STAYING HEALTHY

A menstrual cycle is defined from the first day of menstrual bleeding (called day 1) of one menstrual period to the first day of the next menstrual cycle. An average menstrual cycle lasts 28 days. In a normal menstrual cycle, an ovary releases an egg (ovulation). In an average menstrual cycle of 28 days, ovulation occurs about 14 days before the start of the next menstrual period. When can I become pregnant? After its release, an egg can survive in the fallopian tube for about 24 hours. You can become pregnant if you have sex anywhere from 5 days before ovulation until 1 day after ovulation. Your chance of pregnancy is highest if live sperm is already present when the egg arrives in the fallopian tube. A man’s sperm can survive inside a woman’s body for about 3 days (and sometimes up to 5 days) after sexual intercourse.

The following methods are based on fertility awareness: The fertile window Cervical mucous method Basal body temperature (BBT) method Ovulation testing

The 'fertile window’ is the days in a woman’s menstrual cycle when pregnancy is possible. The ‘fertile window’ depends on the length of the menstrual cycle, which varies among women. The ‘fertile window’ is the day an egg is released from the ovary (ovulation) and the five days beforehand. Having sex (intercourse) every day or every other day during this time gives you the best chance of getting pregnant. When you know your average menstrual cycle length, you can work out when you ovulate and your fertile window. Ovulation happens about 14 days before your period starts. If your average menstrual cycle is 28 days, you ovulate around day 14, then your fertile window is from day 9 to day 15 If your average menstrual cycle is 35 days ovulation happens around day 21 and your fertile window is from day 16 to day 22 Some women have very irregular cycles or find it difficult to work out an average cycle length. This can make it hard to work out when ovulation happens. If it’s all too hard, having sex every 2-3 days covers all bases and improves your chance of getting pregnant.

A few days before ovulation, you may notice your vaginal mucus becomes clear, slick and slippery, and feels a bit like egg white. This is a sign that ovulation is about to happen. It’s the best time to have sex, as sperm travel more easily in this kind of mucus. What is the basal body temperature method? The BBT is your body’s temperature when you are fully at rest. Your BBT rises after ovulation and remains high until the end of the menstrual cycle. BBT by itself is not a good way to prevent or promote pregnancy. It shows only when ovulation has already occurred, not when it is going to occur.

You can use a predictor kit from a pharmacy to test your urine for signs of ovulation. It detects the “LH surge” which is the signal the brain sends to the ovary for releasing an egg. If you start testing your urine a few days before the day you next expect to ovulate, a positive result means you are going to ovulate within the next 24 to 36 hours (one to two days). You should have sex the day you test positive and the next day.

Basal Body Temperature (BBT): The temperature of the body at rest. Cervix: The lower, narrow end of the uterus at the top of the vagina. Egg: The female reproductive cell made in and released from the ovaries. Also called the ovum. Fallopian Tube: Tube through which an egg travels from the ovary to the uterus. Fertility Awareness: A collection of ways to track a woman’s natural body functioning and determine when she is most likely to get pregnant. Menstrual Cycle: The monthly process of changes that occur to prepare a woman’s body for possible pregnancy. Ovary: Organ in women that contains the eggs necessary to get pregnant and makes important hormones, such as estrogen, progesterone, and testosterone. Ovulation: The time when an ovary releases an egg. Sexual Intercourse: The act of the penis of the male entering the vagina of the female. Also called "having sex" or "making love."

The genes most commonly affected in hereditary breast and ovarian cancer are the breast cancer 1 (BRCA1) and breast cancer 2 (BRCA2) genes. About 3% of breast cancers (about 7,500 women per year) and 10% of ovarian cancers (about 2,000 women per year) result from inherited mutations in the BRCA1 and BRCA2 genes. Normally, the BRCA1 and BRCA2 genes protect you from getting certain cancers. But some mutations in the BRCA1 and BRCA2 genes prevent them from working properly, so that if you inherit one of these mutations, you are more likely to get breast, ovarian, and other cancers. However, not everyone who inherits a BRCA1 or BRCA2 mutation will get breast or ovarian cancer. Everyone has two copies of the BRCA1 and BRCA2 genes, one copy inherited from their mother and one from their father. Even if a person inherits a BRCA1 or BRCA2 mutation from one parent, they still have the normal copy of the BRCA1 or BRCA2 gene from the other parent. Cancer occurs when a second mutation happens that affects the normal copy of the gene, so that the person no longer has a BRCA1 or BRCA2 gene that works properly. Unlike the inherited BRCA1 or BRCA2 mutation, the second mutation would not be present throughout the person’s body, but would only be present in the cancer tissue. Breast and ovarian cancer can also be caused by inherited mutations in genes other than BRCA1 and BRCA2. This means that in some families with a history of breast and ovarian cancer, family members will not have mutations in BRCA1 or BRCA2, but can have mutations in one of these other genes. These mutations might be identified through genetic testing using multigene panels, which look for mutations in several different genes at the same time. You and your family members are more likely to have a BRCA1 or BRCA2 mutation if your family has a strong history of breast or ovarian cancer. Family members who inherit BRCA1 and BRCA2 mutations usually share the same mutation. If one of your family members has a known BRCA1 or BRCA2 mutation, other family members who get genetic testing should be checked for that mutation. If you are concerned that you could have a BRCA1, BRCA2, or other mutation related to breast and ovarian cancer, the first step is to collect your family health history of breast and ovarian cancer and share this information with your doctor. Breast cancer screening means checking a woman’s breasts for cancer before there are signs or symptoms of the disease. All women need to be informed by their health care provider about the best screening options for them. When you are told about the benefits and risks of screening and decide with your health care provider whether screening is right for you—and if so, when to have it—this is called informed and shared decision-making. Although breast cancer screening cannot prevent breast cancer, it can help find breast cancer early, when it is easier to treat. Talk to your doctor about which breast cancer screening tests are right for you, and when you should have them.

