Bleeding After Menopause. Should I Be Concerned?

>> Thursday, May 21, 2015

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Bleeding after menopause can be alarming and it can make women think the worst (cancer). Fortunately, cancer or hyperplasia (a type of pre-cancer), are less common than the many other potential causes of bleeding.

Menopause usually happens in a woman's late 40’s to early 50's, and is signaled by the occurrence of hot flashes, night sweats, weight gain, fatigue, difficulty sleeping and lack of sexual desire. During this time, menstrual cycles can start to occur closer together, or become shorter with lighter flow until they stop. Or they can become extremely heavy, painful and prolonged, lasting 7-10 days until they stop.

The majority of post-menopausal bleeding is caused from the wild hormone changes happening. Many women go on hormone replacement to alleviate all the symptoms, and to try to re-balance hormones properly. Use of bio identical hormones can cause a lot of PMB (post-menopausal bleeding).

Another potential cause of PMB is anatomic change. This can be evaluated through ultrasound studies. Anatomic changes can include: ovarian cysts, uterine fibroids, uterine or cervical polyps (all of which can cause irregular bleeding or bleeding after sex). Less common causes of PMB include emotional stress, extreme weight loss, and nutritional imbalances, especially insulin resistance.

Whatever the cause is, when PMB happens, do not delay in making an appointment with your gynecologist.

I hope this helps with your question; please don't hesitate to inquire further. A lot more can be said here, and there are several treatment options which depend on the cause of the bleeding. That may be a good topic for next week. Sounds like fun.

We love hearing from you.

Have a good week,
Dr. Boyd


Side Effects of Birth Control Pills

>> Thursday, May 7, 2015

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Here is a concern I often hear: "Since I started birth control pills, I noticed my vaginal discharge has changed. Most of the time I have an increase in vaginal dryness and I've noticed that I have a lot more yeast and bacterial infections."

These are common side effects because of how the pill works. The pill stops the natural fluctuations of estrogen and progesterone (and a spike called the LH surge - which causes ovulation and an increase in sexual libido.) The pill is made up of estrogen and progesterone and, when taken daily, flattens and overrides the natural fluctuations. This prevents ovulation, reduces vaginal discharge and can suppress our libido.

We've talked many times about how important pH balance is to vaginal health. Any change in hormonal balance can affect vaginal pH - like starting birth control pills, hormone replacement, menopause and the first few months post-partum (i.e. post-partum depression) - making us more susceptible to bacterial and yeast infections.

Bacterial vaginosis can also be triggered by douching and the use of chemicals, vinegar, lemon, or soap to cleanse the vagina. It doesn't matter if it is mixed in water and put inside with a douche bottle, or by using your soap covered fingers to clean up inside the vagina, or if a tampon is soaked in watered down lemon juice, tea tree oil, vinegar etc..

But women can get desperate to get rid of vaginal odor. It is embarrassing, worrisome, makes us want to avoid sex and feels uncomfortable, causing us to have less confidence. So we douche anyway or soap up inside and cover up with lotion. But it only works for a short time before the odor returns and keeps getting worse.

Untreated, BV can lead to significant health problems, including premature births, postpartum infections, pelvic inflammatory disease, and increased vulnerability to HIV infection. It's estimated that up to one-third of women in the United States will have BV at any given time, even during pregnancy.

How can it make us more susceptible to HIV? Because constant irritation causes little openings in the vagina. Think of when you fall and get a "road rash". It's not really a cut, but rather many little scratches. These can lead to a break in the skin or vaginal mucosa, making a way of entry for the HIV. Anal sex can do the same, because the stretching of the anus can cause micro-tearing, making an entry way for bacteria and viruses like HIV.

Bacterial infections can cause PID (pelvic inflammatory disease) because sex or douching can push that bacteria from the vagina up into the uterus and Fallopian tubes. PID is extremely painful and can damage your Fallopian tubes, so you could be unable to get pregnant naturally. It also puts women at risk for ectopic (tubal) pregnancies. This happens because fertilization happens in the Fallopian tube, but because of scarring, the embryo get stuck there. This is a life threatening condition and you can bleed internally and even die.

So don't ignore odor that doesn't go away or an increase of discharge that itches or has an abnormal "fishy" sourish odor. See your doctor if you think you have a bacterial or yeast infection, as you may need antibiotics or anti-fungal medication to clear it. And you may have to repeat it back to back if it's been going on a long time. That's because sex, your period, or taking allergy medications like a steroid injection can bring it right back. It's not that we are not clean enough, in fact most of us fail at clearing these infections by trying to be too clean. It's best to let the vagina heal internally on its own. Washing externally with soap is just fine. Just don't let any soap, or feminine wash, get inside the vagina.

