnetic resonance-guided focused ultrasound (MRgFUS) is the newest type of fibroid procedure. Myolysis and MRgFUS use heat to cut off the blood supply to fibroids.

Women should discuss each option with their doctor. Deciding on the surgical procedure depends on the location, size, and number of fibroids. Certain procedures affect a women’s fertility and are recommended only for women who are past childbearing age or who do not want to become pregnant. The risk for bleeding increases with the surgeon's inexperience, so patients are urged to investigate the surgeon's track record. [See In-Depth Report #73: Uterine fibroids.]

Hysterectomy is the surgical removal of the uterus and is the second most frequently performed surgery in premenopausal women (Cesarean sections are first). About 600,000 hysterectomies are performed each year in the U.S., which is among the highest rate of all countries. By age 60, about a third of American women have had this procedure. The highest hysterectomy rates are in women age 40 - 44. Women in the southern and midwestern areas of the United States are more likely to have the operation than those in the northeast and west.

Click the icon to see an illustrated series detailing a hysterectomy.

A 2007 study suggested that a combination of factors predicts whether a woman will decide to have a hysterectomy. A woman who meets all three of these factors has a 95% chance of having a hysterectomy:

Presence of symptoms (pelvic pain, bleeding, symptomatic fibroids)
Lack of symptom improvement or resolution despite treatment
Previous use of GnRH agonist drugs

Heavy bleeding, often from fibroids, is the reason for about two-thirds of all hysterectomies. However, in about half of these hysterectomies, no abnormalities are detected to explain the bleeding. In one European study, women with menorrhagia were more likely to choose hysterectomy over conservative treatment if they also had pelvic pain and were inconvenienced by the heavy bleeding. The number of procedures has continued to increase, but the rise has slowed substantially in recent years.

In its support, hysterectomy, unlike medical treatments and less invasive procedures, cures menorrhagia completely, and most women are satisfied with the procedure. Less invasive hysterectomy procedures are also improving recovery rates and increasing satisfaction afterward.

Still, in one study in 70% of cases when doctors recommended hysterectomies, they did not give their patients alternative choices or adequate diagnostic evaluations. Some studies suggest that the levonorgestrel-releasing intrauterine system (Mirena) might help avoid hysterectomy in 80% of cases. Any woman, even one who has reached menopause, uncertain about a recommendation for a hysterectomy for fibroids or heavy bleeding should certainly seek a second opinion.

[See In-Depth Report #73: Uterine fibroids or In-Depth Report #74: Endometriosis.]

Some evidence suggests that surgically cutting the pain-conducting nerve fibers leading from the uterus diminishes the pain from dysmenorrhea. Two procedures, uterine nerve ablation and laparoscopic presacral neurectomy, can block such nerves. Small studies have shown benefits from these procedures, but stronger evidence is needed before they can be recommended for women with severe primary dysmenorrhea.

Laparoscopic Uterosacral Nerve Ablation (LUNA). LUNA is a recent approach that uses either laser or cauterization to destroy nerves in a small segment of the ligaments that connect the cervix with the lower back. The ligaments do not appear to provide any structural support. There are few side effects from the procedure. The patient does not lose any sensations associated with sexual activity.

Laparoscopic Presacral Neurectomy (LPSN). LPSN uses laser techniques to sever a web of nerves between the lower spine and tail bone that transmit pain from the uterus. The procedure does not affect fertility. Studies suggest that it may work better than LUNA in the long term, but it also poses a higher risk of complications. These complications include constipation, diarrhea, and urinary problems. However, many women find that these symptoms eventually improve.

Resources

www.acog.org -- American College of Obstetricians and Gynecologists
www.resolve.org -- National Infertility Association
www.asrm.com -- American Society for Reproductive Medicine
www.endometriosisassn.org -- Endometriosis Association
www.pelvicpain.org -- International Pelvic Pain Society

References

American Academy of Pediatrics Committee on Adolescence; American College of Obstetricians and Gynecologists Committee on Adolescent Health Care; Diaz A, Laufer MR, Breech LL. Menstruation in girls and adolescents: using the menstrual cycle as a vital sign. Pediatrics. 2006 Nov;118(5):2245-50.

Han SH, Hur MH, Buckle J, Choi J, Lee MS. Effect of aromatherapy on symptoms of dysmenorrhea in college students: A randomized placebo-controlled clinical trial. J Altern Complement Med. 2006 Jul-Aug;12(6):535-41.

Learman LA, Kuppermann M, Gates E, Gregorich SE, Lewis J, Washington AE. Predictors of hysterectomy in women with common pelvic problems: a uterine survival analysis. J Am Coll Surg. 2007 Apr;204(4):633-41. Epub 2007 Feb 23.

Review Date:
6/16/2007
Reviewed By:
Harvey Simon, MD, Associate Professor of Medicine, Harvard Medical School; Physician, Massachusetts General Hospital.

A.D.A.M. Copyright

adam.com

Endometriosis

FitSugar — Wed, 08 Oct 2008 17:34:57 -0700

In This Report

Highlights
Introduction
Causes
Symptoms
Risk Factors
Complications
Diagnosis
Treatment
Lifestyle Changes
Medications
Conservative Surgery
Hysterectomy
Resources
References

HEALTH GUIDE REFERENCE FROM A.D.A.M

Highlights

Drug Approval

Women with menstrual pain due to endometriosis have a new treatment option. In May 2007, the FDA approved Lybrel, a continuous-dose oral contraceptive that completely eliminates menstrual periods. Lybrel, which contains low doses of the estrogen estradiol and the progesterone levonorgestrol, is taken 365 days a year with active pills. Some women may, however, experience unscheduled bleeding or spotting.

Endometriosis and Adenomyosis

Women who continue to experience menstrual and pelvic pain after surgery for endometriosis may actually have adenomyosis, suggests a 2006 study in Fertility and Sterility. Adenomyosis occurs when knots of endometrial tissue develop within the muscles of the uterus. With endometriosis, endometrial tissue grows outside of the uterus.

Predictors of Hysterectomy

Three factors combined can predict whether a woman will decide to have a hysterectomy, according to a 2007 study published in the Journal of the American College of Surgeons. Women who met all three criteria had a 95% chance of having a hysterectomy:

Presence of symptoms (pelvic pain, bleeding, symptomatic fibroids)
Lack of symptom improvement despite treatment
Previous use of GnRH agonist drugs

Hysterectomy and Sexual Function

Women who have both their uterus and cervix removed (total hysterectomy) are no more likely to experience sexual problems than women who have only their uterus removed (subtotal hysterectomy), suggests a 2006 review in the Cochrane Database. The review also found no differences between total and subtotal hysterectomy for urinary and bowel problems. However, women who had subtotal hysterectomy were more likely to experience cyclical bleeding during the year after surgery than women who had a total hysterectomy.

Hormone Replacement Therapy (HRT) and Breast Cancer Risk

Estrogen-only HRT after hysterectomy does not increase breast cancer risk in the short term (up to 20 years), according to several 2006 studies. Combination estrogen-progestin HRT does increase breast cancer risk.

Introduction

Endometriosis is a condition in which the cells that line the uterus grow outside of the uterus. The condition can interfere with a woman's fertility and ability to become pregnant. Endometriosis can also cause severe pelvic pain, especially during menstruation.

Endometriosis is a common gynecological condition. It was described in medical literature more than 300 years ago and has since been recognized as a chronic, painful, and often progressive disease in women. However, the causes of endometriosis are unknown, it is widely variable in symptoms and severity, and it is difficult to diagnose. In fact, some experts believe that endometriosis is actually several disorders, not just one.

Endometriosis. Endometriosis occurs when cells from the mucus membrane lining the uterus (endometrium) form implants that attach, grow, and function outside the uterus, generally in the pelvic region. Endometrial implants consist of both following cell types:

Gland cells. These cells secrete hormones and other fluids and are normally located in the uterine lining.
Stroma cells. These are the framework cells that build supportive tissue.

Endometrial cells contain receptors that bind to estrogen and progesterone, which promote uterine growth and thickening. During endometriosis these cells become implanted in organs and structures outside the uterus, where these hormonal activities continue to occur, causing bleeding and scarring.

Endometriosis is the condition in which the tissue that normally lines the uterus (endometrium) grows on other areas of the body, causing pain and irregular bleeding.

Endometrial implants vary widely in size, shape, and color. Over the years, they may diminish in size or disappear, or they may grow.

Early implants are usually very small and look like clear pimples.
If they continue to grow they may form flat injured areas (lesions), small nodules, or cysts called endometriomas, which can range from sizes smaller than a pea to larger than a grapefruit.
Implants also vary in color; they may be colorless, red, or very dark brown. These so-called chocolate cysts are endometriomas filled with thick, old, dark brown blood that usually appear on the ovaries.

Implants can form in many areas, most commonly in the following:

The peritoneum. This is the smooth surface lining that covers the entire wall of the abdomen and folds over inner organs in the pelvic area.
On or next to the ovaries.

Less commonly they occur in other areas:

Cul-de-sac, an area between the uterus and rectum
Connective tissue that supports the uterus (called the uterosacral ligaments)
Vagina
Fallopian tube
Urinary tract (in about 20% of cases, usually without causing symptoms).
Gastrointestinal tract (in 12 - 37% of patients)

Click the icon to see an image of the female reproductive anatomy.

Very rarely, they appear in areas far from the pelvis, including the lungs and even the arms and thighs.

The process of endometriosis mimics menstruation at certain stages:

Each month, the exiled endometrial implants respond to the monthly cycle just as they would in the uterus. They fill with blood, thicken, break down and bleed.
Products of the endometrial process cannot be shed through the vagina as menstrual blood and debris are. Instead, the implants develop into collections of blood that form cysts, spots, or patches.
Lesions may grow or reseed as the cycle continues.

The lesions are not cancerous, but they can develop to the point that they cause obstruction or adhesions (web-like scar tissue) that attach to nearby organs, causing pain, inflammation, and sometimes infertility.

The primary structures in the reproductive system are as follows:

The uterus is a pear-shaped organ located between the bladder and lower intestine. It consists of two parts, the body and the cervix.
When a woman is not pregnant the body of the uterus is about the size of a fist, with its walls collapsed and flattened against each other. During pregnancy the walls of the uterus are pushed apart as the fetus grows.
The cervix is the lower portion of the uterus. It has a canal opening into the vagina with an opening called the os, which allows menstrual blood to flow out of the uterus into the vagina.
Leading off each side of the body of the uterus are two tubes known as the fallopian tubes. Near the end of each tube is an ovary.
Ovaries are egg-producing organs that hold 200,000 - 400,000 follicles (from folliculus, meaning "sack" in Latin). These cellular sacks contain the materials needed to produce ripened eggs, or ova.

The inner lining of the uterus is called the endometrium, and during pregnancy it thickens and becomes enriched with blood vessels to house and support the growing fetus. If pregnancy does not occur, the endometrium is shed as part of the menstrual flow. Menstrual flow also consists of blood and mucus from the cervix and vagina.

Reproductive Hormones. The hypothalamus (an area in the brain) and the pituitary gland regulate the reproductive hormones. The pituitary gland is often referred to as the master gland because of its important role in many vital functions, many of which require hormones. In women, six key hormones serve as chemical messengers that regulate the reproductive system:

The hypothalamus first releases the gonadotropin-releasing hormone (GnRH).
This chemical, in turn, stimulates the pituitary gland to produce follicle-stimulating hormone (FSH) and luteinizing hormone (LH).
Estrogen, progesterone, and the male hormone testosterone are secreted by the ovaries at the command of FSH and LH and complete the hormonal group necessary for reproductive health.