MAMMOGRAM A mammogram is an X-ray of the breast. For many women, mammograms are the best way to find breast cancer early, when it is easier to treat and before it is big enough to feel or cause symptoms. Having regular mammograms can lower the risk of dying from breast cancer. At this time, a mammogram is the best way to find breast cancer for most women of screening age. What do mammograms show? Mammograms can often show abnormal areas in the breast. They can’t tell for sure if an abnormal area is cancer, but they can help health care providers decide if more testing (such as a breast biopsy) is needed. The main types of breast changes found with a mammogram are: Calcifications Masses Asymmetries Distortions What are three-dimensional (3D) mammograms? Three-dimensional (3D) mammography is also known as breast tomosynthesis or digital breast tomosynthesis (DBT). As with a standard (2D) mammogram, each breast is compressed from two different angles (once from top to bottom and once from side to side) while x-rays are taken. But for a 3D mammogram, the machine takes many low- dose x-rays as it moves in a small arc around the breast. A computer then puts the images together into a series of thin slices. This allows doctors to see the breast tissues more clearly in three dimensions. (A standard two- dimensional [2D] mammogram can be taken at the same time, or it can be reconstructed from the 3D mammogram images.) Many studies have found that 3D mammography appears to lower the chance of being called back for follow-up testing after screening. It also appears to find more breast cancers, and several studies have shown it can be helpful in women with dense breasts. A large study is now in progress to better compare outcomes between 3D mammograms and standard (2D) mammograms. For more on 3D mammograms, see American Cancer Society Recommendations for the Early Detection of Breast Cancer. Are mammograms safe? Mammograms expose the breasts to small amounts of radiation. But the benefits of mammography outweigh any possible harm from the radiation exposure. Modern machines use low radiation doses to get breast x-rays that are high in image quality. On average the total dose for a typical mammogram with 2 views of each breast is about 0.4 millisieverts, or mSv. (A mSv is a measure of radiation dose.) The radiation dose from 3D mammograms can range from slightly lower to slightly higher than that from standard 2D mammograms. To put these doses into perspective, people in the US are normally exposed to an average of about 3 mSv of radiation each year just from their natural surroundings. (This is called background radiation.) The dose of radiation used for a screening mammogram of both breasts is about the same amount of radiation a woman would get from her natural surroundings over about 7 weeks. If there’s any chance you might be pregnant, let your health care provider and x-ray technologist know. Although the risk to the fetus is very small, and mammograms are generally thought to be safe during pregnancy, screening mammograms aren’t routinely done in pregnant women who aren't at increased risk for breast cancer.

A breast MRI uses magnets and radio waves to take pictures of the breast. Breast MRI is used along with mammograms to screen women who are at high risk for getting breast cancer. Because breast MRIs may appear abnormal even when there is no cancer, they are not used for women at average risk.

Breast ultrasound uses sound waves and their echoes to make computer pictures of the inside of the breast. It can show certain breast changes, like fluid-filled cysts, that can be harder to see on mammograms. It can help your healthcare provider find breast problems. It also lets your healthcare provider see how well blood is flowing to areas in your breasts.

Thermography, also called thermal imaging, uses a special camera to measure the temperature of the skin on the breast’s surface. Thermography is based on two ideas: Because cancer cells are growing and multiplying very fast, blood flow and metabolism are higher in a cancer tumor. As blood flow and metabolism increase, skin temperature goes up. Thermography has been available for several decades, but there is no evidence to show that it’s a good screening tool to detect breast cancer early, when the cancer is most treatable. On Feb. 25, 2019, the U.S. Food and Drug Administration (FDA) put out a safety communication telling people that thermography is not a substitute for a mammogram. “There is no valid scientific data to demonstrate that thermography devices, when used on their own or with another diagnostic test, are an effective screening tool for any medical condition including the early detection of breast cancer or other diseases and health conditions,” the FDA said. “Mammography (taking X-ray pictures of the breasts) is the most effective breast cancer screening method and the only method proven to increase the chance of survival through earlier detection.” Researchers are developing and testing new versions of thermography that someday may improve the test’s accuracy and usefulness. This information is provided by Breastcancer.org.

Clinical Breast Exam A clinical breast exam is an examination by a doctor or nurse, who uses his or her hands to feel for lumps or other changes. Breast Self-Awareness Being familiar with how your breasts look and feel can help you notice symptoms such as lumps, pain, or changes in size that may be of concern. These could include changes found during a breast self-exam. You should report any changes that you notice to your doctor or health care provider. Having a clinical breast exam or doing a breast self-exam has not been found to lower the risk of dying from breast cancer.

