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UNDERSTANDING RECURRENT PREGNANCY LOSS – Part 1: CAUSES

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Having a pregnancy loss can be heartbreaking. Having multiple miscarriages can be truly devastating. Each new pregnancy brings hope, but also great anxiety; each new miscarriage aggravates the feelings of loss, grief and sense of failure… 

It is natural to want answers. Knowing the reason of a pregnancy loss can help you make sense of what has happened. Furthermore, finding the cause of the problem will help prevent it from happening again, or at least reduce its risk. Things are not so simple though when it comes to recurrent miscarriage: most of the times, investigations don’t come out with a clear answer…

The purpose of this article is to help you understand recurrent pregnancy loss and to present the most recent scientific information regarding its cause, diagnosis and treatment. Due to the extensiveness of the subject, this first article will deal only with the known causes of repeated miscarriage; two other articles on testing and treatment will follow.

What is Recurrent Pregnancy Loss?

A pregnancy loss is the spontaneous loss of a pregnancy before 24 weeks of gestation. Recurrent Pregnancy Loss (RPL) is considered after the loss of two or more pregnancies; this includes pregnancies after spontaneous conception or after assisted reproduction (e.g. IUI and IVF/ICSI). Other pregnancy complications such as ectopic pregnancies and molar pregnancies are not included. 

  • Primary RPL is a term used for women who have not had a baby before their pregnancy losses. 
  • Secondary RPL means they have had at least one baby before their losses. 

It is estimated that RPL affects 1 to 2% of couples.

What causes RPL?

There are several factors that may be responsible for RPL. But you should know that in about half (50%) of the RPL cases, no cause is found. This is called unexplained RPL.

Here are some of the causes that are related to multiple miscarriages:

1) Age

The older you are, the greater your risk of having a miscarriage. If a woman is aged over 40, more than 50% of pregnancies end in a miscarriage. The same is true for RPL. Miscarriages may also be more common if the father is older, although it is not clear whether paternal age is related to repeated miscarriages.

2) Genetic problems

  • Genetic defects resulting in an abnormal fetus can be a major cause of miscarriage. About half of all miscarriages in the first three months of pregnancy are due to chromosomal problems, although most of the times this is of random occurrence .
  • In about 4 in 100 couples (4%) with recurrent miscarriage, one partner will have an abnormality on one of their chromosomes. Although this may not affect the parent, it may sometimes cause a miscarriage.

3) Thrombophilia

Thrombophilia is a condition in which your blood clots more than usual; it may be inherited (passed down genetically) or acquired (not inherited). Thrombophilia is not only related to RPL, but also to other pregnancy complications.

  • Inherited thrombophilia is due to certain gene defects. According to the gene involved, it may be related to early or late repeated miscarriage.
  • Antiphospholipid syndrome (APS) is an acquired thrombophilic condition. It is uncommon but strongly related to RPL.

4) Abnormal hormone levels

Miscarriage can occur when the uterine lining does not develop sufficiently, therefore the fertilized egg does not have the best environment for implantation and nourishment; this can be the result of abnormal hormone levels.

Women with thyroid problems and women with diabetes (or insulin problems) are usually at a higher risk for miscarriage due to hormonal imbalances. Women with polycystic ovaries syndrome, are also at risk. In addition, elevated prolactin levels can also disrupt normal uterine lining development.

5) Problems of the uterus

The shape of the uterus may cause miscarriage, usually by interfering with the implantation of the fertilized egg.

  • A septum, that is a fibrous wall which divides the uterine cavity, can cause poor implantation and pregnancy loss.
  • Uterine fibroids, polyps, adhesions may eventually cause pregnancy loss by blocking the opening of the fallopian tube(s) or if their position is affecting the normal functioning of the uterine lining. Their relationship though with RPL is less clear.
  • Another probable cause of miscarriage is an incompetent cervix, meaning the cervical muscle is weak and cannot remain closed; as the developing fetus grows puts pressure on the cervix, it starts to shorten and open, resulting in miscarriage.

6) Immune Causes

It has been suggested that some women miscarry because their immune system does not respond to the baby in the usual way. This is known as an alloimmune reaction. Although numerous immunological factor have been investigated, there is no clear evidence to support this theory at present, and further research is needed.

7) Sperm defects

Sperm DNA is the most important part of the sperm, as it contains the genetic information that will be passed on to the baby. DNA can be damaged during sperm production and transport; this damage is known as DNA fragmentation. The recents years it has become evident that high levels of sperm DNA fragmentation seem to increase the likelihood of pregnancy loss.

Sperm DNA fragmentation can be provoked by stress, smoking, recreational drugs, obesity and other unhealthy lifestyle factors. 

8) Infections

Certain infections have been proposed as the cause of RPL, such as rubella, herpes simplex, ureaplasma, cytomegalovirus and chlamydia. However, the role of these infections in recurrent miscarriage is unclear and probably null. A persistent infection of the endometrium (chronic endometritis) may be related to RPL, but more research is needed to know this for sure.

9) Environmental Factors

Certain toxins you may be exposed to can also result in fetal damage or miscarriage, especially if you experience regular exposure. Toxins such as organochlorine pesticides, certain heavy metals (selenium, lead cadmium), organic solvents, anesthetic gases (occupational exposure), have all been blamed for causing RPL. Likewise, lack of certain micronutrients (zinc, copper, vitamin E) have been proposed as possible causes of RPL. 