Causes

Endometriosis occurs among women all over the world, but researchers have been unable to determine its cause. A combination of genetic, biologic, and environmental factors appear to work together to trigger the initial process, to produce implantation, and to trigger subsequent reseeding and spreading of the implants.

Retrograde Menstruation. One explanation for the development of endometriosis implants involves retrograde menstruation. This occurs during a woman's period, when menstrual tissue flows backward through the fallopian tubes rather than out through the vagina. Early theorists suggested that, in some cases, the redistributed uterine tissue attached and grew in areas outside the uterus, forming endometriosis implants. This theory does not fully explain endometriosis, however. Many women experience some retrograde menstruation, but not all of them develop endometrial cysts. Consequently, other factors must explain why uterine tissue becomes implanted and grows in areas outside the uterus.

Lymphatic Transport. This theory suggests that endometriosis first develops when uterine tissue is separated and then is transported to other organs by way of the lymphatic system or the bloodstream.

The lymphatic system filters fluid from around cells. It is an important part of the immune system. When people refer to swollen glands in the neck, they are usually referring to swollen lymph nodes. Common areas where lymph nodes can be easily felt, especially if they are enlarged, are: the groin, armpits (axilla), above the clavicle (supraclavicular), in the neck (cervical), and the back of the head just above hairline (occipital).

Environmental Toxins. Other suspects for causing initial development of endometriosis are chemicals called organochlorines, which include dioxins (such as PCBs and furans). These chemicals have estrogen-like effects and are widely found in pesticides and other common products. The organochlorines have a particularly powerful impact on the ovary. Organochlorines have been associated with infertility, certain reproductive cancers, and autoimmune disorders, conditions that also occur with higher frequency in women with endometriosis.

Candida. There is absolutely no evidence that endometriosis is caused by candida (commonly called yeast infection), as claimed in some consumer publications.

There are two basic mysteries surrounding the persistence and growth of endometriosis:

Why do endometrial implants survive the attack by the immune system, which is typically launched against any foreign presence in the body?
How do these endometrial travelers develop new blood vessels and implant themselves in other locations?

Impaired Immune System.Some research is focused on possible immune disorders in women with endometriosis. One theory proposes that women with endometriosis have fewer natural killer (NK) cells, which are factors in the immune system important for surveillance. In their absence, the immune system is weakened and may allow endometrial tissue to invade and take root. A recent study suggests that other types of immune system cells are also underactive in women with endometriosis, allowing the woman's body to tolerate the implanted tissue.

Some evidence suggests that endometriosis represents an autoimmune condition, in which the immune system launches an attack on its own cells and tissue. Much of the evidence rests on the relatively high incidence of other inflammatory autoimmune disorders (multiple sclerosis, rheumatoid arthritis, lupus) that occur in women with endometriosis. It is unclear, however, how this response relates to endometriosis itself and whether endometriosis should be treated as an autoimmune condition.

Growth Factors and Angiogenesis. Macrophages also produce growth factors, which are of particular interest because they play important roles in angiogenesis, a natural process by which new blood vessels form.

Vascular endothelial growth factor (VEGF) is secreted by endometrial cells, and so is of special interest. Under normal conditions, VEGF is secreted within the uterus. When oxygen levels drop following menstruation and blood loss, VEGF levels rise and promote the growth of new blood vessels. This process is important for repairing the uterus following menstruation.

When endometrial cells land outside the uterus, however, investigators theorize that this same process occurs with unfortunate results. The cells secrete VEGF when they are deprived of blood and oxygen, which in turn stimulates blood vessel growth. In this case, however, blood vessel growth serves to promote implantation outside the womb.

Other growth factors involved in angiogenesis that may play a role in endometriosis include transforming growth factors (such as TGF-beta), platelet-derived endothelial growth factor (PD-ECGF), and tumor necrosis growth factors.

Inflammatory Response. The damage, infertility, and pain produced by endometriosis may be due to an overactive response by the immune system to the early presence of endometrial implants. The body, perceiving the implants as hostile, launches an attack. Levels of large white blood cells called macrophages are elevated in endometriosis. Macrophages produce very potent factors, which include cytokines (particularly those known as interleukins) and prostaglandins. Such factors are known to produce inflammation and damage in tissues and cells.

A major study is underway to uncover the genetic factors that predispose certain women to endometriosis. The incidence of endometriosis in women who have a mother or sister with the disorder may be up to 10 times higher than average.

Symptoms

Pain at the time of menstruation (dysmenorrhea ) is the primary symptom and occurs in nearly all girls and women with endometriosis. Studies suggest that endometriosis is the cause of about 15% of cases of pain in the pelvic region in women.

Timing of Pain. In addition to menstruation, endometrial pain can occur at other times of the month. A survey published by the Endometriosis Association reported the following findings on the timing of endometrial pain:

71% of women reported pain within 2 days after their periods started.
47% reported pain in the middle of a cycle. (A sharp pain during ovulation may be due to an endometrial cyst located in the fallopian tube that ruptures as the egg passes through.)
40% reported pain at other times of the month.
20% reported continual pain.
7% said there was no pattern.
Many women with endometriosis experience pain during intercourse.
Adolescents are more likely to experience pain that occurs both during their periods and at other times in the cycle, while in older women endometrial pain is more likely to occur during menstruation.

Location of Pain. Nearly all women with endometrial pain experience it in the pelvic area (the lower part of the trunk of the body). The pain is often a severe cramping that occurs on both sides of the pelvis, radiating to the lower back and rectal area and even down the legs.

Occasionally, however, pain may also occur in other regions if endometriosis affects other part of the pelvic area, such as the bladder or intestine.

Severity of Pain. The severity of the pain also varies widely and does not appear to be related to the extent of the endometriosis itself. In other words, a woman can have very small or few implants and have severe pain, while those with extensive endometriosis may have very few signs of the disorder except for infertility. Large cysts can rupture and cause very severe pain at any time.

Patients may experience additional symptoms, which include the following:

Joint and muscle aches
Fatigue
Bloating
Nausea
Dizziness
Heavy menstrual bleeding
Headaches
Depression and malaise (feeling generally low)
Sleep problems

Risk Factors

Endometriosis affects at least 5.5 million women in North America and millions more worldwide. An estimated 2 - 4% of all premenopausal adult women have detectable endometriosis, and over a third of these women experience noticeable pain. Because many women with endometriosis have no symptoms, the actual percentage of premenopausal women with the disorder may be as high as 15%. Some experts believe endometriosis may be responsible for between 45 - 70% of chronic menstrual pain in adolescence.

Age. Endometriosis can occur in women of all ages. It has been reported in girls as young as age 8 (and has been documented before the onset of menstruation), and in women over age 75, with the average age being between 25 - 29. About 40 - 60% of women with endometriosis report symptoms before age 25.

Ethnic Groups. Endometriosis is most common among Asian women, with Caucasians next. It is reported least frequently in African-American women.

Women at higher risk for endometriosis tend to have more problems with menstruation. Those at higher risk have a shorter than normal cycle, heavier periods, and longer periods. Heavier, more frequent periods, or longer exposure may simply make the risk for retrograde menstruation more likely. (This is the condition in which menstrual flows backward and is believed to be at least partially responsible for the initial development of endometriosis.) Menopause usually brings an end to mild-to-moderate endometriosis, although if women with a history of endometriosis take hormone replacement therapy (HRT), the condition may be reactivated.

Not having children has been associated with a greater risk for endometriosis. Some evidence suggests that early pregnancy may be protective against endometriosis because the cervix becomes dilated during labor, which reduces the risk for retrograde menstruation (menstrual backflow). On the other hand, endometriosis itself can increase the risk for infertility, so it may be a cause rather than a result of not having children. Some studies have found no protection against endometriosis with pregnancy, although women with the condition find relief from symptoms during pregnancy.

Some experts report that almost 7% of first-degree female relatives of endometriosis patients also develop it. A family history of endometriosis not only puts women at high risk for the condition but possibly a more severe manifestation of it as well.

Women may also be at higher risk for endometriosis if they were born with uterine abnormalities that obstruct the normal outflow of blood and cause retrograde menstruation.

There have been reports of endometriosis developing after cesarean sections, including implants developing in surgical scars and in the urinary tract. Some experts believe endometriosis should be suspected in women with urinary tract symptoms and a history of cesarean section.

Various disorders occur in greater rates in women who have endometriosis. In some cases, these disorders and endometriosis may be caused by common factors, but it is not clear what they are.

They include:

Certain cancers, particularly for early-onset breast and ovarian cancers, non-Hodgkin's lymphomas, and melanoma.
Autoimmune diseases such as systemic lupus erythematosus, rheumatoid arthritis, and multiple sclerosis. In all of these diseases, the immune system launches a destructive inflammatory response against the body's own cells (which differ in location depending on the disease). These are uncommon disorders, but in a major 2002 survey of women with endometriosis, they occurred in 12% of these women. This provides some support to the theory that endometriosis, too, is an autoimmune condition.
Hypothyroidism. In the same 2002 survey mentioned above, 42% of women had low thyroid or some other hormonal disorder.
Fibromyalgia and chronic fatigue syndrome. In the same survey, 31% reported one of these conditions.
Diabetes.
Allergies and asthma. Endometriosis is more prevalent in women with a family history of asthma and allergies, including food and skin allergies and hay fever.
Migraine. A small 2006 study suggested that women who have migraine headaches are at increased risk of endometriosis.

Some studies have reported a higher incidence of certain factors in women with endometriosis:

Women with endometriosis tend to be taller and thinner than average.
Women with red hair have an increased risk for endometriosis. Experts guess that the gene determining red hair might be located near other genes that make such women susceptible to endometriosis.

Alcohol and caffeine use have been associated with a higher risk.

Complications

Endometriosis is a chronic disease that is difficult to diagnose and treat. Without treatment, endometriosis gets progressively worse in 65 - 80% of patients. Even with treatment, endometriosis continues to advance in 20% of patients. Cysts and implants may grow and spread to other parts of the pelvis, and in very severe cases, to the urinary or intestinal tracts. Eventually adhesions may form. These are dense, web-like structures of scar tissue that can attach to nearby organs and cause pain, infertility, and intestinal obstruction.

Pain is the most common complaint for women with endometriosis, and it can significantly impair the quality of life. The pain experienced around menstruation can be so debilitating that up to 25% of women with the condition are incapacitated for 2 - 6 days of each month. In severe cases, regular activities may be curtailed for up to 2 weeks per month. Sleeping problems have been reported in 75% of patients, mostly due to pain.

Endometriosis may account for as many as 30% of infertility cases. Some evidence suggests that between 30 - 50% of women with endometriosis are infertile. Often, however, it is difficult to determine if endometriosis is the primary cause of infertility, particularly in women who have mild endometriosis. In an attempt to determine the chances for infertility with endometriosis, researchers have come up with a staging system based on findings during diagnostic surgery.

Endometriosis rarely causes an absolute inability to conceive, but it can contribute to infertility both directly and indirectly.

Direct Effect of Endometrial Cysts. Endometrial cysts may directly prevent infertility in a number of ways:

If implants occur in the fallopian tubes, they may block the egg's passage.
Implants that occur in the ovaries prevent the release of the egg.
Severe endometriosis can eventually form rigid webs of scar tissue (adhesions) between the uterus, ovaries, and fallopian tubes, thereby preventing the transfer of the egg to the tube.