Menopause is the natural transition in a woman's life that marks the end of her reproductive years. Typically between the ages of 45 and 55, a woman’s ovaries stop producing hormones and she stops having menstrual periods.

Estrogen is used by many parts of a woman’s body. As levels of estrogen decrease, you could have various symptoms. Many women experience mild symptoms that can be treated by lifestyle changes such as avoiding caffeine or carrying a portable fan. Some women don’t require any treatment at all, but for others, symptoms can be more severe. The severity of symptoms varies greatly around the world and by race and ethnicity. Change in your Period This might be what you notice first. Your periods may no longer be regular. They may be shorter or last longer. You might bleed more or less than usual. These are all normal changes, but to make sure there isn’t a problem, see your doctor if: Your periods happen very close together, less than 21 days You have heavy bleeding. You have spotting. Your periods last more than a week. Your periods resume after no bleeding for more than a year. Hot Flashes Many women have hot flashes, which can last for many years after menopause. They may be related to changing estrogen levels. A hot flash is a sudden feeling of heat in the upper part or all of your body. Your face and neck may become flushed. Red blotches may appear on your chest, back, and arms. Heavy sweating and cold shivering can follow. Hot flashes can be very mild or strong enough to wake you up (called night sweats). Most hot flashes last between 30 seconds and 10 minutes. They can happen several times an hour, a few times a day, or just once or twice a week. Hot Flashes: What can I do? Sleep Problems The years of the menopausal transition are often a time when there are other changes in a woman’s life. You may be caring for aging parents, supporting children as they move into adulthood, taking on more responsibilities at work, and reflecting on your own life journey. Add symptoms of menopause on top of all this, and you may find yourself having trouble sleeping at night. Hot flashes, especially night sweats, and changes in mood — depression in particular — can contribute to poor sleep. Managing these issues may help to manage sleep symptoms as well. Some women who have trouble sleeping may use over-the-counter sleep aids such as Melatonin or Doxylamine. Others use prescription medications to help them sleep, which may help when used for a short time. But these are not a cure for sleep disturbances, such as insomnia, and should not be used long term. Sleep Problems: What Can I Do? What is melatonin and how does it work? Melatonin is a hormone that your brain produces in response to darkness. It helps with the timing of your circadian rhythms (24-hour internal clock) and with sleep. Being exposed to light at night can block melatonin production. Research suggests that melatonin plays other important roles in the body beyond sleep. However, these effects are not fully understood. Melatonin dietary supplements can be made from animals or microorganisms, but most often they’re made synthetically. The information below is about melatonin dietary supplements. Not getting enough sleep can affect all areas of life. Mood changes You might feel moodier or more irritable around the time of menopause. Scientists don’t know why this happens. It’s possible that stress, family changes such as growing children or aging parents, a history of depression, or feeling tired could be causing these mood changes. Talk with your primary care provider or a mental health professional about what you’re experiencing. There are treatments available to help. Your body seems different Your waist could get larger. You could lose muscle and gain fat. Your skin could become thinner. You might have memory problems, and your joints and muscles could feel stiff and achy. Researchers are exploring such changes and how they relate to hormones and growing older. In addition, for some women, symptoms may include aches and pains, headaches and heart palpitations. Follow up with a doctor. Because menopausal symptoms may be caused by changing hormone levels, it is unpredictable how often women will experience symptoms and how severe they will be. Vaginal health and sexuality After menopause, the vagina may become drier, which can make sexual intercourse uncomfortable. Read about options for addressing vaginal pain during sex in Sex and Menopause: Treatment for Symptoms. You may also find that your feelings about sex are changing. You could be less interested, or you could feel freer and sexier because after one full year without a period, you can no longer become pregnant. However, you could still be at risk for sexually transmitted diseases (STDs). Your risk for an STD increases if you have sex with more than one person or with someone who has sex with others. If so, make sure your partner uses a condom each time you have sex.

Some women have vaginal dryness with menopause. This can make sex painful. Women may also experience a tightening of the vaginal opening, burning, itching, and dryness (called vaginal atrophy). Fortunately, there are options for women to address these issues. Talk with your provider at Redefined For Her to discuss treatment options. Sex is becoming painful: What can I do? Pain during sexual activity is called dyspareunia. Like other symptoms of the menopausal transition, dyspareunia may be minor and not greatly affect a woman’s quality of life. However, some women experience severe dyspareunia that prevents them from engaging in any sexual activity without pain. Many find relief from vaginal dryness during sex by using a nonprescription water-based lubricant; however, silicone based lubricants can offer longer lasting lubrication. Other women try over-the-counter vaginal moisturizers or natural oils like coconut oil or olive olive oil, which are used regularly and not just during sex to replenish moisture and relieve dryness. Local vaginal treatments (such as estrogen creams, rings, or tablets) are often used to treat this symptom. These treatments provide lower hormone doses to the rest of the body than a pill or patch. The U.S. Food and Drug Administration has approved two nonhormone medications, called ospemifene and prasterone, to treat moderate to severe dyspareunia caused by vaginal changes that occur with menopause. For more information on sex and menopause Office on Women's Health Department of Health and Human Services 800-994-9662 www.womenshealth.gov American College of Obstetricians and Gynecologists 800-673-8444 resources@acog.org www.acog.org North American Menopause Society 440-442-7550 info@menopause.org www.menopause.org Services & Advocacy for Gay, Lesbian, Bisexual & Transgender Elders (SAGE) 212-741-2247 info@sageusa.org www.sageusa.org Sexuality Information and Education Council of the United States 202-265-2405 www.siecus.org