Although exposure to possible hazardous substances should be avoided during pregnancy (this is true for all pregnant women), there are insufficient data to recommend protection against a certain occupational or environmental factor in women with RPL.

10) Lifestyle-related factors 

  • Studies also indicate that the use of marijuana, tobacco, alcohol and excessive consumption of caffeine can all affect fetal development and result in miscarriage. Although their relationship with RPL is not clear, it is recommended that women limit or avoid their use during pregnancy.
  • Being overweight or significantly underweight have been both associated with miscarriages, as well as with pregnancy and childbirth complications. While maternal obesity is a strong risk factor in RPL, the association with very low weight is less clear. Male overweight may also be a negative factor, since is responsible for DNA damage (see above). Striving for a healthy, normal weight is recommended, both for the female and male partner. 
  • Intensive exercise or no exercise at all have been both blamed as a cause of RPL, but there is not clear scientific evidence and further research is needed. Moderate (leisure) physical activity seems to be safe, and beneficial for other pregnancy complications, such as diabetes and hypertension of pregnancy.
  • Whether stress increases the chances of another pregnancy loss in the next pregnancy is a major concern for all couples with RPL. Studies to date indicate that there is an association between stress and pregnancy loss, but it is not whether the stress is a result or a causal factor in RPL.

 

Read the second part here: Understanding Recurrent Pregnancy Loss – Testing (coming soon)

 

Photo credits

futurelab-ksa.com

 

TRYING TO GET PREGNANT: 14 FERTILITY MYTHS DEBUNKED

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We live in the era of informatics. Knowledge is easily accessible to us: we can learn virtually anything by just googling it. But paradoxically too much information many times leads to misinformation.

When it comes to fertility issues, there is a lot of disinformation going around. Therefore, it is no surprising what a recent survey showed: knowledge regarding ovulation, fertility, and conception issues is limited among women, and many tend to believe certain myths and misconceptions.

These are 14 fertility myths most people believe, but that science has debunked:

MYTH #1.  Maternity wise, 40s is the new 30s

Our life expectancy is longer, and we tend to postpone maternity due to career or study purposes. From that aspect, the 40s can be easily regarded as the new 30s. Unfortunately, this is not true for our ovaries: by the age of 30, a healthy woman has about a 20% chance of conceiving each month, by the time she reaches 40 her odds drop to about 5%.

This is one of the most commonly believed misconceptions: unaware of the age-related fertility decline, many women start seeking  help to conceive in their 40s, when they may have already missed the opportunity to become parents. 

You should be aware that there is a biological clock, and it’s ticking! If for personal reasons you cannot have a child right now, you may freeze your eggs to use them in the future.

MYTH #2. Certain sex positions increase the chances of getting pregnant

You will find plenty of (mis)information on this topic! In general, it is said that the best positions for getting pregnant are the missionary position (the woman lying on her back, her partner on top) and the “doggy position” (rear vaginal penetration, with the woman on her hands and knees) because they provide the deepest penetration, allowing the man to ejaculate closer to the opening of the cervix. 

In fact, there’s no scientific evidence to prove that. This belief is largely based on a single study that looked at the position of the penis in relation to these two sex positions, but it didn’t address pregnancy chances at all.

Therefore, no position seems to be better when it comes to maximizing your chances of making a baby. Sperm can be found in the cervical canal just a few seconds after ejaculation, and within 5 minutes in the tube, regardless of the coital position.

MYTH #3. Lifting your legs in the air for 20 minutes after having sex will help you get pregnant

You have probably heard this one: “lie in bed with your feet in the air after having sex to increase your chances of getting pregnant”. In fact, this is not (totally) true. You may lay in bed for 10-15 minutes after intercourse, as by this time the sperm have largely reached the cervix, and many may even be inside the tube.

In fact, a new study challenged both beliefs: women having artificial insemination were split into two groups – one that rested on their back with their knees raised for 15 minutes after the procedure and one that got up immediately. It turned out that, after several courses of treatment, 32% of the immobile group fell pregnant, compared with 40% per cent in the active group.

Therefore, there is no need to put pillows under your bottom during intercourse to get an advantageous tilt, or to perform cycling motions with your feet in the air.

MYTH #4. If we have sex every day the sperm becomes too weak, reducing our chances of getting pregnant 

How often should we make love to boost our chances of pregnancy? You will find all sorts of advice on the web: every other day, 3 times a week, every single day! Which one is correct?

One thing is clear: abstinence intervals greater than 5 days impair the sperm number and quality. Nevertheless, there is not much difference whether men ejaculate every day or every other day. Most fertility specialists used to recommend intercourse every other day, as this would increase sperm quality, particularly in men with lower sperm counts (oligozoospermia). However, recent studies show exactly the opposite: oligozoospermic men had better semen quality with daily ejaculation!

Recent scientific evidence suggests that making love every day confers a slight advantage: the highest chances of pregnancy (37% per cycle) were associated with daily intercourse, although sex on alternate days had comparable pregnancy rates (33%). On the other hand, we should keep in mind that the “obligation” to have sex every day may induce unnecessary stress to the couple, resulting in lack of sexual desire, low self esteem, and ultimately reduced frequency of intercourse.

Therefore, reproductive efficiency is highest when you have sex every day or every other day. The optimal frequency, though, is best defined by each couple’s own preference.