Immune Factors and the Inflammatory Response. Researchers are focusing on defects in the immune system that not only may be responsible for endometriosis in the first place but also may cause the infertility associated with endometriosis. Even in early stage endometriosis, investigators have observed increased immune system activity. It is possible that in such cases, the body perceives these foreign endometrial implants as hostile, and launches an attack.

In this process, the body overproduces specific immune factors that contribute to infertility:

Cytokines. Cytokines are very potent immune factors that, when overproduced, cause damage and inflammation in the very regions that are directed to protect. Such damage could produce scarring and obstructions that interfere with implantation and development of a fertilized egg. In severe endometriosis, there is inflammation in the fluid surrounding the uterus, which could create a hostile environment for the sperm.
Prostaglandins. Elevated levels of these hormone-like factors not only produce inflammation but also increase uterine contractions. (Women with endometriosis have a higher than average risk for miscarriage.)
Other Immune Factors. Growth factors, which stimulate growth of new blood vessels, and toxins produced by implants may impair fertility.

Other Conditions Linking Endometriosis and Infertility. Researchers have noted unusually low levels of specific substances that enable a fertilized egg to adhere to the uterine lining. Such abnormalities are more often a factor in infertility in women with mild-to-moderate endometriosis than in those with severe cases.

One study found that the eggs in women with endometriosis appeared to have more genetic abnormalities than those in women without the disorder.

Implants can also occur in the bladder (although rare) and cause pain and even bleeding during urination. Implants also sometimes form in the intestine and cause painful bowel movements, constipation, or diarrhea. Hormonal treatments, the standard therapies for endometriosis, are not helpful in such cases, and surgery may be needed.

Endometriosis has characteristics that are similar to cancerous tumors, including cellular invasion of other tissues, unrestrained growth, development of new blood vessels, and impaired ability of cells to naturally self-destruct. It is not a malignant disease, however, but experts have been debating for years whether it represents any significant danger.

The possible risks for ovarian and endometrial cancers are of specific concern. Some researchers have identified certain genetic mutations that may transform endometrial cells into ovarian or endometrial cancers in rare cases. Some evidence suggests that ovarian cancer associated with endometriosis may differ from most ovarian cancer cases, and, in fact, have a better outlook.

Of additional concern are studies suggesting that women with endometriosis have a higher risk for other cancers, particularly for early-onset breast cancer and non-Hodgkin's lymphoma (NHL).

The emotional effect of severe endometriosis can be almost as devastating as the pain. It can affect marriage and work. In one survey conducted by the Endometriosis Association, patients reported the following emotional effects from this disease:

84% of patients reported feeling depressed during periods of pain
75% felt irritable
More than 50% reported feelings of anxiety and anger
About 20% said they felt hopeless

In one study, during the days around menstruation 30% of women with endometriosis increased their alcohol intake compared to 14% of women with other gynecological problems and only 9.5% of women with no gynecological disorders.

Diagnosis

Although endometriosis is the most commonly diagnosed uterine disorder, it is often misdiagnosed or missed altogether. In a study of women with proven endometriosis, more than half of them had been told by a doctor that nothing was wrong. In another study, half of women with endometriosis reported that they visited a doctor five or more times before they were diagnosed.

Endometriosis frequently begins to develop in adolescence, but it is not typically diagnosed until a woman is in her mid-20s or early 30s. There are a number of reasons for this:

The symptoms vary widely, and sometimes do not occur at all. Some women do not know they have endometriosis until they fail to become pregnant and seek help for infertility.
Pain in the pelvic or abdominal area can be caused by so many conditions that it is often difficult to pin down the precise cause.

Endometriosis should be highly suspected in women with severe menstrual cramps who are also infertile. Laparoscopy, an invasive diagnostic procedure, is the only definitive method for diagnosing endometriosis. However, a trial using one of several hormonal therapies is usually sufficient to confirm or rule out endometriosis. Such drugs include danazol, GnRH agonists, and progestins.

Many conditions cause pelvic pain. In many cases, the cause is unknown and it often resolves on its own. In one study, pelvic pain improved or resolved without treatment in 77% of women over a 15-month period. However, some causes of pelvic pain can be serious and should be ruled out during a work-up for endometriosis.

Primary Dysmenorrhea. Primary dysmenorrhea is recurrent pelvic pain associated with menstruation. Dysmenorrhea is common in many women. [See In-Depth Report #100: Menstrual disorders.]

Adenomyosis. A condition called adenomyosis occurs when nodules (knots) of endometrial tissue develop within the deep muscle layers of the uterus. This disorder is often classified with endometriosis, but adenomyosis is a different disease. (Endometriosis occurs when endometrial tissue grows and functions outside the uterus.) Adenomyosis is a significant cause of severe pelvic pain and menstrual irregularities. Until recently adenomyosis was diagnosed only after a hysterectomy, but advanced imaging techniques using ultrasound and magnetic resonance imaging scans may be able to detect it. A 2006 study indicated that women who have had surgery for endometriosis, yet continue to suffer from menstrual and pelvic pain, may actually have adenomyosis.

Adenomyosis typically occurs in women who have uterine fibroids, women age 40 - 50, and women who have had children. [See In-Depth Report #73: Uterine fibroids.]

Fibroid tumors may not need to be removed if they are not causing pain, bleeding excessively, or growing rapidly.

Other Causes of Pelvic Pain. Many conditions cause pelvic pain that may or may not be related to menstruation. Some causes of pelvic pain can be serious and should be ruled out:

Uterine fibroids
Pelvic inflammatory disease (which is a result of infections in the pelvic area)
Miscarriage
Ectopic pregnancy

Click the icon to see an image of an ectopic pregnancy.

Pelvic cancer (rare)
Uterine polyps
The use of an intrauterine device (IUD) for contraception

Conditions that may mimic symptoms of endometriosis but which are unrelated to problems in the reproductive organs include:

Severe kidney or urinary tract infections
Celiac disease
Appendicitis
Interstitial cystitis
Inflammatory bowel disease
Diverticulitis
Irritable bowel syndrome

The doctor may be able to feel tender masses or nodules during a pelvic examination, but these signs can indicate many conditions and do not necessarily mean endometriosis is present.

Click the icon to see an image of laparoscopy.

The procedure is as follows:

The surgeon makes tiny abdominal incisions through which a fiber optic tube, equipped with small camera lenses, is inserted. The doctor uses these devices to view the uterus, ovaries, tubes, and peritoneum (lining of the pelvis) on a video monitor.
Carbon dioxide gas is injected into the abdomen, distending it and pushing the bowel away so that the doctor has a wider view.
A blue dye may be flushed through the fallopian tubes to determine blockage; if there is an obstruction, the dye will not flow through the tube.
If the surgeon needs to remove small endometrial cysts or other lesions during the procedure (operative laparoscopy), tiny surgical instruments are passed through a tube.

The procedure is used for detecting and staging endometriosis to determine its severity. In some cases, the procedure itself will restore fertility in women with endometriosis.

Hysteroscopy. Hysteroscopy is a procedure that may be used to detect the presence of fibroids, polyps, or other causes of bleeding. (It may miss cases of uterine cancer, however, and is not substitute for more invasive procedures, such as D&C or endometrial biopsy, if cancer is suspected.)

An ultrasound is performed in cases where other conditions are suspected, such as uterine fibroids, ovarian cysts, or ectopic pregnancy. This non-invasive imaging technique can detect endometriomas, or cysts that are usually located on the ovaries and filled with thick dark blood. Ultrasound can also pick up cysts larger than 1 cm (about 1/3 inch), but will miss smaller cysts, or small and shallow endometrial implants on the surface of ovaries, or on the peritoneum (lining of the pelvis).

Once a diagnosis is made, more sophisticated imaging techniques, such as computed tomography (CT) scanning or magnetic resonance imaging (MRI), may be used to obtain a more accurate image of severe endometriosis.

Investigators are studying certain chemicals detected in blood tests that may prove to help diagnose endometriosis and so avoid invasive diagnostic procedures in many women. Among the most studied to date are CA-125 and CA19-9. Both are elevated in women with severe endometriosis. Higher levels of both chemicals occur in many other diseases, however, including ovarian cancer, so results using this test alone do not provide enough information for a definitive diagnosis of endometriosis.

During laparoscopy, the surgeon determines the number, size, and location of endometrial implants and adhesions. This information helps rank endometriosis by the extent of the disease and give the likelihood of infertility:

Minimal (stage I)
Mild (stage II)
Moderate (stage III)
Severe (stage IV)

A number of experts do not believe these categories are useful, because they often do not relate to the intensity of the pain, or to treatment success rates.

Some experts believe it is more accurate to further categorize endometriosis by the depth of penetration:

Superficial Endometriosis. Endometriosis that lies more on the surface is more highly associated with infertility than deep implants.
Infiltrative Endometriosis. Implants deeper than 5 - 6 mm; deep implants are believed to be the best indicator of progression and severe symptoms.

Treatment

There is no perfect way of managing endometriosis. The three basic treatment approaches are:

Watchful waiting (to relieve symptoms)
Hormonal therapy (to reduce endometrial implants)
Surgery (to reduce endometrial implants, restore fertility, or possibly cure the condition)

The choice depends on a number of factors, including the woman's symptoms, her age, whether fertility is a factor, and the severity of the disease.

In general, watchful waiting is a good initial choice for:

Women with mild pain who, if fertile, do not wish to become pregnant. If women with mild endometriosis wish to become pregnant, the doctor may recommend unprotected sex for 6 months to year. If pregnancy does not occur, then treatment may be started.
Women approaching menopause.

Some experts believe that early diagnosis and treatment in young women without symptoms might prevent some cases of infertility later on. Unfortunately, however, some treatments for endometriosis may actually trigger symptoms in those who do not yet experience them.

Hormone therapies are used to mimic states in which ovulation does not occur (such as pregnancy or menopause) or to directly block ovulation. Hormonal drugs include oral contraceptives, progestins, GnRH agonists, and danazol. They can be very effective in relieving endometriosis symptoms. Some of these drugs may also be used after surgery to help prevent recurrence of endometriosis. There is also some evidence that GnRH agonists and danazol may improve immune factors associated with endometriosis. But there are downsides:

None of these drugs can cure the problem. Symptoms recur in about half of patients within 5 years of treatment.
They do not improve fertility rates and may delay conception in women who use them.
Side effects of these drugs can be distressing. There is a high dropout rate with the use of nearly all these hormonal treatments.
Women who take GnRH agonists, danazol, or similar drugs should use non-hormonal birth control methods (such as the diaphragm, cervical cap, or condoms) because these drugs can increase the risk for birth defects.

Surgery is an option for the following women:

Women with severe pain that does not respond to watchful waiting and medical treatment.
Women who want to become pregnant and endometriosis is most likely the major contributor to infertility.

There are two basic surgical approaches for endometriosis:

Conservative Surgery (Laparoscopy or Laparotomy). Conservative surgery uses laparotomy or laparoscopy to remove the endometriosis implants without removing any other reproductive organs. It is a good option for women who wish to become pregnant or who cannot tolerate hormone therapy. Some experts believe that laparoscopy surgery should be the treatment of choice for women with endometriosis. Endometriosis often recurs after conservative surgery, however. Recurrence rates at 2 years range from 2 - 47%. The risk for recurrence or residual pain after any procedure increases with the severity of the condition, particularly if endometriosis has affected areas outside the uterus.
Radical Surgical Therapy (Hysterectomy). Hysterectomy with removal of ovaries (oophorectomy) along with all endometrial implants is the only potential cure for endometriosis. If endometriosis has developed outside the uterus than even this procedure is not curative. Removing only the uterus with hysterectomy, in any case, has the same risk for recurrence as conservative surgery.