Hormone therapy was once routinely used to treat menopausal symptoms and protect long-term health. Then large clinical trials showed health risks. What does this mean for you? -Adapted from By Mayo Clinic Staff Hormone replacement therapy is medication that contains female hormones. You take the medication to replace the estrogen that your body stops making during menopause. Hormone therapy is most often used to treat common menopausal symptoms, including hot flashes and vaginal discomfort. Hormone therapy has also been proved to prevent bone loss and reduce fracture in postmenopausal women. However, there are risks associated with using hormone therapy. These risks depend on the type of hormone therapy, the dose, how long the medication is taken and your individual health risks. For best results, hormone therapy should be tailored to each person and reevaluated every so often to be sure the benefits still outweigh the risks. What are the basic types of hormone therapy? Hormone replacement therapy primarily focuses on replacing the estrogen that your body no longer makes after menopause. There are two main types of estrogen therapy: Systemic Hormone Therapy Systemic estrogen — which comes in pill, skin patch, ring, gel, cream or spray form — typically contains a higher dose of estrogen that is absorbed throughout the body. It can be used to treat any of the common symptoms of menopause. Low-dose vaginal products Low-dose vaginal preparations of estrogen — which come in cream, tablet or ring form — minimize the amount of estrogen absorbed by the body. Because of this, low-dose vaginal preparations are usually only used to treat the vaginal and urinary symptoms of menopause. If you haven't had your uterus removed, your doctor will typically prescribe estrogen along with progesterone or progestin (progesterone-like medication). This is because estrogen alone, when not balanced by progesterone, can stimulate growth of the lining of the uterus, increasing the risk of endometrial cancer. If you have had your uterus removed (hysterectomy), you may not need to take progestin What are the risks of hormone therapy? In the largest clinical trial to date, hormone replacement therapy that consisted of an estrogen-progestin pill (Prempro) increased the risk of certain serious conditions, including: Heart disease Stroke Blood clots Breast cancer Subsequent studies have suggested that these risks vary depending on: Age. Women who begin hormone therapy at age 60 or older or more than 10 years from the onset of menopause are at greater risk of the above conditions. But if hormone therapy is started before the age of 60 or within 10 years of menopause, the benefits appear to outweigh the risks. Type of hormone therapy. The risks of hormone therapy vary depending on whether estrogen is given alone or with progestin, and on the dose and type of estrogen. Health history. Your family history and your personal medical history and risk of cancer, heart disease, stroke, blood clots, liver disease and osteoporosis are important factors in determining whether hormone replacement therapy is appropriate for you. All of these risks should be considered by you and your provider when deciding whether hormone therapy might be an option for you. Who can benefit from hormone therapy? The benefits of hormone therapy may outweigh the risks if you're healthy and you: Have moderate to severe hot flashes. Systemic estrogen therapy remains the most effective treatment for the relief of troublesome menopausal hot flashes and night sweats. Have other symptoms of menopause. Estrogen can ease vaginal symptoms of menopause, such as dryness, itching, burning and discomfort with intercourse. Need to prevent bone loss or fractures. Systemic estrogen helps protect against the bone-thinning disease called osteoporosis. However, a medication category called bisphosphonates, is the usual first medication recommended to treat osteoporosis. But estrogen therapy may help if you either can't tolerate or aren't benefiting from other treatments. Experience early menopause or have estrogen deficiency. If you had your ovaries surgically removed before age 45, stopped having periods before age 45 (premature or early menopause) or lost normal function of your ovaries before age 40 (primary ovarian insufficiency), your body has been exposed to less estrogen than the bodies of women who experience typical menopause. Estrogen therapy can help decrease your risk of certain health conditions, including osteoporosis, heart disease, stroke, dementia and mood changes. If you take hormone therapy, how can you reduce risk? Talk to your provider about these strategies: Find the best product and delivery method for you. You can take estrogen in the form of a pill, patch, gel, vaginal cream, or slow-releasing suppository or ring that you place in your vagina. If you experience only vaginal symptoms related to menopause, estrogen in a low-dose vaginal cream, tablet or ring is usually a better choice than an oral pill or a skin patch. Minimize the amount of medication you take. Use the lowest effective dose for the shortest amount of time needed to treat your symptoms. If you're younger than age 45, you need enough estrogen to provide protection against the long-term health effects of estrogen deficiency. If you have lasting menopausal symptoms that significantly impair your quality of life, your doctor may recommend longer term treatment. Seek regular follow-up care. See your provider regularly to ensure that the benefits of hormone therapy continue to outweigh the risks, and for screenings such as mammograms and pelvic exams. Make healthy lifestyle choices. Include physical activity and exercise in your daily routine, eat a healthy diet, maintain a healthy weight, don't smoke, limit alcohol, manage stress, and manage chronic health conditions, such as high cholesterol or high blood pressure. If you haven't had a hysterectomy and are using systemic estrogen therapy, you'll also need progestin. Your provider can help you find the delivery method that offers the most benefits and convenience with the least risks and cost. What can you do if you can't take hormone therapy? You may be able to manage menopausal hot flashes with healthy-lifestyle approaches such as keeping cool, limiting caffeinated beverages and alcohol, and practicing paced relaxed breathing or other relaxation techniques. There are also several nonhormone prescription medications that may help relieve hot flashes. For vaginal concerns such as dryness or painful intercourse, a vaginal moisturizer or lubricant may provide relief. You might also ask your provider about the prescription medication ospemifene (Osphena), which may help with episodes of painful intercourse. The bottom line: Hormone therapy isn't all good or all bad To determine if hormone therapy is a good treatment option for you, talk to us about your individual symptoms and health risks. Be sure to keep the conversation going throughout your menopausal years. As researchers learn more about hormone therapy and other menopausal treatments, recommendations may change. If you continue to have othersome menopausal symptoms, review treatment options with your doctor on a regular basis.