MYTH # 5. We only have sex when I ovulate, on day 14 of my cycle

Ovulation (when the egg drops from the ovary into the tubes) occurs once a month, usually between day 11 and day 21 of the cycle (measured from the first day of your period).

Each woman ovulates on her own schedule. While it is usually said that a woman with a 28-day cycle ovulates on cycle day 14, that’s not necessarily true: a study found that fewer than 10 percent of women with regular, 28-day cycles were ovulating on day 14.

We know that sperm cells are able to survive in the reproductive tract of a woman for about 5 days, and that once the egg is released, it will die in about 12-24 hours. Therefore, the fertile period -or “fertile window”- is a 6-day interval ending on the day of ovulation.

To boost your odds to become pregnant, have sex before and during ovulation, every day or every other day. If your cycles are irregular and you cannot figure out your fertile days, you may use an ovulation predictor kit, or otherwise visit a specialist, who can help you find your fertile window.

MYTH # 6. Smoking doesn’t affect our chances of getting pregnant. I will quit smoking as soon as I get pregnant

You are most likely aware that smoking during pregnancy is dangerous, as it can lead to miscarriage, premature birth, low-birthweight babies and -according to recent studies– congenital malformations.

But you should also know that smoking is harmful for your fertility: smoking as few as five cigarettes per day is associated with reduced fertility, both in women and men, and this seems to be true even for secondhand smoking. It has been estimated that smokers may have a 10-40% lower monthly fecundity (fertility) rate, and that up to 13% of infertility is due to smoking.

Smoking can affect ovulation, as well as the ability of the fertilized egg to implant in the uterus. The effect of tobacco is so harmful for the ovaries that menopause occurs, on average, one to four years earlier in smoking women than in nonsmoking ones.

Men are also affected by tobacco: decreases in sperm density, motility, and abnormalities in sperm morphology have been observed in men who smoke, which impact a man’s ability to fertilize an egg. 

Therefore, before trying for a baby, do yourself a favor … and put out the cigarette for good!

MYTH # 7. You don’t need to worry about your age. There’s always IVF

Another common misconception! Many women believe that, if age-related infertility strikes, they can overcome their problem by getting treated with in vitro fertilization (IVF). In fact, just as natural fertility declines with age, success rates with IVF also decline as a woman gets older.

According to the USA Center for Disease Control and Prevention (CDC), women younger than 35 years old have 33% chances of having a baby after IVF; for women ages 38 to 40 the success rate drops to 17%, while those 43 to 44 years old have only 3% chances of giving birth after IVF (using their own eggs).

IVF is not a guarantee to have a baby, and does not extend a woman’s reproductive life. Despite the number of celebrities having babies in their mid-40s and beyond, they may have not necessarily used their own eggs. While every woman has the right to keep her privacy, there is a wrong perception left that fertility treatments can extend a woman’s fertility span. There is a very low probability of improving success of conceiving after age 43 by using assisted reproduction using your own eggs. Nevertheless, you may opt to use oocyte donation (eggs of a younger woman) if age-related infertility stands in the way of parenthood.

MYTH # 8. A woman can’t get pregnant if she doesn’t have an orgasm

For men, things are clear: no orgasm, no pregnancy, as ejaculation occurs during orgasm. Well, that’s not entirely true: semen can be released during intercourse prior to orgasm in the so-called pre-ejaculation fluid, or pre-come (read more here).

For women though, getting pregnant has nothing to do with an orgasm. But could female orgasm improve the chances for conception? The answer is not clear.

Researchers have wondered for years about the purpose of female orgasm, and many theories have been proposed: 

  • Just the pleasure it provokes, so that women want to reproduce and preserve the species!
  • The “poleaxe” hypothesis: orgasms make women feel relaxed and sleepy so that they will lie down after sex and the sperm reach their destination more easily.
  • The “upsuck” theory: the contractions of the uterus “suck up” the sperm released in the vagina and help them travel through the uterus to the tubes.
  • Pair bonding: the hormones produced during orgasm (such as oxytocin and prolactin) contribute to warm feelings towards her partner.

Orgasms are not necessary to get pregnant, but there are plenty of good reasons to have one! Nevertheless, it is not uncommon that women trying to conceive link the desire for an orgasm with their desire to have a baby; this leads to psychological pressure and difficulty achieving orgasm, adding frustration to a process that is supposed to be pleasurable…

Try not to consider the orgasm just as goal to get pregnant. Enjoy the intimate time with your partner, without any pressure. If you have an orgasm, great. If not, that’s fine, too!

MYTH #9. We’ve already had one child, so conceiving again will be easy

Perhaps, but it’s no guarantee. Many individuals experience secondary infertility, or difficulty conceiving a second or subsequent child. 

Secondary infertility may be caused by age-related factors, both for you and your partner. Sometimes, a new underlying medical condition develops. Eventually, a fertility issue that always existed gets worse; while it didn’t prevent pregnancy before, now it has become a problem. A previous pregnancy may actually be the reason you don’t get pregnant again: surgical complications or infection after childbirth may have provoked scarring, which may in turn led to infertility.

Things change with time. Even if you got easily pregnant on your own before, if you’re struggling to have another child talk to your doctor, who can advice you on the next steps to follow.

MYTH #10. Infertility is a woman’s issue

Typically, the causes of infertility break down like this: 

  • Approximately one third of the couples struggle with male infertility;
  • In another third, the problem is female infertility;
  • The remaining third will either face both male and female fertility issues, or a cause will never be found (unexplained infertility).