Click the icon to see an illustrated series detailing hysterectomy.

In choosing between hysterectomy (with or without oophorectomy) and conservative surgeries, age and the desire for children are important factors. One study reported a greater sense of loss, more residual symptoms, and more pain in younger women (under age 30) who have undergone hysterectomy than in older women. In one study, 37% of such younger women regretted their decision to have a hysterectomy.

Once careful instruction is given for all the risks and benefits of the different surgical options, the doctor must respect any decision a patient makes to retain as much of her reproductive system as she wants, even if she is past menopause. Both the patient and the doctor should also be clear about the possibility of changing procedures once the operation has begun, depending on what the surgeon may observe. For example, the surgeon may find abnormalities that require more extensive surgery.

Much of the success of any procedure relies on the experience of the surgeon. A woman should always ask for a doctor's track record, or the number of times the doctor has performed the procedure in question. The more, the better. Asking for complication rates may be helpful, but a patient should realize that an experienced surgeon may have a higher number of high-risk patients, and therefore, a higher complication rate than a less experienced surgeon with fewer serious cases.

For women with severe endometriosis who want to become pregnant, conservative surgery (typically laparoscopy) is the appropriate approach for restoring fertility. Hormonal therapies that treat endometriosis itself, such as GnRH agonist or progestins, are generally considered not to help fertility. However, a 2002 study suggested that the use of the GnRH agonists after surgery helped improve conception rates in women who subsequently undergo assisted reproductive techniques (ART), such as in vitro fertilization (IVF). A 2006 study indicated that GnRH agonists given along with infertility treatments may help improve a woman's chance of becoming pregnant. This research is still preliminary.

In any case, ART and hyperstimulation of the ovary using fertility drugs to produce eggs are the standard fertility treatments available to women if surgery fails. ART includes techniques such as in vitro fertilization (IVF) and intracytoplasmic sperm injection (ICSI). Hyperstimulation is the less expensive approach. In a 2003 study, however, ART achieved much greater conception rates in women with endometriosis, particularly those with late-stage disease.

It is not clear whether women with early -stage endometriosis do any better with fertility treatment than simply trying to become pregnant through non-aggressive means. Women with endometriosis who are trying to conceive should discuss all treatment options with a specialist. [See In-Depth Report #22: Infertility in women.]

Lifestyle Changes

Some women report relief by avoiding dairy products and having a diet rich in fiber and low in saturated (animal) fats. Fiber-rich foods (such as fruits and vegetables) along with plenty of fluids (water or juice, not caffeine) are not only healthy but help prevent constipation, which can intensify symptoms. If women choose a diet that limits dairy products, they should be sure to have sufficient calcium from other sources.

A 2005 study involving over 500 women reported that red meat and ham consumption increased the risk for endometriosis. Diets high in green vegetables and fresh fruit appeared to protect against it.

Fat compounds called omega-3 fatty acids may have specific anti-inflammatory effects. They are found in certain oily fish (sardines, mackerel) and can be obtained in supplements. Supplements may be labeled either omega-3 fatty acids or EPA-DHA (which are the important compounds). Evening primrose oil and black currant oil, found in health food stores, contain similar fatty acids that may be helpful. However, food sources are the healthier choice.

Omega-3 fatty acids, found plentifully in oily fish and flaxseed and canola oils, are beneficial to people who have IBD (inflammatory bowel disease).

Drinking alcohol and and smoking cigarettes may increase endometriosis risk. It is unclear whether caffeine is a significant risk factor.

A sitz bath is simply sitting in a basin of water. Some people report relief by alternating between sitting 3 minutes in a hot water basin and then 1 minute in a cold water basin. This is repeated three times. The procedure is performed twice a day 3 - 4 days a week, except during menstruation.

A warm bath or application of heated abdominal pad may help relieve painful menstrual cramps.

Kegel exercises are designed to strengthen the muscles of the pelvic floor that both support the bladder and close the sphincters. Some people find they help endometriosis. The exercises consist of tightening and releasing the pelvic muscle. Since the muscle is internal and sometimes difficult to isolate, doctors often recommend practicing while urinating on the toilet. The patient tries to contract the muscle until the flow of urine is slowed or stopped and then releases it. (However, once learned, Kegel exercises should not be regularly performed while urinating as this practice may eventually weaken the muscles.)

Exercise may be very helpful for women with endometriosis. It relieves stress and tension and may reduce hormonal levels that can contribute to endometrial growth.

Acupuncture and Acupressure. Some studies have reported relief from pelvic pain after acupuncture or acupressure, a technique that applies small pins or pressure to specific points on the body. Some women report relief with reflexology, a technique that uses manual pressure on acupuncture points on the ears, hands, and feet.

Click the icon to see an image of acupuncture.

Transcutaneous Electrical Nerve Stimulation. Transcutaneous electric nerve stimulation (TENS) applies electrodes to certain parts of the body and administers low-level electrical pulses to those locations. Research suggests that it works by altering the body's ability to receive pain signals. The standard approach is to give 80 - 100 pulses per second, for 45 minutes, three times a day. TENS is painless and patients are barely aware of the sensation. A 2002 analysis suggested that this approach may help some women with dysmenorrhea.

Yoga and Meditative Techniques. Yoga and meditative techniques that promote relaxation may also be helpful for menstrual cramps.

Herbal and Other So-Called Natural Remedies for Cramp Relief. Researchers have not conducted many rigorous studies on herbal remedies for menstrual and pelvic pain. Small studies have suggested that pycnogenol, a plant extract derived from the bark of the French maritime pine tree, may help reduce endometriosis symptoms. Some patients have reported relief from menstrual cramps with aromatherapy using lavender, sage, and rose oils.

Generally, manufacturers of herbal remedies and dietary supplements do not need FDA approval to sell their products. Just like a drug, herbs and supplements can affect the body's chemistry, and therefore have the potential to produce side effects that may be harmful. There have been a number of reported cases of serious and even lethal side effects from herbal products. Always check with your doctor before using any herbal remedies or dietary supplements.

Medications

The basic approach in hormonal treatments for endometriosis is to block production of female hormones (estrogen and progesterone) or to prevent ovulation. Hormonal drugs are used for pain relief only. None have been proven to improve fertility rates and in some cases may delay conception. Specific hormonal drugs may have different effects for women with endometriosis.

Inducing Pseudopregnancy. Oral contraceptives that contain estrogen and progestins mimic a pregnant state and block ovulation. (Progestins are natural or synthetic forms of progesterone). Progestins may also be used alone, since they have specific effects that can cause the endometrial tissue itself to atrophy.
Inducing Pseudomenopause. Gonadotropin-releasing hormone (GnRH) agonists or gestrinone, an anti-progesterone that mimic menopause. They reduce estrogen and progesterone to their lowest level.
Inducing On-going Blockage of Ovulation. Danazol, a derivative of male hormones, is a powerful ovulation blocker.

Studies report that around 80% of women achieve pain relief after taking these drugs. To date, comparison studies have found few differences in effectiveness among the major hormonal treatments. Differences occur mostly in their side effects. Women should discuss the effects of particular medications with their doctors to determine the best choice.

Oral contraceptives (OCs), commonly called "the Pill," contain combinations of an estrogen and a progestin (either a natural progesterone or the synthetic form called progestin). For some patients, OCs may provide better endometriosis pain relief than gonadotropin releasing hormone agonist drugs. OCs may reduce the risk of ovarian cancer by 30 - 50% and of endometrial cancer by 50%, a potentially important benefit in women with endometriosis. Patch contraceptives are available, but they may increase the risk for menstrual cramping.

Click the icon to see an illustrated series detailing the birth control pill.

When used throughout a menstrual cycle, OCs suppress the actions of other reproductive hormones (luteinizing hormone, or LH, and follicle stimulating hormone, or FSH) and prevent ovulation. There are many brands available. The estrogen compound used in most oral contraceptives is estradiol. Many different progestins are used, and there are many brands. None to date have proven to be superior over others. Women should discuss the best options for their individual situations with their doctor.

Standard OCs come in a 28-pill pack that contains 21 active pills and 7 inactive pills. Newer “continuous-dosing” (also called “continuous-use”) oral contraceptives aim to reduce -- or even eliminate -- monthly periods and thereby prevent the pain and discomfort that often accompanies menstruation. These OCs contain a combination of estradiol and the progesterone levonorgestrel, but use extending dosing of active pills.

Seasonale, the first continuous-dosing contraceptive, was approved in 2003. It contains 81 days of active pills followed by 7 days of inactive pills. Women who take Seasonale have on average a period every 3 months. Seasonique, a follow-up to Seasonale, was approved in 2006. As with Seasonale, it produces about 4 periods a year. With Seasonique, a woman takes 84 days of levonorgestrol-estradiol pills followed by 7 days of pills that contain only low-dose estradiol.

In 2007, the FDA approved Lybrel, which supplies a daily low dose of levonorgestrel and estradiol with no inactive pills. Because Lybrel contains only active pills, which are taken 365 days a year, it completely eliminates monthly menstrual periods. In clinical trials, 59% of women who took Lybrel completely stopped menstrual periods by the end of the first year. Some women, however, experienced occasional unscheduled bleeding or spotting during the first 3 - 6 months.

Estrogen and progestin each cause different side effects. The most serious side effects are due to the estrogen in the combined pill. Uncommon but more dangerous complications of OCs include high blood pressure and deep-vein blood clots (thrombosis), which may contribute to heart attack or stroke. Studies have been conflicting about whether estrogen in oral contraception increases the chances for breast cancer and, if it does, which women are at risk.

Progestins alone may be helpful and are the oldest drugs used for endometriosis. Progestins can prevent ovulation and reduce the risk for endometriosis in the following ways:

They block luteinizing hormone (LH), one of the reproductive hormones important in ovulation.
They change the lining of the uterus and eventually cause it to atrophy.
They may provide pain relief equivalent to the more powerful hormone drugs. Some experts recommend them as the first choice for women with endometriosis who do not want to become pregnant.

Specific Progestins. Progestins are available in pill or injectable form, or as a progestin-releasing intrauterine device (IUD). Medroxyprogesterone (Depo-Provera), which is administered by injection every 3 months, is one of the standard progestins used. A new low-dose formulation, Depo-subQ Provera 104, was approved in 2005. Oral progestins include norethindrone (Micronor, Aygestin, Norlutate). Norethindrone is also known as norethisterone.

A 2006 study compared low-dose depot medroxyprogesterone with the gonadotropin releasing hormone (GnRH) agonist leuprolide (Lupron). The two drugs worked equally well in controlling endometriosis pain. However, leuprolide caused more loss of bone mineral density, a condition associated with osteoporosis. Patients who received medroxyprogesterone injections had fewer hot flashes than those who received leuprolide, but they had more episodes of bleeding and spotting.

Progestin-releasing IUDs can be very helpful for many women with endometriosis, particularly an advanced version called the levonorgestrel-releasing intrauterine system, or LNG-IUS (Mirena). Studies suggest that the LNG-IUS reduces endometrial cell proliferation and increases cell self-destruction. Progestin released by the IUD mainly affects the uterus and cervix and causes fewer widespread side effects than other forms of progestins.

The LNG-IUS has proved effective for heavy bleeding (menorrhagia), and studies indicate that it helps control the symptoms of minimal-to-moderate endometriosis. Studies indicate that the LNG-IUS works as well as GnRH agonists in managing endometriosis pain, and causes less loss of estrogen. Some experts think that the LNG-IUS could become the treatment of choice for women with endometriosis pelvic pain who do not wish to become pregnant.