Osteoporosis causes bones to become weak and brittle — so brittle that a fall or even mild stresses such as bending over or coughing can cause a fracture. Osteoporosis-related fractures most commonly occur in the hip, wrist or spine. Bone is living tissue that is constantly being broken down and replaced. Osteoporosis occurs when the creation of new bone doesn't keep up with the loss of old bone. Osteoporosis affects men and women of all races. But white and Asian women, especially older women who are past menopause, are at highest risk. Medications, healthy diet and weight-bearing exercise can help prevent bone loss or strengthen already weak bones. Symptoms There typically are no symptoms in the early stages of bone loss. But once your bones have been weakened by osteoporosis, you might have signs and symptoms that include: Back pain, caused by a fractured or collapsed vertebra Loss of height over time A stooped posture A bone that breaks much more easily than expected When to see a provider Talk to your provider at Redefined for Her about osteoporosis if you went through early menopause or took corticosteroids for several months at a time, or if either of your parents had hip fractures.

Bone Density Scan (DEXA Scan) DEXA (dual x-ray absorptiometry) scans measure bone density (thickness and strength of bones) by passing a high and low energy x-ray beam (a form of ionizing radiation) through the body, usually in the hip and the spine. This procedure is important for diagnosing (seeing if someone has) osteoporosis or bone thinning and may be repeated over time to track changes in bone density. The amount of radiation used in DEXA scans is very low and similar to the amount of radiation used in common x-rays. Although we all are exposed to ionizing radiation every day from the natural environment, added exposures can slightly increase the risk of developing cancer later in life. What You Should Know Your healthcare provider may recommend a DEXA scan to test for osteoporosis or thinning of your bones. Screening for osteoporosis is recommended for women who are 65 years old or older and for women who are 50 to 64 and have certain risk factors, such as having a parent who has broken a hip. However, there are other risk factors for osteoporosis besides age and gender, such as some intestinal disorders, multiple sclerosis, or low body weight. Your healthcare provider may recommend a DEXA scan if you have any of these other risk factors. DEXA scans should be used when the health benefits outweigh the risks. Talk to your healthcare provider about any concerns you have before a DEXA scan. Nearly 1in 5 women and 1 in 20 men over the age of 50 are affected by osteoporosis. Osteoporosis increases the risk for broken bones and can have serious effects in older adults. What To Expect Before the scan Make sure to let your healthcare provider or radiologist (medical professional specially trained in radiation procedures) if you are pregnant or think you may or could be pregnant. Dress in loose, comfortable clothing. Don’t wear anything that has metal on it like buckles, buttons, or zippers. Metal can interfere with test results. Find information on special considerations pregnant women and children. During the scan You may be asked to remove jewelry, eyeglasses, and any clothing that may interfere with the imaging. You will lay on a table and the radiologist or medical assistant will position your legs on a padded box. They also may place your foot in a device so that your hip is turned inward. While the image is taken, lay still and follow instructions. You may need to hold your breath for a few seconds After the scan The procedure typically lasts about 15-20 minutes. Your healthcare provider will follow up with you with your results. They will show a T-score and a Z-score. The T-score shows how your bone density compares to the optimal peak bone density for your gender. The Z-score shows how your bone density compares to the bone densities of others who are the same age, gender, and ethnicity. Benefits and Risks of DEXA Scans DEXA scans are different from other imaging procedures because they are used to screen for a specific condition. Benefits: Detects weak or brittle bones to help predict the odds of a future fracture Determines if bone density is improving, worsening, or staying the same Can help you and your healthcare provider come up with plans to improve your bone strength and prevent worsening conditions Risks: A very slight increase in possibility of future cancer, similar to the risks from x-rays.