Common causes of female infertily are: age, PCOS (polycystic ovary syndrome), tubal or pelvic issues, endometriosis, and family history. 

Common causes of male infertility tend to be from prior surgery, infection, or a problem present at birth.

As part of the preliminary work-up to determine the cause and treatment of infertility, both women and men will need to undergo clinical and specialized complementary exams.

MYTH #11. Men’s age doesn’t matter

While some men can father children into their 50’s or 60’s, men’s fertility isn’t age-proof: it starts declining in their 40s, although less drastically as compared to women’s fertility.

As a man ages, the concentration of mobile, healthy sperm and semen volume overall will decrease. It is clear now that men over the age of 40 have higher chances of having children with chromosomal abnormalities, causing miscarriages in their female partners. Moreover, researchers have found a direct link between paternal age and an increased risk of autism and schizophrenia. 

A man’s age does matter. While men may not have a complete drop off in fertility like women do, “advanced paternal age” is something couples should be aware of. Men’s biological clock is also ticking!

MYTH #12. If I take good care of my general health, my fertility will be in check too

Whereas a healthy body and mind may boost fertility in certain cases, most infertility situations cannot be resolved by a lifestyle or diet change, particularly those related to age.

It is a common belief that certain diet types can help you get pregnant. There is no evidence that vegetarian diets, low-fat diets, antioxidant- or vitamin-enriched diets will increase your chances of having a child.

A woman’s weight plays a role in fertility: those who are either very thin or obese may find it hard to conceive. If you are trying to get pregnant, learn more about some lifestyle tips to boost your chances of getting pregnant here.

MYTH #13. If a man can ejaculate, his fertility is fine

Many myths surround male fertility and their sexual performance. It is a common (and unfortunate) myth that if a man’s fertility is compromised, this means his sexual performance is the problem. This is not true. Problems with sperm count, shape, and movement are the primary causes of male infertility. 

Another common myth is that you can tell there is a problem with the sperm just by looking at the semen. In fact, even men that have no sperm cells at all (azoospermia) usually have normal-looking semen. 

For the vast majority of men with infertility, there are no visible or obvious signs that anything is wrong. Healthy erectile function and normal ejaculation are not guarantee that the sperm is in good shape.

That said, erectile dysfunction can be a possible symptom of infertility; it may due to low testosterone levels or a physical injury. Difficulty with ejaculation can also be a signal certain medical problems. But these are uncommon signs of male infertility.

If you are struggling to get pregnant, have your partner check in with his doctor. A semen analysis will help clarify whether his sperm are fit for conception.

MYTH #14. The birth control pill will affect your future fertility

All scientific evidence agrees that hormonal contraceptives do not make women sterile. Moreover, they may confer increased likelihood of pregnancy with long-term use, and in certain cases they can also preserve fertility. Read more on the contraceptive pill here.

 

To summarize:

Myths and misconceptions regarding fertility and conception are, unfortunately, widely disseminated. This is a serious problem, as misinformation may lead not only to unnecessary stress, but also to take wrong decisions…

Get yourself well informed! Consult your gynecologist, who can help you with any concerns you have. Your doctor can also give you some tips on lifestyle changes to optimize your fertility, prescribe some exams, and tell you when to come back if you don’t achieve pregnancy on your own.

Last, a good piece of advice: if you want to get pregnant, have lots of sex – as much as you want, whenever you want – and enjoy it! After you have had sex, do whatever you want – just don’t smoke 😉

 

Photo credits

Intro: pixabay.com; 1: rma-fl.com; 2: motherandbaby.co.uk; 3: romper.com; 4: pixabay.com; 5: wsaw.com; 6: babycenter.com; 7: nexter.org; 8: irishtimes.com; 9: health.clevelandclinic.org; 10: thefertilechickonline.com; 11: businessinsider.com; 12: hayatouki.com; 13: livescience.com; 14: pinterest.com

FACT OR MYTH? TRUTHS, HALF-TRUTHS AND MISCONCEPTIONS ABOUT THE BIRTH CONTROL PILL

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When introduced in the 1960s, the birth control pill became a symbol of female liberation

The contraceptive pill made its appearance more than 50 years ago. Emerging during a period of social and political upheaval, it  gave women the possibility to choose how and when to have a family, and to enjoy their sexual life. Thus, it is regarded as one of the greatest scientific inventions of the 20th century and one of the utmost symbols of female liberation.

From the very beginning though, this revolutionary method of contraception has been a source of controversy: some people thought it would create “a society with unbridled sexuality likely to undermine the foundations of the family”; others feared harmful effects and the birth abnormal children.

Fifty years later, the pill remains even more controversial than before and -paradoxically enough- more and more women are “liberating” from their “liberator”: the pill’s popularity is on the decline, a trend observed in many countries. The reasons behind this shift are many, but fear of side effects seems to the most recurrent. Arguably the web and social media, with the spread of countless personal stories with dramatic headlines and numerous pill scares have influenced women’s perception on the pill’s risks. But are these fears legitimate? How dangerous is the contraceptive pill? What is true and what is false?

Let’s see what science answers to the pill’s most common assumptions…

1) The pill harms your future fertility

FALSE. All scientific evidence agrees that hormonal contraceptives do not make women sterile in the long run. Sometimes it may take three to six cycles for fertility to fully return, but within a year after going off the pill, women trying to conceive are as likely to get pregnant (80%) as those who were never on the pill. In certain cases of long-term use, there may be even increased likelihood of pregnancy within 6-12 months after discontinuing it.