Click the icon to see an image of an IUD.

Side Effects of Progestins. Side effects of progestin occur in both the combination oral contraceptives and any contraceptive that uses only progestin, although they may be less or more severe depending on the form and dosage of the contraceptive. Side effects may include:

Changes in uterine bleeding, such as higher amounts during periods, spotting and bleeding between periods (called break-through bleeding), or absence of periods
Unexpected flow of breast milk
Abdominal pain or cramps
Diarrhea
Fatigue, unusual tiredness, weakness
Hot flashes
Decreased sex drive
Nausea
Trouble sleeping
Acne or skin rash (although low-dose OCs actually improve acne)
Depression, irritability, or other mood changes
Swelling in the face, ankles, or feet
Weight gain

Newer formulations of combination pills that use low-dose estrogen and newer progestins may reduce and even avoid many of these side effects. Progestins used in non-oral contraceptives, such as the LNG-IUS IUD, also may not pose as high a risk for these side effects. If side effects persist or are severe, a woman should always talk to her doctor. Many women do not experience these side effects, or if they do, their bodies eventually adjust.

Gonadotropin releasing hormone (GnRH) agonists are effective hormone treatments for endometriosis. They are able to block the release of the reproductive hormones LH (luteinizing hormone) and FSH (follicular-stimulating hormone). As a result, the ovaries stop ovulating and no longer produce estrogen. Ovulation and menstruation resume around 4 - 10 weeks after stopping the drug. The specific length of time depends on the type of GnRH agonist used.

Women with endometriosis often have a difficult time getting pregnant. A 2006 review suggested that GnRH agonists may help women with endometriosis become pregnant when the drug is given along with in vitro fertilization (IVF) or intracytoplasmic sperm injection (ICSI). (IVF and ICSI are standard infertility treatments.) The review found that 3 - 6 months of GnRH therapy in combination with infertility treatment quadrupled the pregnancy rate. However, the study did not supply data on how many women actually gave birth. In addition, there is not enough information on whether these drugs may adversely affect a woman or her fetus.

Specific GnRH Agonists. GnRH agonists include goserelin (Zoladex), buserelin, a monthly injection of leuprolide (depot Lupron), and a nasal spray, Nafarelin (Synarel). Studies have reported that nafarelin shrank all implants and significantly relieved symptoms in 85% of patients, delayed recurrence of endometriosis after surgery, and in comparison with leuprolide, was less expensive, had fewer side effects, and a provided better quality of life.

Side Effects and Complications. Commonly reported side effects (which can be severe in some women) include menopause-like symptoms that include hot flashes, night sweat, and changes in the vagina, weight change, and depression. The side effects vary in intensity depending on the GnRH agonist. They may be more intense with leuprolide and persist after the drug has been stopped.

The most important concern is possible osteoporosis from estrogen loss. Women ordinarily should not take GnRH agonists for more than 6 months. Certain approaches may preserve enough estrogen to protect bones and still effectively relieve endometriosis symptoms:

Add-back therapy provides doses of estrogen and progestin that are high enough to maintain bone density, but are too low to offset the beneficial effects of the GnRH agonist. Studies suggest this is safe and effective for protecting bone.
Intermittent leuprolide uses repeated 6-month courses of GnRH agonists followed by an average of 9 months of symptom control only.
Taking GnRH agonists in very low doses is an alternate approach, but is still largely untested.
Adding bone-protective drugs may be helpful. The standard ones are bisphosphonates and include alendronate (Fosamax), risedronate (Actonel), and etidronate (Didronel). Other drugs are being tested in combination with a GnRH agonist to preserve bone. They include the parathyroid hormone teriparatide (Forteo) and selective estrogen-receptor modulators (SERMs), such as raloxifene (Evista).

Danazol (Danocrine) is a synthetic drug that resembles a male hormone (androgen). It suppresses the pathway leading to ovulation. Studies have shown symptomatic improvement in 90% of women, although in one study, only about 58% of women expressed satisfaction with this therapy. A high drop-out rate occurs, most often because of adverse side effects, particularly male characteristics, such as growth of facial hair, acne, weight gain, dandruff and deepening of the voice.

Danazol may increase the risk for unhealthy cholesterol levels. A few cases of blood clots and strokes have also been reported, as well as rare cases of liver damage. One study reported that taking a low dose may relieve endometrial symptoms and reduce the risk for these side effects. Exercise may also help reduce side effects. As with GnRH drugs, pregnant women or those trying to become pregnant should not take this drug because it may cause birth defects.

Antiprogestins are promising drugs for endometriosis because they reduce both estrogen and progesterone receptors.

Gestrinone. Gestrinone is the most studied antiprogestin and appears comparable to GnRH agonists in reducing pain and while causing fewer menopausal symptoms. In one study, bone density even increased slightly. Adverse effects of gestrinone include male hormone symptoms, such as acne, and possibly the development of unhealthy cholesterol levels.

Mifepristone. Mifepristone (Mifeprex) is another antiprogestin that may be helpful for treating endometriosis. In one 6-month study, mifepristone improved symptoms and reduced endometrial implants without causing menopausal side effects. Long-term use, however, may cause changes in the uterine tissue and cell proliferation.

Nonsteroidal Anti-inflammatory Drugs (NSAIDs). Over-the-counter NSAIDs may be sufficient for about 75% of women with endometrial pain. NSAIDs block prostaglandins (the substances that increase uterine contractions). They are effective painkillers and also have other properties that act against inflammatory factors. Aspirin is the most common NSAID, but there are dozens of others available over the counter or by prescription. Among the most effective NSAIDs for menstrual disorders are ibuprofen (Advil, Motrin, Midol PMS), naproxen (Aleve, Naprosyn, Naprelan, Anaprox), and mefenamic acid (Ponstel). For maximum benefit, they should be taken 7 - 10 days before a period is expected. However, long-term use of NSAIDs can increase the risk for gastrointestinal bleeding and ulcers. One study of women with iron deficiency anemia reported that overuse of NSAIDs for menstrual disorders contributes to anemia.

Acetaminophen. Acetaminophen (Tylenol) reduces levels of female hormones (gonadotropins and estradiol, an estrogen), which may have some beneficial effect on menstrual disorders. A combination of acetaminophen and pamabrom (Women's Tylenol Menstrual Relief) is specifically aimed at treating menstrual pain and bloating. (Pamabrom is a diuretic, a drug used to reduce fluid build-up and bloating.)

Opioids. Drugs containing codeine should not generally be used for endometriosis pain management. They can cause pelvic congestion and constipation, which can worsen symptoms in patients with gastrointestinal distress.

GnRH Antagonists. GnRH antagonists include ganirelix (Antagon) and cetrorelix (Cetrotide). These newer drugs differ from GnRH agonists in that they have a direct effect on the pituitary gland. The result is quicker action. They also pose a lower risk for complications and side effects.

Aromatase Inhibitors.Drugs that inhibit aromatase, an enzyme that is a major source of estrogen, are being studied for effects against endometriosis. Such drugs include anastrozole, letrozole, exemestane, and vorozole. Aromatase levels may be abnormal in women with endometriosis. A 2004 pilot study of letrozole combined with a progestin showed reduction of endometriosis as well as decrease in pelvic pain, suggesting that this treatment holds promise.

Selective Estrogen-Receptor Modulators (SERMs). Drugs known as selective estrogen-receptor modulators (SERMs) are thought to act like estrogen in some tissues but behave like estrogen blockers (antiestrogens) in others. They have not been widely studied for endometriosis since tamoxifen (Nolvadex), the most commonly used SERM, may worsen endometriosis. However, the actions of other SERMs, such as raloxifene (Evista) or tibolone (only available in Europe), may be beneficial and warrant more research.

Selective Progesterone Receptor Modulators (SPRMs). SPRMs, also called mesoprogestins, have both agonist and antagonist properties. This new class of drugs may be effective for suppressing endometrial growth.

Other investigational drugs for treatment of endometriosis include tumor necrosis factor alpha (TNF-alpha) inhibitors, angiogenesis inhibitors, and various immune modulators.

Conservative Surgery

The goal of conservative surgery is to aggressively remove as many endometrial implants and cysts as possible without causing surgical scarring and subsequent adhesions that could cause fertility problems. The two conservative procedures used are either laparoscopy or laparotomy.

Improving Fertility. Surgery has been shown to improve infertility rates in women with severe endometriosis (stages III and IV). Whether it offers any advantage in pregnancy rates in women with mild-to-moderate endometriosis (stage I or II) is unclear. Nevertheless, some doctors recommend conservative surgery even in early-stage endometriosis, because of the progressive nature of the disorder some evidence suggests it improves fertility. Fertility can often be restored even if the surgery does not remove all the endometrial implants. However, the best fertility rates in such cases occur in the early postoperative period. They decline over time if implants have not been completely eliminated. Subsequent surgeries become less effective in restoring fertility.

Reducing Pain and its Recurrence. Studies report pain reduction after surgery in more than 60% of women. Conservative surgery, however, can miss microscopic implants that may continue to cause pain and other symptoms after the procedure.

Even with very successful surgery, endometriosis usually recurs within a period of between 2 months and several years. In one study, the risk for recurrence after conservative surgery was highest in women who have had previous surgery or who have stage IV disease (large endometriotic cysts). Other factors including age, pregnancy, or the number of cysts, did not seem to influence the degree of risk. An earlier study indicated that women who became pregnant after surgery for endometriosis had a lower risk for recurrence, but pregnancy itself does not cure endometriosis. The use of GnRH agonists after surgery may delay recurrence without affecting fertility.

Both laparoscopy and laparotomy are effective, but there are differences. Some experts believe that laparoscopy surgery should be the treatment of choice for women with endometriosis.

Laparoscopy is currently the gold standard treatment for endometriosis. It is usually done under general anesthetic and involves the following:

Carbon dioxide gas is injected into the abdomen, distending it and pushing the bowel away so that the doctor has a wider view.
The procedure requires making small incisions at the navel and above the pubic bone.
The laparoscope (a hollow tube equipped with camera lenses and a fiber optic light source) is inserted through the incision at the navel (the umbilical incision).
A probe is then inserted through the second incision, allowing the doctor to directly view the outside surface of the uterus, fallopian tubes, and ovaries.
One or two additional small incisions can be made on either side of the lower abdomen through these incisions. Surgical instruments or other devices are passed through these accessory incisions to destroy or remove abnormal tissue. Implants can be removed by excision (surgical removal) using a laser or scissors or by destroying the area with lasers or with electricity (or electrocautery).

In one study, laparoscopy achieved pain relief in over 62% of women. A more recent study conducted 3 - 12 months post-surgery in women with severe (stage III/IV) endometriosis suggested 88% of patients were satisfied with the procedure.

In addition, pregnancy rates can range from 20% to over 50% after laparoscopy. (The procedure does not reduce the chances for pregnancy in women who must still undergo assisted reproductive techniques to conceive.) Still, recurrence rates for laparoscopy are no better than those with laparotomy -- the more invasive procedure.

Laparotomy uses a wide abdominal incision and conventional surgical instruments. It is more invasive and requires a longer recovery time. In some severe cases, the doctor may need a wider view of the pelvic area and will perform this procedure. Laparotomy is typically used for infiltrating endometriosis, although the less invasive laparoscopy is showing increasing effectiveness, even for deep implants.