Levonorgestrel intrauterine system (LNG IUD)—The LNG IUD is a small T-shaped device like the Copper T IUD. It is placed inside the uterus by a doctor. It releases a small amount of progestin each day to keep you from getting pregnant. The LNG IUD stays in your uterus for up to 3 to 6 years, depending on the device. Typical use failure rate: 0.1-0.4%. Copper T intrauterine device (IUD)—This IUD is a small device that is shaped in the form of a “T.” Your doctor places it inside the uterus to prevent pregnancy. It can stay in your uterus for up to 10 years. Typical use failure rate: 0.8%.

Implant— The implant is a single, thin rod that is inserted under the skin of a women’s upper arm. The rod contains a progestin that is released into the body over 3 years. Typical use failure rate 0.1% Injection or "shot"— Women get shots of the hormone progestin in the buttocks or arm every three months from their doctor. Typical use failure rate: 4%. Combined oral contraceptives— Also called “the pill,” combined oral contraceptives contain the hormones estrogen and progestin. It is prescribed by a doctor. A pill is taken at the same time each day. If you are older than 35 years and smoke, have a history of blood clots or breast cancer, your doctor may advise you not to take the pill. Typical use failure rate: 7%. Progestin only pill— Unlike the combined pill, the progestin-only pill (sometimes called the mini-pill) only has one hormone, progestin, instead of both estrogen and progestin. It is prescribed by a doctor. It is taken at the same time each day. It may be a good option for women who can’t take estrogen. Typical use failure rate: 7%. Patch— This skin patch is worn on the lower abdomen, buttocks, or upper body (but not on the breasts). This method is prescribed by a doctor. It releases hormones progestin and estrogen into the bloodstream. You put on a new patch once a week for three weeks. During the fourth week, you do not wear a patch, so you can have a menstrual period. Typical use failure rate: 7%. Hormonal vaginal contraceptive ring— The ring releases the hormones progestin and estrogen. You place the ring inside your vagina. You wear the ring for three weeks, take it out for the week you have your period, and then put in a new ring. Typical use failure rate: 7%.

Diaphragm or cervical cap— Each of these barrier methods are placed inside the vagina to cover the cervix to block sperm. The diaphragm is shaped like a shallow cup. The cervical cap is a thimble-shaped cup. Before sexual intercourse, you insert them with spermicide to block or kill sperm. Visit your doctor for a proper fitting because diaphragms and cervical caps come in different sizes. Typical use failure rate for the diaphragm: 17%. Sponge— The contraceptive sponge contains spermicide and is placed in the vagina where it fits over the cervix. The sponge works for up to 24 hours, and must be left in the vagina for at least 6 hours after the last act of intercourse, at which time it is removed and discarded. Typical use failure rate: 14% for women who have never had a baby and 27% for women who have had a baby. Male Condom— Worn by the man, a male condom keeps sperm from getting into a woman’s body. Latex condoms, the most common type, help prevent pregnancy, HIV and other STDs, as do the newer synthetic condoms. “Natural” or “lambskin” condoms also help prevent pregnancy, but may not provide protection against STDs, including HIV. Typical use failure rate: 13%.Condoms can only be used once. You can buy condoms, KY jelly, or water-based lubricants at a drug store. Do not use oil-based lubricants such as massage oils, baby oil, lotions, or petroleum jelly with latex condoms. They will weaken the condom, causing it to tear or break. Female Condom— Worn by the woman, the female condom helps keeps sperm from getting into her body. It is packaged with a lubricant and is available at drug stores. It can be inserted up to eight hours before sexual intercourse. Typical use failure rate: 21%, and also may help prevent STDs. Spermicides— These products work by killing sperm and come in several forms—foam, gel, cream, film, suppository, or tablet. They are placed in the vagina no more than one hour before intercourse. You leave them in place at least six to eight hours after intercourse. You can use a spermicide in addition to a male condom, diaphragm, or cervical cap. They can be purchased at drug stores. Typical use failure rate: 21%.

Fertility awareness- based methods— Understanding your monthly fertility pattern can help you plan to get pregnant or avoid getting pregnant. Your fertility pattern is the number of days in the month when you are fertile (able to get pregnant), days when you are infertile, and days when fertility is unlikely, but possible. If you have a regular menstrual cycle, you have about nine or more fertile days each month. If you do not want to get pregnant, you do not have sex on the days you are fertile, or you use a barrier method of birth control on those days. Failure rates vary across these methods. Range of typical use failure rates: 2-23%.

For women who have recently had a baby and are breastfeeding, the Lactational Amenorrhea Method (LAM) can be used as birth control when three conditions are met: amenorrhea (not having any menstrual periods after delivering a baby) fully or nearly fully breastfeeding, and less than 6 months after delivering a baby. LAM is a temporary method of birth control, and another birth control method must be used when any of the three conditions are not met.

Emergency contraception is NOT a regular method of birth control. Emergency contraception can be used after no birth control was used during sex, or if the birth control method failed, such as if a condom broke. Copper IUD— Women can have the copper T IUD inserted within five days of unprotected sex. Emergency contraceptive pills— Women can take emergency contraceptive pills up to 5 days after unprotected sex, but the sooner the pills are taken, the better they will work. There are three different types of emergency contraceptive pills available in the United States. Some emergency contraceptive pills are available over the counter.