Moreover, hormonal birth control may preserve fertility by offering protection against pelvic inflammatory disease, endometriosis, ectopic pregnancy, ovarian cysts, ovarian and uterine cancer (see below).

2) The pill reduces sexual desire

MOSTLY FALSE. In most cases, birth control pills don’t affect libido (sexual desire): out of 10 women taking the pill, 7  experience no change in their sex drive, 2 observe increased libido, and 1 will feel less desire.

Recently, a study provided evidence that the pill does not kill desire: contextual factors, such as the relationship with the partner, stress, fatigue, family problems, recent childbirth, have a more considerable impact on sexual drive than the type of contraception used.

3) The pill makes you fat

MOSTLY FALSE. A recent extensive review study showed no evidence that birth control pills cause weight gain in most women. Although some persons may gain some weight when they start taking it, it’s often a temporary side effect due to fluid retention, not extra fat. And, like most side effects, it usually goes away within 2 to 3 months.

A woman’s weight may fluctuate naturally due to changes in age or life circumstances. Because changes in weight are common, many times they will wrongly attribute their weight gain or loss to the use of the pill.

4) The pill increases the risk of blood clots

TRUE. From the 1960s it is known that combined contraceptives pills may increase the risk of venous thrombosis, that is, a blood clot obstructing a vein, a serious and potentially life-threatening complication. Combined contraceptives contain synthetic versions of the hormones estrogen and progesterone. It is the estrogen that is mostly associated with the formation of blood clots, but the latest years it became evident that the type of progesterone also influences the risk. Indeed, the most “modern” formulations of the combined pill – the so-called third and fourth generation – containing the synthetic progesterones gestodene, desogestrel and drospirenone are associated with higher risk of thrombosis.

The European Medicines Agency (EMA) provides the following values ​​for the incidence (frequency) of deep vein thrombosis in 100,000 women of childbearing age:

  • 5 to 10 in non-pregnant women who do not use oral contraceptives,
  • 20 for women using a second generation combination pill (containing levonorgestrel),
  • 40 among women taking third and fourth generation pill.

Factors that may increase the risk of thrombosis are smoking, high blood pressure, obesity, age over 35 years, and a family or personal history of vascular accidents.

Although these figures may look scary, they should be analyzed in perspective:

  • In absence of risk factors, the absolute risk of thrombosis is very low.
  • The mortality rate of clotting events is about 1%. Thus, the odds of dying as a result of having a clot attributable to the use of the pill would be about 2 to 4 per million women.
  • The risk remains considerably lower than that related to pregnancy and birth (estimated  1 in 1000- 2000 deliveries).
  • Indicative of this is the 1995 pill scare in the UK, when a warning was issued on the increased risk of thrombosis related to third generation pills. This led many women coming off the pill, resulting in 12,400 additional births and a 9% abortions rise in 1996.

Overall, the odds of having a thrombotic episode related to the pill are very low, in particular with combined pills containing low dose of estrogen (30 or less micrograms) and old-generation progesterone (such as levonorgestrel).

The minipill, also known as the progestin-only birth control pill, is a form of oral contraception that does not contain estrogen, and its progestin dose is lower than that in the combined formulation. Although its efficacy is slightly reduced as compared to the combined pill, the minipill does not increase the risk of venous thromboembolism or arterial thrombotic accidents (see below).

5) The pill increases the risk of heart attack and stroke

TRUE. An extensive review study looking at arterial vascular accidents attributed to the pill (myocardial infarction and ischemic stroke) showed that the overall risk of arterial thrombosis was 60% increased in women using oral contraceptive pills compared to non-users. Unlike venous thrombosis, the risk did not vary according to the type of synthetic progesterone. However, it was twice as high in women taking pills with higher doses of estrogen (the older formulations of contraceptive pills).

Therefore, the combined pill containing levonorgestrel and low dose estrogen (no more than 30 µg) is the safest oral form of hormonal contraception. The minipill may also be considered in high risk women (see above).

6) A woman should not take the pill if she smokes

TRUE.  There is some evidence that smoking may decrease the effectiveness of hormonal birth control. When taking the pill, smokers experience more frequently irregular bleeding than non-smokers; this could signal that the efficacy of the pill is lowered, but more research needs to be conducted to better understand the effect of smoking on the pill’s action.

But what we do know for sure is that smokers who take combined oral contraceptives have increased risk of venous thrombosis and heart disease (see above). This risk is higher for women that smoke more than 15 cigarettes/day, are older than 35 years old or take formulations with high estrogen levels.

If you are under 35 years old and smoke, you should be extremely careful about using the pill, and the decision to take it should be individualized considering other risk factors such as personal and familiar history of high blood pressure, high cholesterol or heart disease. Smokers aged 35 or over should not take the combined contraceptive pill.

If you smoke you may opt for the mini pill, which does not seem to increase the risk of venous thromboembolism or arterial thrombotic accidents; otherwise you should discuss with your doctor about another contraceptive method, such as the intra-uterine device (IUD).

7) The pill causes mood changes and depression

DEBATABLE. Most studies have shown no effect of the pill on depression and mood changes; some studies have even found a protective effect. In 2016, an extensive review on hormonal contraception and mood changes confirmed the existing evidence, and concluded that “… negative mood changes are infrequent and combined hormonal contraception may be prescribed with confidence”.