Complications after Surgery. Many patients experience temporary but severe discomfort in the shoulders after laparoscopy due to residual carbon dioxide gas that puts pressure on the diaphragm. The incisions, even with laparoscopy, may cause pain afterward, which can usually be treated effectively with mild pain relievers. There are small risks for bleeding, infection, and reaction to anesthesia. Surgery in the pelvic area may also cause scarring, which may cause pain and interfere with fertility.

Preoperative Drug Treatment. Hormonal drugs administered before laparoscopy and laparotomy are being investigated to reduce the size of endometrial cysts and so perhaps to improve outlook. A 2000 study, for example, reported that the GnRH agonist goserelin injected monthly 12 weeks before laparoscopy resulted in much smaller implants and better treatment of the disease than treatment with surgery alone.

Postoperative Drug Treatment. A number of studies have also been conducted to determine if taking hormonal drugs after surgery can provide further pain relief. Results have been mixed, and the benefits, if any, are probably slight.

Hysterectomy

Hysterectomy, the surgical removal of the uterus, is the second most frequently performed surgery in premenopausal women (Cesarean sections are first). About 600,000 hysterectomies are performed each year in the U.S., which is among the highest rate of all countries. By age 60, about a third of American women have had this procedure. The highest hysterectomy rates are in women age 40 - 44. Women in the southern and midwestern areas of the United States are more likely to have the operation than those in the northeast and west.

Presence of symptoms (pelvic pain, bleeding, symptomatic fibroids)
Lack of symptom improvement or resolution despite treatment
Previous use of GnRH agonist drugs

The number of procedures has continued to increase, but only slightly in recent years. Endometriosis accounts for 18% of these procedures, but the rates vary widely by ethnic group, with the great majority of endometriosis-related hysterectomies performed in Caucasian women.

Hysterectomy does not necessarily cure endometriosis. One study reported that endometriosis reappeared in 13% of women within 3 years of a hysterectomy and in 40% after 5 years.

Most women are satisfied with the procedure. A major analysis of evidence on hysterectomies reported that symptoms related to menstrual problems decline significantly in most women, although none completely disappear for all women. The majority of women also experience improved quality of life and emotional functioning. Women who have a hysterectomy are less likely to experience hot flashes than women who have a natural menopause.

Still, one study suggested that 70% of recommendations for hysterectomies did not meet the standard of care as determined by expert groups. In such cases, patients were not given alternative choices or adequate diagnostic evaluations. Any woman, even one who has reached menopause, who is uncertain about a recommendation for a hysterectomy should certainly seek a second opinion.

Once a decision for a hysterectomy has been made, the patient should discuss with her doctor what will be removed. The common choices are:

Total Hysterectomy (Removal of uterus and cervix). Removing only the uterus with hysterectomy has the same risk for recurrence as conservative surgery.
Supracervical Hysterectomy (Removal of uterus and preservation of the cervix). Procedure is performed in about 20 - 25% of cases.
Bilateral Salpingo-Oophorectomy (Removal of the fallopian tubes and ovaries). It can be used with either total or supracervical hysterectomy. This is the only potential cure for endometriosis. If endometriosis has developed outside the uterus then even this procedure is not curative.

Hysterectomy is surgical removal of the uterus, resulting in inability to become pregnant. This surgery may be done for a variety of reasons including, but not restricted to, chronic pelvic inflammatory disease, uterine fibroids and cancer. A hysterectomy may be done through an abdominal or a vaginal incision.

Total Hysterectomy. In a total hysterectomy the uterus and cervix are removed; this eliminates the risk of uterine and cervical cancer. (Given technical advances and growing surgical experience, a total hysterectomy may eventually be unnecessary except in special circumstances, such as when cancer is present.)

Supracervical Hysterectomy. In a supracervical hysterectomy (also called subtotal hysterectomy), only the uterus is removed. Retaining the cervix helps support the pelvic floor and may help maintain full sexual sensation, but the risk for cervical cancer remains. Women may experience cyclical bleeding for up to a year after surgery.

Bilateral Oophorectomy. Bilateral oophorectomy is the removal of both ovaries. (When only one ovary is removed, the procedure is called oophorectomy.) Bilatera salpingo-oophorectomy is the removal of both fallopian tubes plus both ovaries. These procedures may be performed with either total or supracervical hysterectomy. When a woman decides to have her ovaries removed, she should be aware of both the positive and negative consequences.

Oophorectomy significantly reduces the rates of re-operation and endometrial pain recurrence compared to hysterectomy alone. By removing the ovaries, oophorectomy causes estrogen loss and helps to reduce the risk for ovarian cancer and breast cancer. Premenopausal women should realize, however, that oophorectomy causes immediate menopause, which poses a risk for a number of health problems. These problems include osteoporosis, heart disease, skin wrinkling, and reduction in muscle tone. Estrogen replacement can help offset them. Women who have a bilateral oophorectomy and do not receive hormone replacement therapy may experience more severe hot flashes than women who enter menopause naturally.

There is still a further choice, which is whether the hysterectomy should be performed through an incision in the abdomen or through the vagina. A variant of vaginal hysterectomy, called laparoscopic-assisted vaginal hysterectomy (LAVH), is yet another option.

Abdominal Hysterectomy. Abdominal hysterectomy is the most common procedure and is used in over 80% of hysterectomies in African-American women and about 60% in Caucasian and other ethnic groups. With the abdominal procedure, a wide incision is required to open the abdominal area, from which the surgeon removes the uterus. If possible, the incision should cut horizontally across the top of the pubic hairline (called a bikini incision). This incision heals faster and is less noticeable than a vertical incision, which is used in more complicated cases. The patient may need to remain in the hospital for 3 - 4 days, and recuperation at home takes about 4 - 6 weeks.

Vaginal Hysterectomy. Vaginal hysterectomy requires only a vaginal incision through which the uterus is removed. It is used in less than 20% of cases in African-American women and slightly under 40% among Caucasian and other groups.

A variation of the vaginal approach is called laparoscopic-assisted vaginal hysterectomy (LAVH). It uses several small abdominal incisions through which the surgeon severs the attachments to the uterus and ovaries. They can then be removed through the vaginal incision, as in the standard approach. Hospitalization stays may be longer and costs are greater than with standard vaginal hysterectomy. The use of LAVH has risen significantly and is now employed in over a quarter of vaginal procedures. LAVH is very costly, however, and some experts question whether it adds any significant benefits compared to the standard vaginal procedure.

If possible, a patient should ask a family member or friend to help out for the first few days at home. The following are some of the precautions and tips for postoperative care:

For a day or two after surgery, the patient is given medications to prevent nausea and painkillers to relieve pain at the incision site.
As soon as the doctor recommends it, usually within a day of the operation, the patient should get up and walk in order to help prevent pneumonia, reduce the risk of blood-clot formation, and to hasten recovery.
Walking and slow, deep breathing exercises may help to relieve gas pains, which can cause major distress for the first few days.
Coughing can cause pain, which may be reduced by holding a pillow over a surgical abdominal wound or by crossing the legs after vaginal surgery.
Patients are advised not to lift heavy objects, not to douche or take baths, and not to climb stairs or drive for several weeks.
For the first few days after surgery, many women weep frequently and unexpectedly. These mood swings may be due to depression from the loss of reproductive capabilities and form abrupt changes in hormones, particularly if the ovaries have been removed.

The patient should discuss with the doctor when they can start exercise programs that more intense than walking. The abdominal muscles are important for supporting the upper body, and recovering strength may take a long time. Even after the wound has healed, the patient may experience an on-going feeling of overall weakness, which can be demoralizing, particularly in women used to physical health. Some women do not feel completely well for as long as a year; others may recover in only a few weeks.

Minor complications after hysterectomy are very common. About half of women develop minor and treatable urinary tract infections. There is usually mild pain and light vaginal bleeding post operation. The infrequent occurrence of severe bleeding or hemorrhaging after vaginal hysterectomy, or laparoscopic-assisted vaginal hysterectomy, may be promptly treated by laparoscopy.

More serious complications, such as those described below, are uncommon, but patients should be aware of their symptoms and call the doctor immediately if they occur.

Among the three procedures, a 2001 study reported that complication rates were 44% for abdominal hysterectomy, 24% for vaginal hysterectomy, and only 2% for LAVH. (LAVH is used in less than 4% of hysterectomies, however.)

Infection. Infection occurs in 10 - 15% of patients, the risk being higher with abdominal than with vaginal surgery. Risk factors for infection appear to be obesity, a longer than normal operative time, and low socioeconomic status. Patients should be aware of any symptoms and call the doctor immediately if they occur:

Continuing or increasingly severe pain
Fever
Heavy discharge
Bleeding (antibiotics given at the time of surgery help to reduce this risk)

Blood Clots. There is a slight risk for small blood clots, usually in veins of the legs (thrombophlebitis). A sudden swelling or discoloration in the leg can indicate this condition and require immediate medical attention.

Click the icon to see an image of thrombophlebitis.

Other Serious Complications. Other serious and even life-threatening complications are rare but can include:

Pulmonary embolism (blood clots that travel to the lung)

Click the icon to see an image of a pulmonary embolism.

Surgical injury of the urinary or intestinal tracts.
Abscesses.
Perforation of the bowel.
Fistulas (a passage that bores from an organ to the skin or to another organ).
Dehiscence (opening of the surgical wound).

Long-Term Complications. Women who have had a total hysterectomy are at higher risk for the following long-term complications:

Muscle weakness in the pelvic area.
Prolapse (descent) of the bladder, vagina, and rectum if the muscle’s walls are overly weakened; may require further surgery.
Bowel problems may develop if adhesions (extensive scarring) have formed and obstruct the intestines, sometimes requiring additional surgery.
Shortening of the vagina is a possible complication specific to vaginal hysterectomy. It can cause pain during intercourse.

Such complications are uncommon.

After hysterectomy, women may experience hot flashes, a symptom of menopause, even if they retain their ovaries. However, women who have a hysterectomy are less likely to experience hot flashes than women who have a natural menopause. Surgery may have temporarily blocked blood flow to the ovaries, therefore suppressing estrogen release. If both ovaries have been removed in premenopausal women, the procedure causes premature menopause. Other menopausal symptoms include vaginal dryness and irritation, insomnia, and weight gain.

The most important complications occur in women who have had their ovaries removed. This causes estrogen loss, which places women at risk for osteoporosis (loss of bone density) and a possible increase in risks for heart disease and stroke. A number of drugs are available that can help protect both bones and heart.

Women have typically taken hormone replacement therapy (HRT) after surgery if their ovaries have been removed. HRT can help prevent hot flashes. There have been concerns about HRT-related health risks, including the risk for breast cancer. However, several 2006 studies of postmenopausal women who had hysterectomy indicated that estrogen-only HRT does not increase the risk for breast cancer, except if it is taken for many decades. (Two studies showed no increased risk for breast cancer after 7 years and 15 years, respectively. Women who took estrogen-only HRT for more than 20 years after hysterectomy had only a moderately increased risk.) Combination estrogen-progestin HRT does increase breast cancer risk.

In premenopausal women, such preventive measures are not needed if the ovaries are left intact. The ovaries will usually continue to function and secrete hormones even after the uterus is removed, but the lifespan of the ovaries is reduced by an average of 3 - 5 years. In rare cases, complete ovarian failure occurs right after hysterectomy, presumably because the surgery has permanently cut off the blood supply to the ovaries.