Femail Sterilization—Implant Tubal ligation or "tying tubes"— A woman can have her fallopian tubes tied (or closed) so that sperm and eggs cannot meet for fertilization. The procedure can be done in a hospital or in an outpatient surgical center. You can go home the same day of the surgery and resume your normal activities within a few days. This method is effective immediately. Typical use failure rate: 0.5%. Male Sterilization-Vasectomy— This operation is done to keep a man’s sperm from going to his penis, so his ejaculate never has any sperm in it that can fertilize an egg. The procedure is typically done at an outpatient surgical center. The man can go home the same day. Recovery time is less than one week. After the operation, a man visits his doctor for tests to count his sperm and to make sure the sperm count has dropped to zero; this takes about 12 weeks. Another form of birth control should be used until the man’s sperm count has dropped to zero. Typical use failure rate: 0.15%.

A hysterectomy is defined as removal of a woman’s uterus (womb). This surgical procedure is done for many reasons that include uterine fibroids or abnormal uterine bleeding, not responsive to medical treatment, cancer and chronic pelvic pain. This procedure can be done using an open abdominal incision, through the vagina or, in a minimally invasive fashion by laparoscopy. Types of hysterectomies include a: total abdominal hysterectomy, laparoscopically assisted vaginal hysterectomy, total laparoscopically hysterectomy (with and without robot assistance), supra-cervical hysterectomy (the cervix remains in place but the top of the uterus is removed) and total vaginal hysterectomy. In recent years, it is customary to remove both fallopian tubes when a hysterectomy is performed. A separate procedure that involves removing one or both of the ovaries may also be performed at the time of a hysterectomy depending on the circumstances.

Laparoscopy is a minimally invasive surgical procedure. It is characterized this way because the abdominal incisions in this procedure are much smaller than an open abdominal incision. A special camera and instruments are passed through these small opening in order to visualize the pelvic organs and perform the intended surgery. This approach to surgery, when possible, decreases hospital stay, post operative pain and decreases the time for recovery.

Myomectomy is a surgery that removes fibroids from the uterus, while leaving the uterus in place. This can be done through an open abdominal incision, by laparoscopy using the assistance of a robot and with hysteroscopy.

Hysteroscopy is done with a tool called a hysteroscope that allows the surgeon to look inside of the uterus through the vagina. The hysteroscope, contains a light, that enables visualization of the uterine cavity. This is often done to evaluate and treat abnormal uterine bleeding by removing fibroids, polyps, scar tissue and to perform endometrial ablations.

This is a procedure done using laparoscopy and occasionally laparotomy (an open abdominal incision) depending on the size and type of cyst.

There are times when ovaries become diseased or need to be removed for other reasons and they typically may be removed using the laparoscopic approach.

There are certain conditions that may cause a patient to develop adhesions or scar tissue within their pelvis. Adhesions cause pelvic surfaces to stick to each other and can cause pain and dysfunction. This may occur with previous surgeries, pelvic infections or endometriosis. Laparoscopy may be used to remove adhesions, restore function and minimize or relieve associated pain.

It is estimated that up to 50% of women between the age of 50-79 have some degree of pelvic prolapse or pelvic relaxation on physical exam. Not all of these women are symptomatic but for those that are the options of pelvic floor physical therapy, pessary and surgery are available. Symptoms may include bowel or bladder function problems, discomfort with intercourse and pelvic pain.

Removal of the fallopian tubes or the sealing of them are surgical ways that a person who no longer wants to bear children can obtain permanent sterilization.

The loop electrosurgical excision procedure (LEEP) is an outpatient procedure used to remove cells and tissue from the cervix as a means of diagnosing or treating abnormal or cancerous cells.

In the United States, among heterosexual women aged 15 to 49 years with no prior births, about 1 in 5 (19%) are unable to get pregnant after one year of trying (infertility). Both men and women can contribute to infertility.