However, a recent publication came to challenge this assertion. Danish researchers went through the health records of more than a million women using hormonal contraception. They found that those on the combined pill were 23% more likely to be prescribed an antidepressant than those not on hormonal contraception. For those on the minipill (and on other progesterone-only methods, including the hormonal IUD), the figure rose to 34%. It increased even further, to 80% more likely, for girls 15 to 19 years old on the combined pill.

There are a few important points to consider about these results:

  • Depression is a complex condition whose cause is still poorly understood. Several factors seem to play a role: genetic, environmental, psychological and social. Therefore, it is very difficult to evaluate the link between depression and hormonal contraception.
  • The Danish study does not prove that hormones are responsible for the depression – “association” does not necessarily translate into “causation”.
  • The risk of being diagnosed with depression peaks at two to three months of contraceptive use, but then begins to fall.
  •  Even if these findings are confirmed, the number of affected women remains small: 2.2 out of 100 women who use hormonal birth control develop depression, compared to 1.7 out of 100 non-users.

In conclusion, the pill may have impact on some women’s emotions, but further research is needed to establish whether hormonal contraceptives are indeed the cause of depression and mood changes.

8) The pill is 100% reliable

FALSE. Theoretically, with perfect use, the pill is 99.7% effective at preventing unwanted pregnancy. However, there are many factors that may interfere with the pill’s level of effectiveness: forgetting to take it, not taking it as directed, certain medications or medical problems…Therefore, when it comes to real life, the pill is about 92% effective: about 8 in 100 women using the combined pill will get pregnant in a year.

In any case, the birth control pill remains one of the most reliable contraceptive methods.

9) If you take the pill you don’t need the condom

FALSE. A survey conducted in France showed that “…one in ten young women 15 to 20 years old is not aware that the pill does not protect against HIV and sexually transmitted infections (STI)”. As stated before, the pill is a very good at preventing unwanted pregnancy but it offers no STI protection at all. In fact, the only contraceptive method that protects against sexually transmitted infections is the condom. Read more here.

10) The pill causes cancer

TRUE AND FALSE. The pill seems to increase the risk of certain cancers, but it protects again others. Overall, with the use of oral contraceptives the risk of endometrial and ovarian cancer is reduced, whereas the risk of breast and cervical cancer appears to be increased.

The protective effect on ovarian and endometrial cancer (the lining of the uterus) has been consistently demonstrated in many studies. This effect increases with the length of time oral contraceptives are used and continues for many years after a woman stops using the pill.

Long-term use of oral contraceptives is associated with an increased risk of cervical cancer. This correlation is not completely understood, as virtually all cervical cancers are caused by certain types of human papillomavirus (HPV). It has been suggested that women who use the pill may be less likely to use condoms, therefore increasing their risk of being exposed to HPV.

An extensive analysis of more than 70 studies suggested an increased risk of breast cancer among current and recent users of hormonal contraception. The risk was highest for women who started using oral contraceptives as teenagers. However, by 10 years after cessation of use, their risk was similar to that in women who had never used it.

Since most studies so far have evaluated birth control pill older formulations with higher doses of hormones, until recently it was assumed that the newer-generation pills available now would be safer regarding breast cancer risk. Yet a new study from Denmark found that even with the current pills, hormonal contraception users experienced a 20% increase in the risk of breast cancer compared to non-users; the odds rose among women who used hormones for more than 10 years. The risk was similar in magnitude to that of older pill types.

Whether oral contraceptive use increases the risk of liver cancer is not clear: while some studies found more cases of hepatocellular carcinoma ( a type of liver cancer) in women who took the pill for more than 5 years, others did not confirm this correlation.

Hormonal contraception seems to have a protective effect on colo-rectal (bowel) cancer, but this has not been yet consistently proven.

Since the pill seems to reduce the frequency of certain cancers and increase the risk of others, an interesting question arises: Does the pill increase the overall risk of cancer? The answer is NO. A recently published study provided epidemiological data on more than 40,000 women followed for more than 40 years. The results showed that users of oral contraceptives are protected from colo-rectal, endometrial, and ovarian cancer; this beneficial effect lasts for many years after stopping the pill. An increased breast and cervical cancer risk was seen in current and recent users, which appears to be lost within approximately 5 years of stopping oral contraception, with no evidence of either cancer recurring at increased risk in ever users with time. These results are reassuring and provide strong evidence that most women do not expose themselves to long-term cancer harm if they choose to use oral contraception; indeed, many are likely to be protected.

11) The pill has many bothersome side effects

TRUE AND FALSE. Some women refuse to take the pill because they fear certain annoying symptoms. Indeed, the birth control pill is a medication, and as such, it has possible side effects.

The most common adverse reactions associated with use of combined contraceptives include changes in bleeding patterns, nausea, breast tenderness, headaches, missed periods, vaginal discharge and visual changes with contact lenses; few women may also experience changes in sexual desire and mood changes, or temporary weight gain related to fluid retention (see above). In general, these side effects are not a sign of illness, and usually stop within the first few months of using the pill.