Sexual intercourse may resume 4 - 6 weeks following surgery. The effect of hysterectomy on sexuality is unclear. Studies have reported that up to 25% of women experience increased sexual drive. Nevertheless, some women report no change, and other women develop problems related to sexual function. For example, around 10% of women experience vaginal dryness, about 2% of women develop pain during sex, and another 2% also appear to lose capacity for orgasm.

Two procedures associated with hysterectomy may affect sexuality directly.

Although the clitoris can trigger orgasm even if the cervix is removed, some experts believe that uterine contractions stimulated by sexual intercourse also cause a so-called “deep orgasm.” Retaining the cervix may help to retain this sensation. However, a 2006 review found that women who undergo a total hysterectomy (removal of both uterus and cervix) are no more likely to have sexual difficulties or problems with urinary and bowel function than women who have only their uterus removed.
Patients who have both ovaries removed may be at higher risk for loss of sexuality. Ovaries produce small amounts of testosterone (the male hormone responsible for sexual drive) even after menopause.

Testosterone Replacement. Testosterone replacement therapy may restore sexuality in women who experience a decline in sexual drive. Occasionally, oral or injection treatments can produce male characteristics such as facial hair and voice change. A slow-release pellet inserted every 6 months under the skin in the hip appears to reduce these side effects. Taking hormones long-term almost always carries some risk, and it is not yet known what danger testosterone replacement may pose in women.

Annual Pap smears are recommended for all women with an intact cervix who are 18 years or older or who have become sexually active. After a total hysterectomy, in which the cervix has been removed, a woman does not need annual Pap smears of the cervix. However, she still should get regular pelvic and breast exams. Also, women with a history of abnormal Pap smears usually require annual screening.

Resources

www.asrm.com -- American Society for Reproductive Medicine
www.acog.com -- American College of Obstetricians and Gynecologists
www.endometriosisassn.org -- The Endometriosis Association
www.nichd.nih.gov -- National Institute of Child Health and Human Development
www.endozone.org -- Endometriosis Zone
www.pelvicpain.org -- International Pelvic Pain Society
www.endocenter.org -- Endometriosis Research Center
www.resolve.org -- National Infertility Association

References

Chen WY, Manson JE, Hankinson SE, Rosner B, Holmes MD, Willett WC, et al. Unopposed estrogen therapy and the risk of invasive breast cancer. Arch Intern Med. 2006 May 8;166(9):1027-32.

Lethaby A, Ivanova V, Johnson NP. Total versus subtotal hysterectomy for benign gynaecological conditions. Cochrane Database Syst Rev. 2006 Apr 19;(2):CD004993.

Parker JD, Leondires M, Sinaii N, Premkumar A, Nieman LK, Stratton P. Persistence of dysmenorrhea and nonmenstrual pain after optimal endometriosis surgery may indicate adenomyosis. Fertil Steril. 2006 Sep;86(3):711-5. Epub 2006 Jun 16.

Stefanick ML, Anderson GL, Margolis KL, Hendrix SL, Rodabough RJ, Paskett ED, et al. Effects of conjugated equine estrogens on breast cancer and mammography screening in postmenopausal women with hysterectomy. JAMA. 2006 Apr 12;295(14):1647-57.

Review Date:
6/16/2007
Reviewed By:
Harvey Simon, MD, Associate Professor of Medicine, Harvard Medical School; Physician, Massachusetts General Hospital.

A.D.A.M. Copyright

adam.com

Birth control and family planning

admin — Thu, 04 Sep 2008 18:49:47 -0700

HEALTH GUIDE REFERENCE FROM A.D.A.M

Definition

Which form of birth control you choose depends on a number of different factors, including your health, how often you have sex, and whether or not you want children.

Alternative Names

Contraception; Family planning and contraception

Information

Here are some factors to consider when selecting a birth control method:

Effectiveness -- how well does the method prevent pregnancy? Look at the number of pregnancies in 100 women using that method over a period of one year. If an unplanned pregnancy would be viewed as potentially devastating to the individual or couple, a highly effective method should be chosen. In contrast, if a couple is simply trying to postpone pregnancy, but feels that a pregnancy could be welcomed if it occurred earlier than planned, a less effective method may be a reasonable choice.
Cost -- is the method affordable?
Health risk -- learn any potential health risks. For example, birth control pills are usually not recommended for women over age 35 who also smoke.
Partner involvement -- The willingness of a partner to accept and support a given method may affect your choice of birth control. However, you also may want to re-consider a sexual relationship with a partner unwilling to take an active and supportive role.
Permanence -- do you want a temporary (and generally less effective) method, or a long-term or even permanent (and more effective) method?
Preventing HIV and sexually transmitted diseases (STDs) -- many methods offer no protection against STDs. In general, condoms are the best choice for preventing STDs, especially combined with spermicides.
Availability -- Can the method be used without a prescription, provider visit, or, in the case of minors, parental consent?

CONDOMS

A condom is a thin latex or polyurethane sheath. The male condom is placed around the erect penis. The female condom is placed inside the vagina before intercourse. Semen collects inside the condom, which must be carefully removed after intercourse.
Condoms are available in most drug and grocery stores. Some family planning clinics offer free condoms.
Latex condoms help prevent HIV and other STDs. Polyurethane condoms may give some protection against STDs, but they are not as effective as latex ones.
About 14 pregnancies occur over 1 year out of 100 couples using male condoms, and about 21 pregnancies occur over 1 year out of 100 couples using female condoms. They are more effective when spermicide is also used.
Risks include irritation and allergic reactions, particularly to latex.
Condoms are used only once.

SPERMICIDES

Spermicides are chemical jellies, foams, creams, or suppositories that kill sperm.
They can be purchased in most drug and grocery stores.
This method used by itself is not very effective. About 26 pregnancies occur over 1 year out of 100 women using this method alone.
Spermicides are generally combined with other methods (such as condoms or diaphragm) as extra protection.
Warning: The spermicide nonoxynol-9 can help prevent pregnancy, but also may increase the risk of HIV transmission.
Risks include irritation and allergic reactions.

DIAPHRAGM AND CERVICAL CAP

A diaphragm is a flexible rubber cup that is filled with spermicidal cream or jelly.
It is placed into the vagina over the cervix, before intercourse, to prevent sperm from reaching the uterus.
It should be left in place for 6 to 8 hours after intercourse.
Diaphragms must be prescribed by a woman's health care provider, who determines the correct type and size of diaphragm for the woman.
About 5-20 pregnancies occur over 1 year in 100 women using this method, depending on proper use.
A similar, smaller device is called a cervical cap.
Risks include irritation and allergic reactions to the diaphragm or spermicide, and urinary tract infection. In rare cases, toxic shock syndrome may develop in women who leave the diaphragm in too long. A cervical cap may cause an abnormal Pap test.

VAGINAL SPONGE

Vaginal contraceptive sponges are soft synthetic sponges saturated with a spermicide. Prior to intercourse, the sponge is moistened, inserted into the vagina, and placed over the cervix. After intercourse, the sponge is left in place for 6 to 8 hours.
It is quite similar to the diaphragm as a barrier mechanism, but you do not need to be fitted by your doctor. The sponge can be purchased over the counter.
In April 2005, the FDA granted re-approval for the Today sponge to return to the U.S. market.
About 18 to 28 pregnancies occur over one year for every 100 women using this method.
The sponge may be more effective in women who have not previously delivered a baby.
Risks include irritation, allergic reaction, trouble removing the sponge. In rare cases, toxic shock syndrome may occur.

COMBINATION BIRTH CONTROL PILLS

Also called oral contraceptives or just the "pill", this method combines the hormones estrogen and progestin to prevent ovulation.
A health care provider must prescribe birth control pills.
The method is highly effective if the woman remembers to take her pill consistently each day.
Women who experience unpleasant side effects on one type of pill are usually able to adjust to a different type.
About 2 to 3 pregnancies occur over 1 year out of 100 women who never miss a pill.
Birth control pills may cause a number of side effects including: Dizziness, irregular menstrual cycles, nausea, mood changes, and weight gain. In rare cases, they can lead to high blood pressure, blood clots, heart attack, and stroke.

THE MINI-PILL

The "mini-pill" is a type of birth control pill that contains only progestin, no estrogen.
It is an alternative for women who are sensitive to estrogen or cannot take estrogen for other reasons.
The effectiveness of progestin-only oral contraceptives is slightly less than that of the combination type. About 3 pregnancies occur over a 1 year period in 100 women using this method.
Risks include irregular bleeding, weight gain, and breast tenderness.

THREE-MONTH PILL (SEASONALE)

In 2003, the FDA-approved an estrogen and progestin pill called Seasonale. It is taken for three straight months, followed by one week of inactive pills.
A women gets her period about four times a year, during the 13th week of her cycle.
Seasonale is available by prescription.
Fewer than 2 out of 100 women per year get pregnant using this method.
The risks are similar to other birth control pills. Some women may have more spotting between periods.
The pills must be taken daily, preferably at the same time of day.

PROGESTIN IMPLANTS

Implants are small rods implanted surgically beneath the skin, usually on the upper arm. The rods release a continuous dose of progestin to prevent ovulation.
Implants work for 5 years. The initial cost is generally higher than some other methods, but the overall cost may be less over the 5-year period.
The Norplant implant has been removed from the U.S. market. A similar implanted rod system, Implanon, is available. It works for 3 years.
Less than 1 pregnancy occurs over 1 year out of 100 women using this type of contraception.

HORMONE INJECTIONS

Progestin injections, such as Depo-Provera, are given into the muscles of the upper arm or buttocks. This injection prevents ovulation.
A single shot works for up to 90 days.
Less than 1 pregnancy occurs over 1 year in 100 women using this method.

SKIN PATCH

The skin patch (Ortho Evra) is placed on your shoulder, buttocks, or other convenient location. It continually releases progestin and estrogen. Like other hormone methods, a prescription is required.
The patch provides weekly protection. A new patch is applied each week for three weeks, followed by one week without a patch.
About 1 pregnancy occurs over 1 year out of 100 women using this method.
Estrogen levels are higher with the patch than with birth control pills. In theory, higher estrogen levels may increase your risk of blood clots.

VAGINAL RING

The vaginal ring (NuvaRing) is a flexible ring about 2 inches in diameter that is inserted into the vagina. It releases progestin and estrogen.
A prescription is required.
The woman inserts it herself and it stays in the vagina for 3 weeks. Then, she takes it out for one week.
About 1 pregnancy occurs over 1 year out of 100 women using this method.
Risks include vaginal discharge and vaginitis, as well as those similar to the combined birth control pill.

IUD

The IUD is a small plastic or copper device placed inside the woman's uterus by her health care provider. Some IUDs release small amounts of progestin. IUDs may be left in place for 5 - 10 years, depending on the device used
IUDs can be placed at almost any time.
IUDs are safe and work well. Fewer than 1 out of 100 women per year will get pregnant using an IUD.
Risks and complications include cramps, bleeding (sometimes severe), and perforation of the uterus.

NATURAL FAMILY PLANNING

This method involves observing a variety of body changes in the woman (such as cervical mucus changes, basal body temperature changes) and recording them on a calendar to determine when ovulation occurs. The couple abstains from unprotected sex for several days before and after the assumed day ovulation occurs.
This method requires education and training in recognizing the body's changes as well as a great deal of continuous and committed effort.
About 15 to 20 pregnancies occur over 1 year out of 100 women using this method (for those who are properly trained).