Disruption of ovarian function (presence or absence of ovulation) When a woman doesn’t ovulate during a menstrual cycle, it’s called anovulation. Potential causes of anovulation include the following: Polycystic ovary syndrome (PCOS). PCOS is a condition that causes women to not ovulate, or to ovulate irregularly. Some women with PCOS have elevated levels of testosterone, which can cause acne and excess hair growth. PCOS is the most common cause of female infertility. Diminished ovarian reserve (DOR). Women are born with all of the eggs that they will ever have, and the number of eggs declines naturally over time. DOR is a condition in which there are fewer eggs remaining in the ovaries than expected for a given age. It may occur due to congenital (condition present at birth), medical, surgical, or unexplained causes. Women with DOR may be able to conceive naturally, but will produce fewer eggs in response to fertility treatments. Premature ovarian insufficiency (POI). POI, sometimes referred to as premature menopause, occurs when a woman’s ovaries fail before she is 40 years of age. Although certain exposures, such as chemotherapy or pelvic radiation therapy, and certain medical conditions may cause POI, the cause is often unexplained. About 5% to 10% of women with POI conceive naturally and have a normal pregnancy. Menopause is a natural decline in ovarian function that usually occurs around age 50. By definition, a woman in menopause has not had a period for at least one year. Many women experience hot flashes, mood changes, difficulty sleeping, and other symptoms as well. Fallopian tube obstruction (whether fallopian tubes are open, blocked or swollen) Risk factors for blocked fallopian tubes (Tubal occlusion) can include a history of pelvic infection, rupture appendix, gonorrhea, chlamydia, endometriosis, or prior abdominal surgery. Physical characteristics of the uterus Depending on a woman’s symptoms, the uterus may be evaluated by transvaginal ultrasound to look for fibroids or other problems, including intrauterine adhesions, endometrial polyps, adenomyosis, and congenital anomalies of the uterus. A sonohysterogram or hysteroscopy may also be performed to further evaluate the uterine environment. Disruption of testicular or ejaculatory function Varicocele, a condition in which the veins within a man’s testicle are enlarged. This can affect the number or shape of the sperm. Trauma to the testes may affect sperm production and result in lower number of sperm. Heavy alcohol use, smoking, anabolic steroid use, and illicit drug use. Cancer treatment involving certain types of chemotherapy, radiation, or surgery to remove one or both testicles. Medical conditions such as diabetes, cystic fibrosis, certain types of autoimmune disorders, and certain types of infections may cause testicular failure. Hormonal Disorders Improper function of the hypothalamus or pituitary glands. The hypothalamus and pituitary glands in the brain produce hormones that maintain normal ovulation and testicular function. Genetic Disorders Click to take genetic testing quiz

Most experts suggest women younger than age 35 with no apparent health or fertility problems and regular menstrual cycles should try to conceive for at least one year before seeing a doctor. However, for women aged 35 years or older, couples should see a health care provider after 6 months of trying unsuccessfully. Women over 40 years may consider seeking more immediate evaluation and treatment. Some health problems also increase the risk of infertility. So, couples with the following signs or symptoms should not delay seeing their health care provider when they are trying to become pregnant: For women: Irregular periods or no menstrual periods Endometriosis A history of pelvic inflammatory disease Known or suspected uterine or tubal disease A history of more than one miscarriage Genetic or acquired conditions that predispose to diminished ovarian reserve (chemotherapy, radiation) For men: A history of testicular trauma Prior hernia surgery Prior use of chemotherapy A history of infertility with another partner Sexual dysfunction

Doctors will begin by collecting medical and sexual history from both partners. The initial evaluation may include a semen analysis, ovulation testing, and tubal evaluation.

Infertility can be treated with medicine, surgery, intrauterine insemination, or assisted reproductive technology. Often, medication and intrauterine insemination are used at the same time. Doctors recommend specific treatments for infertility on the basis of: The factors contributing to infertility. The duration of infertility. The age of the female. The couple’s treatment preference after counseling about success rates, risks, and benefits of each treatment option.

There are two situations in which fertility drugs may be useful. First, these drugs can be used to induce an egg to develop and be released in women who are not ovulating on their own. This is known as ovulation induction. Fertility drugs can also be used to increase the chances of pregnancy in women who are already ovulating. This is known as superovulation. Some common medicines used to treat infertility in women include: Clomiphene citrate, sold under the trade name Clomid, is a medicine that causes ovulation by acting on the pituitary gland. This medicine is taken by mouth Letrozole, sold under the trade name Femara, is a medication that has been widely used in women with breast cancer. Letrozole belongs to a class of medications known as aromatase inhibitors. Aromatase is an enzyme that is responsible for the production of estrogen in the body. Letrozole works by inhibiting aromatase thereby suppressing estrogen production which causes the brain to naturally make more follicle-stimulating hormone (FSH). This medicine is taken by mouth Human menopausal gonadotropin (hMG) is an injectable medication often used for women who don’t ovulate because of problems with their pituitary gland—hMG acts directly on the ovaries to stimulate development of mature eggs. Follicle-stimulating hormone or FSH is an injectable medication that works much like hMG. It stimulates development of mature eggs within the ovaries. Metformin, sold under the trade name Glucophage, is a medicine doctors use for women who have insulin resistance or diabetes and PCOS. This drug helps lower the high levels of insulin in women with these conditions. This helps the body to ovulate. This medicine is taken by mouth. Bromocriptine is a medication used for women with ovulation problems because of high levels of prolactin. These medications are taken by mouth.

Intrauterine insemination (IUI) is an infertility treatment that is often called artificial insemination. In this procedure, specially prepared sperm are inserted into the woman’s uterus. Sometimes the woman is also treated with medicines that stimulate ovulation before IUI. IUI is often used to treat: Mild male factor infertility. Couples with unexplained infertility.

Assisted Reproductive Technology (ART) includes all fertility treatments in which either eggs or embryos are handled outside of the body. In general, ART procedures involve removing mature eggs from a woman’s ovaries using a needle, combining the eggs with sperm in the laboratory, and returning the embryos to the woman’s body or donating them to another woman. The main type of ART is in vitro fertilization (IVF).

Bullet ovulation induction Tubal surgery: Robotic removal of uterine fibroids (myomectomy) Robotic resection of endometriosis IUI with partner sperm IUI with donor sperm Sperm wash (coming soon)