While some women may experience bothersome symptoms, the pill provides important non-contraceptive health benefits:

  • Decreased risk of certain cancers (see above)
  • Improved bone mineral density (in older women)
  • Protection against pelvic inflammatory disease
  • Prevention of ovarian cysts
  • Reduction of menstrual bleeding problems
  • Prevention of menstrual migraines (with non-stop formulations)
  • Protection against iron-deficiency anemia
  • Reduction of ovulation pain
  • Treatment of acne
  • Treatment of bleeding from fibroids
  • Treatment of dysmenorrhea (painful periods)
  • Treatment of excess hair on face or body
  • Treatment of premenstrual syndrome (PMS)
  • Reduction of endometriosis symptoms
  • Reduction of polycystic ovarian syndrome symptoms
  • Induction of amenorrhea for lifestyle considerations (when you need to stop your period for a while; you can also advance or delay your period with the pill)

So, how dangerous is the pill?

There is no perfect contraception method. I wish there were. And it is true that hormonal contraception, like any other medication, may have annoying side effects and serious health risks. Does it mean that no one should take the pill? Of course not!

We should keep in mind that severe risks are very rare and most bothersome symptoms are short-lived; in addition, the pill offers many non-contraceptive health benefits. But when discussing about the pill’s pros and cons, sometimes we forget a very important issue: the birth control pill is one of the most effective contraceptive methods. And effective birth control prevents from unwanted pregnancy, which may have not only devastating psychological consequences, but may also lead to severe physical harm.

Therefore, the potential problems of the birth control pill should be analyzed in perspective: we shouldn’t just pay attention to downsides, forgetting to place them in context with the upsides. Every woman considering taking the pill should thoroughly discuss with her healthcare provider not only the possible risks, but also its significant benefits, which for many women will be greater than the harms.

 

Photo credits

Heading: vintag.es; 1: thebump.com; 2: breakingmuscle.com; 3: thejewel.com; 4: health.harvard.edu; 5: newhealthadvisor.com; 6: pinterest.com; 7: pinterest.com; 8: pinterest.com; 9: blog.path.org; 10: purelyb.com; 11: buzzfeed.com; Conclusion: bigthink.com

PHTHALATES LINKED TO PREGNANCY LOSS -AND OTHER HEALTH PROBLEMS

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A recent study came -again- to incriminate certain environmental toxins known as phthalates as being responsible for pregnancy losses. Women undergoing assisted reproduction techniques (in-vitro fertilization or intra-uterine insemination) had urine exams to assess the presence of certain phthalates; it became evident that women with high levels of phthalates had up to three times increased risk of pregnancy loss. The study was recently presented at the Annual Meeting of American Society for Reproductive Medicine (ASRM).

For several years now we have been hearing about the toxic effects of phthalates, but what are they exactly? Where do we find them? Are they really harmful? Check out this article to learn more about these enigmatic toxins…

What are Phthalates?

Phthalates are chemicals used to soften plastics and make them more flexible (they are also known as plasticizers). These substances do not bound to plastics, therefore they are continuously released into the air, foods or liquids. Certain phthalates are used as dissolving agents for other materials.

Where do we find them?

Phthalates are used in an astounding array of products. They are most commonly found in:

  • Plastic bottles.Phthalates plastic bottles
  • Plastic containers and plastic wraps.
  • Cosmetics: in creams and lotions (to help them penetrate and soften the skin), in perfumes (to help them last longer), in hair sprays (to reduce stiffness), in nail polish (to prevent chipping), in deodorants, soaps, shampoos and almost every cosmetic with fragrance, including baby products.
  • Household products: air fresheners, paints, plastic flooring.
  • Plastic toys and other baby products such as teethers.
  • Certain medical devices, e.g., blood bags, intubation tubes, intravenous catheters.
  • Objects made of vinyl or PVC.
  • Phthalates are present even in seemingly unexpected sources. One example is milk: even in glass bottles, high levels of phthalates have been found, presumedly due to the plastic tubing used in milking machines.

We get exposed to phthalates by:

  • Ingestion: eating food contaminated from food packaging; drinking beverages from plastic bottles that leach the chemical; sucking plastic objects (e.g., baby toys, teethers).
  • Absortion: using cosmetics products. According to the CDC, women of childbearing age have the highest levels of phthalates, possibly due to the use of cosmetics.
  • Inhalation: breathing dust or fumes from products containing vinyl (vinyl floors, the interior of cars, shower curtains, etc).

Which are the most commonly used phthalates?

Phthalates perfumeThese chemicals have very difficult names, but there are a few you may want to keep in mind (see the studies below):

-In cosmetics: the primary phthalates used in cosmetic products have been dibutylphthalate (DBP), used in nail polishes; dimethylphthalate (DMP), used in hair sprays; and diethylphthalate (DEP), used as a solvent and fixative in fragrances. According to latest survey of cosmetics conducted by the Food and Drug Administration (FDA) in 2010, DBP and DMP are being used rarely, while DEP is the most commonly used phthalate. The use of DBP and DEHP is banned in the European Union  but they are still found in cosmetic products.

-In food packaging: the most commonly used is Di-(2-ethylhexyl) phthalate (DEHP). Bisphenol-A (BPA) is not a phthalate, but is also being used as plasticizer in food packaging and plastic bottles.

-In paints, plastic and PVC objects, solvents and adhesives: DEHP, Diisobutyl phthalate (DIBP) and DBP (also called DnBP).