TUBAL LIGATION

During tubal ligation, a woman's fallopian tubes are cut, sealed, or blocked by a special clip, preventing eggs and sperm from entering the tubes. It is usually performed immediately after childbirth, or by laparoscopic surgery.
Tubal ligations are best for women and couples who believe they never wish to have children in the future. While viewed as a permanent method, the operation can sometimes be reversed if a woman later chooses to become pregnant.

VASECTOMY

A vasectomy is a simple, permanent procedure for men. The vas deferens (the tubes that carry sperm) are cut and sealed.
A vasectomy is performed safely in a doctor’s office using a local anesthetic to numb the area.
Vasectomies are best for men and couples who believe they never wish to have children in the future. While often viewed as a permanent method, they can sometimes be reversed.

EMERGENCY ("MORNING AFTER") BIRTH CONTROL

The "morning after" pill consists of two doses of hormone pills taken as soon as possible within 72 hours after unprotected intercourse.
The pill is available without a prescription for purchase by anyone 18 years and older.
The pill may prevent pregnancy by temporarily blocking eggs from being produced, by stopping fertilization, or keeping a fertilized egg from becoming implanted in the uterus.
The morning after pill may be appropriate in cases of rape; having a condom break or slip off during sex; missing two or more birth control pills during a monthly cycle; and having unplanned sex.
Risks include nausea, vomiting, abdominal pain, fatigue, and headache.

UNRELIABLE METHODS

Coitus interruptus is the withdrawal of the penis from the vagina prior to ejaculation. Some semen frequently escapes prior to full withdrawal, enough to cause a pregnancy.
Douching shortly after sex is ineffective because sperm can make their way past the cervix within 90 seconds after ejaculation.
Breastfeeding. Despite the myths, women who are breastfeeding can become pregnant.

CALL YOUR HEALTH CARE PROVIDER IF:

You would like to further information about birth control options.
You want to start using a specific method of birth control that requires a prescription or needs to be inserted by a health care provider.
You have had unprotected intercourse or method failure (for example, a broken condom) within the past 72 hours, and you do not want to become pregnant.

References

Johansson ED. Future developments in hormonal contraception. Am J Obstet Gynecol. 2004 Apr;190(4 Suppl):S69-71.

MacIsaac L.Intrauterine contraception: the pendulum swings back. Obstet Gynecol Clin North Am. 2007 March;34(1):91-111, ix.

Mishell DR Jr. State of the art in hormonal contraception: an overview. Am J Obstet Gynecol. 2004; 190(4 Suppl): S1-4.

Roddy RE, Zekeng L, Ryan KA, Tamoufé U, Tweedy KG. Nonoxynol-9 gel did not improve protection against sexually transmitted infections in condom users. Evidence-based Obstetrics & Gynecology. 2002; 4(4): 177-178.

Shulman LP. Advances in female hormonal contraception: current alternatives to oral regimens. Treat Endocrinol. 2003;2(4):247-56.

US Food and Drug Administration. Birth Control Guide. Rockville, MD: FDA Office of Public Affairs; December 2003.

Review Date: 3/25/2008

Reviewed By: A.D.A.M. Editorial Team: David Zieve, MD, MHA, Greg Juhn, MTPW, David R. Eltz, Kelli A. Stacy, ELS. Previously reviewed by Rachel A. Lewis, MD, FAAP, Columbia University Pediatric Faculty Practice, New York, NY. Review provided by VeriMed Healthcare Network (5/6/2007).

A.D.A.M. Copyright

adam.com

Source Doc: 1_001946

PMS: Oh, it's Real !!!

FitSugar — Thu, 12 Apr 2007 11:00:00 -0700

When I was growing up, I remember being in a bad mood and some stupid boy saying, "Oh, you must be on the rag!" That really pissed me off. Just because I'm not happy does not necessarily mean I have or am getting my period!!

Although the truth is, right before my period, I really do feel crappy and not myself. It's not just a dumb joke between guys - it's completely REAL, but why does it happen?

Premenstrual Syndrome (PMS) happens because your body goes through a series of hormonal changes in the 2 weeks leading up to your period. The female hormone estrogen starts to rise after menstruation and peaks around mid-cycle (ovulation). It then rapidly drops only to slowly rise and then fall again in the time before you finally get your period. These crazy changes can trigger disruptive symptoms that affect you both emotionally and physically.

PMS affects women differently, and its effects can also vary from month to month. For most women, symptoms include mood swings (1 minute you're happy, 1 minute you're mad), uncontrollable crying, feeling depressed or anxious, and feeling "out-of-control."

Want to know what else PMS causes? Then read more

You can also experience headaches or migraines, dizziness, abdominal pains, backache, constipation, fluid retention (that's my fave right there), acne, breast tenderness, weight gain, heart palpitations, painful joints, cravings for certain foods like chocolate, or fatigue. Fun stuff.

The severity of your symptoms may be hereditary, and some women experience symptoms that disrupt their ability to function. If you're concerned about your symptoms, keep a calendar and write down how you feel each day. This way, when you see your gynecologist, your doctor may have some ideas for treatments.

Fit's Tips: Going on the Pill may help to regulate your hormone levels, and because you're not ovulating, your symptoms may become greatly alleviated. Monophasic birth control, like the Nuvaring or Seasonale may be a better option since they deliver an equal amount of hormones to you each day.

Myths on the Pill Debunked

FitSugar — Wed, 14 Mar 2007 07:30:00 -0700

Do you take "the pill?" If so, you're not alone. However, despite the overwhelming number of women on the pill right now, there are still some serious myths floating around out there, giving the pill a very bad rep.

Health.com has taken note and talked to the professionals to finally debunk the most common myths on the pill:

It’s risky to stop your period: Studies show it’s safe to suppress your period using various methods: Seasonale, a pill that limits you to four periods a year; Seasonique, a similar pill that may help fight PMS; or others like Depo-Provera injections that may eliminate your period. “The hormones keep the lining of your uterus thin, so nothing builds up,” says Rebecca Gould, MD, an OB-GYN at Delaware County Memorial Hospital in Drexel Hill, Pennsylvania. Side effects that usually go away include breakthrough bleeding. Menstrual suppression is great for women with particularly heavy flows, painful cramps, and menstrual migraines.

Does the pill make you fat or give you cancer? To find out, read more

The Pill ups your cancer risks: Actually, the risk of endometrial and ovarian can-cers goes down the longer you’re on the Pill. After one year, endometrial-cancer risk decreases by 50 per-cent, and after just three to six months, ovarian-cancer risk decreases by 40 percent. After 10 years, the risks are 80 percent lower than normal. “The longer you keep the endometrium thin and the ovaries inactive, you are reducing the chance of the inappropriate cell divi-sion that characterizes cancer,” explains Katharine O’Connell, MD, assistant clinical professor of OB-GYN at Columbia University.
The Pill may also lower the risk of colon cancer: What about breast cancer? The research is inconclusive. A recent review of previous studies, published in the Mayo Clinic Proceedings, suggests a tiny elevation in risk among current users, which disappears when you quit. (There’s no debate for women who have-or have had-breast cancer: They should steer clear because the hormones can stimulate some cancerous cells.)
The Pill makes you fat (and frigid): Wrong. Most women link the Pill to weight gain, but only breakthrough bleeding is a proven side effect. (Women often put on pounds after getting the Depo-Provera injection.) As for libido, while some studies show a decreased sex drive, others show an increase-a lower chance of pregnancy can be quite an aphrodisiac.
An IUD ruins your fertility: The Dalkon Shield, pulled from the market in the 1970s, may have contributed to infections that led to infertility. It was also linked to 17 deaths. But not the new and safe IUDs, such as ParaGard and Mirena. Plus, they’re more effective and cheaper than the Pill.

Cons? Pain during insertion (for about 3 minutes you’ll feel a sensation akin to intense menstrual cramps), and cramps and bleeding that can occur for a week afterward. Also, there’s an increased chance of infection during the first 3 weeks, usually because bacteria have been introduced during insertion; this can be easily treated with an anti-biotic, though.

The Sponge is as good as the Pill: Nope. The Sponge, which blocks the cervix and contains a spermicide, leaves much to chance. Its failure rate is 32 percent for women who have delivered a child vaginally (because the cervix is larger after childbirth); for those who haven’t, the failure rate is 16 percent. For better protection, pair it with condoms.
Long-term use of the Pill is a no-no: You may risk getting pregnant if you take a break. “This is how my brother was conceived,” Gould says. There’s no medical reason to stop. It’s possible to get pregnant right away after quitting. Half of women get pregnant within three months-a good reason not to take that break!
Pill side effects last forever: Not at all. The first three months of any new hormonal birth control method brings side effects that eventually go away, Gould says. It’s past month three, and your doctor’s telling you to “gut it out”? Time for a second opinion.
Taking the Pill past age 40 is risky: Not if you’re healthy. You can take it till menopause. But if you’re over 35 and you smoke, or have uncontrolled high blood pressure or long-term or uncontrolled diabetes, your heart disease and stroke risks are elevated, and the Pill raises them. Anyone who fits this profile is fine on a progestin-only “mini-pill” (or Depo-Provera).
It’s OK to take any medicine with the Pill: Wrong. St. John’s Wort, a popular sup-plement used for depression, cuts the Pill’s effectiveness. Researchers think the herb makes your body speed up the metabolization of the Pill, preventing the hormones from doing their job. On the flip side, the Pill may exaggerate antidepressant effects.
The Pill makes migraines worse: The Pill doesn’t aid or aggravate migraine symptoms. But birth control pills may increase stroke risk in women who suffer from migraines with aura (added symptoms like numbness, weakness, hallucinations, or blurred vision). For them, the mini-pill and other estrogen-free hormonal methods are OK.

To read the full article and other fabulous information, visit Health.com.

FitSugar

New Birth Control Pill Means NO PERIOD!!!

Reduce Your Flow

Levonorgestrel/ethinyl estradiol (By mouth)

Overview

Introduction

Ethinyl Estradiol (ETH-in-il es-tra-DYE-ole), Levonorgestrel (LEE-voe-nor-jes-trel)

Prevents pregnancy. This medicine is an oral contraceptive (birth control pill).

Brand Name(s)

Aviane, Trivora-28, Levora-28, Lutera, Enpresse-28, Seasonale, Portia-28, Lessina 28, Levlite 28, Levlen, Nordette-28, Jolessa, Quasense, Sronyx, Seasonique

When This Medicine Should Not Be Used

How to Use This Medicine

Tablet

If a dose is missed:

How to Store and Dispose of This Medicine

Drugs and Foods to Avoid

Ask your doctor or pharmacist before using any other medicine, including over-the-counter medicines, vitamins, and herbal products.

Warnings While Using This Medicine

Possible Side Effects While Using This Medicine

Call your doctor right away if you notice any of these side effects:

If you notice these less serious side effects, talk with your doctor:

Birth control options for women

In This Report

Highlights

Introduction

Oral Contraception

Implant Contraception

Injected Contraception

Intrauterine Devices (IUDs)

Spermicidal and Barrier Contraception

Natural Family Planning Methods

Emergency Contraception

Female Sterilization

Resources

References

Menstrual disorders

In This Report

Highlights

Introduction

Menstrual Disorders

Causes

Risk Factors

Complications

Diagnosis

Treatment

Medications

Surgery

Resources

References

Endometriosis

In This Report

Highlights

Introduction

Causes

Symptoms

Risk Factors

Complications

Diagnosis

Treatment

Lifestyle Changes

Medications

Conservative Surgery

Hysterectomy

Resources

References

Birth control and family planning

Overview

Illustrations

Definition

Alternative Names

Information

References

PMS: Oh, it's Real !!!

Myths on the Pill Debunked