-In children toys and child care products: In the USA, phthalates used in these products have been divided in three categories:Phthalates toy ducks

  1. permanent ban (permanently prohibits the sale of any “children’s toy or child care article” individually containing concentrations of more than 0.1% of DBP, BBP or DEHP);
  2. interim ban (prohibits on an interim basis the sale of “any children’s toy that can be placed in a child’s mouth” or “child care article” containing concentrations of more than 0.1% of DNOP, DINP, or DIDP); and
  3. currently unrestricted under Section 108 of the Consumer Product Safety Improvement Act of 2008 (DMP, DEP, DIBP, DCHP, DIHEPP, DIOP, DPHP).

Similar recommendations apply in Europe, where the six above-mentioned products are banned.

What is the evidence linking phthalates to pregnancy losses?

In addition to the recent American study (where they measured metabolites of DEHP), two previous studies had found a relationship between phthalates and miscarriages:

In 2012, a Danish study  found an increased risk of early pregnancy loss in women with high urine levels of DEHP‘s breakdown products. More recently, a Chinese study, comparing urine samples of women who had miscarriages and healthy women found that pregnancy loss was associated with higher levels or three phthalates: DEP, DBP, and di-isobutyl phthalate (DiBP).

Another American study also found and increased risk of miscarriages in women with high levels of BPA.

Eliminating phthalates and BPA from our lives is virtually impossible, but you can take some measures to minimize exposure, especially if you are trying to conceive, are pregnant or have young children”

Are there any other health risks?

Phthalates are widely known as endocrine disruptors: they mimic hormones, interfering with their function. Some possible consequences of this are:

Effect on male fertility: phthalate exposure in men was associated with reduced fecundity.

Birth defects in baby boys: several studies have found abnormalities in baby boys’ genitals when pregnant women were exposed to high levels of certain phthalates; another study found increased risk of hypospadias (the opening of the urethra is on the underside of the penis) in occupational exposure of pregnant women.

Neurological problems in newborns, infants and children: such as attention deficit hyperactivity disorder (ADHD), reduced IQ, behaviour problems.

Obesity: both in children and adults.

Asthma: in children when pregnant women were exposed to high level of phthalates.

Interference with puberty in girls: the evidence is inconsistent on this subject; while some studies found that phthalates may be related with precocious puberty, others reported delayed puberty.

Breast cancer: a small study showed increased breast cancer risk, but the evidence is not conclusive; there is a large study being conducted in the USA, which will provide more clear answers on this matter.

What can I do to reduce exposure to phthalates?

Phthalates glass food containersEliminating phthalates and BPA from our lives is virtually impossible -they seem to be everywhere- but you can take some measures to minimize exposure, especially if you are trying to conceive, are pregnant or have young children:

  1. Read labels on personal care products. Unfortunately, manufacturers are not forced to list phthalates, and  they can be added as a part of the “fragrance.” Many companies have voluntarily removed phthalates from their products, so you may search for products labelled as “phthalate-free”.
  2. Limit the use of baby care products in babies and young children.
  3. Don’t microwave food in plastic, or use only “microwave safe” and phthalate-free containers to microwave food or drinks. Phthalates can leach from containers (or plastic wrap) into foods on contact and when heated, particularly oily foods or with a high fat content. Don’t put plastic containers in the dishwasher (heat will increase phthalates leaching).
  4. Replace plastic bottles, cups, dishes and food containers with those made of glass, porcelain or stainless steel, especially for hot food and beverages.
  5. Check labels on plastic bottles and containers: choose only those with recycle codes 1, 2, 4, or 5. Plastics made of polyethylene terephthalate (PET) or high-density polyethylene (HDPE) are safer than those made of PVC (“PET” or “HDPE” may be printed on the label or the bottom of the bottle).
  6. Use only toys and toothbrushes labeled “phthalate- free”. There are strict regulations banning the most dangerous phthalates in toys and baby products, both in the USA and in Europe.
  7. Reduce your use of canned foods, as they are often lined with material that contains BPA. Prefer fresh products or those in glass containers. Avoid canned milk (including canned formula for babies).
  8. Phthalates baby bottlesChoose only bottles and cups that are BPA-free. In fact, BPA was banned in all baby products in 2011 in Europe, and since 2012 in the USA.
  9. When using paints or solvents, keeps the area well ventilated. Prefer natural paints, phthalate-free (DBP is the phthalate usually used in these products).
  10. Choose non-vinyl products, such as shower curtains, raincoats or furniture, as the chemical off-gassing from these products introduces phthalates to your environment.
  11. Keep your house clean, as phthalates can remain in dust.
  12. Avoid air fresheners; prefer essential oils instead.

Is anything being done?

Phthalates safe cosmeticsAs people are becoming more aware of the harmful effects of phthalates, increasing information is being available to consumers; websites such as the Campaign for Safe Cosmetics have actively advocated the elimination of dangerous chemicals from cosmetics and personal care products. As a result, certain companies and retailers have been taking measures to reduce toxic substances in their products.

Initiatives are also being taken at governmental level. European authorities have restricted the use of phthalates in some baby products, cosmetics, and plastics designed to come into contact with food; more phthalates will be soon banned from medical equipment, electrical and electronic devices. Recently, a very extensive Report to the U.S. Consumer Product Safety Commission by the Chronic Hazard Advisory Panel on Phthalates and Phthalates alternatives (CHAP) analyzed the available data on each phthalate and phthalates alternative and provided recommendations, which will hopefully lead to banning certain phthalates that proved to be toxic.

 

Photo credits

Getty Images; Reciclado creativo, Flickr.com; Etienne, Flickr.com; Pixabay.com; Target.com; Alicia Voorhies, Flickr.com; jillsamter.com