Now wouldn't you love to have a safe way to cleanse your vagina internally? Wouldn't it be wonderful to wash out old period blood, excess discharge, or semen after sex?

Well there is an FDA cleared device called WaterWorks that we can use every day for feminine hygiene purposes and to keep odor away. Many of my patients use it every day to feel clean or after sex to rinse out semen and at the end of their period to rinse the old blood out.

WaterWorks is reusable and uses only plain water. It appears to be a reusable douching system but is nothing like that. The water sprinkles downward out of the stainless steel tip. The reaction that happens between the stainless steel, water and vaginal mucous works similar to the stainless steel bars that chefs use to get onion and garlic odors off their hands.

My patients who struggled with odor for years have not had vaginal odor for years now and rarely have a yeast or bacterial infection as the pH balance is under control.

I'm pleased and amazed myself at how well WaterWorks performs and how well made this device is.

I hope you are all well and safe. Have fun.
Dr. Susan L. Boyd, MD


Losing the sensation in my clitoris. What can I do?

>> Friday, May 1, 2015

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Over the past three years my once oversized clitoris is lacking the ability to engorge and the size and sensation of my clitoris has decreased, the size is approximately 1/5 in size and it is a challenge for my partner to find let alone stimulate.

Have I damaged this area? Is there anything I can do? Please help!

Desperate in Ontario

Many women struggle with the difficulty of having an orgasm due to clitoral shrinkage. This is due to the hormone changes that come with aging and menopause. You still may be having regular cycles, which means that your ovaries continue to produce some hormones.

Most women will begin peri-menopause sometime in their forties. Peri-menopause is the beginning of mild or severe hormone fluctuations. It's a roller coaster - at times your hormones will function normally, and then the next month we can have shifting, drop offs or severe imbalances, all causing emotional and physical changes in our bodies. Living a healthy lifestyle with exercise and good diet are all important during this time.

The good news is that many of these symptoms and changes can be reversed by replacing naturally back to your body all the hormones that are dropping off. This takes much dedication and hard work.

Estrogen and Testosterone are the two key players. However, most women will have a drop in progesterone first, then estrogen. This begins the imbalance. Testosterone is tricky, especially if you don't have a previous testosterone level on yourself. This is because testosterone does not fluctuate with our cycles like estrogen and progesterone, but as we approach menopause it slowly drops off, yet may never show up as a deficiency.

Estrogen can also appear normal or even high on a blood test while adrenal hormones and progesterone drop to a deficiency level. It's all about balance, not just adding back what's deficient. It is also important to note that we have 3 different types of estrogen: E1, E2, and E3. E2, or estradiol, is the main estrogen that drives everything for most of our reproductive years, including our breast development, sex drive, moods, periods etc. E1, or estrone, is a minor player until menopause, then E1 and E2 flip, and E1 becomes the dominate estrogen. E3, or estriol, is only dominant during pregnancy, but is second highest behind E2.

Imbalance may cause our sex drive to drop off and reduce clitoral sensitivity and size. The happy news is even though your clitoris may never return to pre-menopausal size, through hormone balancing, the sensitivity and size can greatly improve.

Many women use testosterone implants or injections along with testosterone gel, which helps greatly. This must be accompanied with DHEA, one of the main adrenal hormones, to make sure E2 remains the dominant estrogen in your body.

Progesterone is not as important for clitoral size or sensitivity, but is our mood balancer, removes water retention, helps with anxiety, weight loss and sleeping.

So you need to find a doctor who understands the importance of hormone balancing and can help you figure out what is happening in your body.

Note, like a recent writer mentioned many women use masturbation to help with sleeping. It is frustrating when a vibrator or manual stimulation takes 30 minutes to an hour to orgasm and the orgasm intensity is decreased dramatically.

I have many patients who have found that the above hormone balancing can be the help. We can't replace female hormones or thyroid hormones with herbs and medications. The same is true if a man's testicles stopped producing their hormones and dried up - an herb wouldn't help him. He would need testosterone replacement to sexually perform and feel well.

I hope this helps you. God bless and be safe.
Dr. Susan L. Boyd, MD


Abnormal Vaginal Bleeding or Spotting

>> Sunday, April 12, 2015

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So many women, whether young, middle aged or menopausal, will experience abnormal vaginal bleeding or spotting between periods at some time in their lives.

In fact, it would be uncommon for any woman to not have abnormal bleeding at some point. By the time many of you have made an appointment and come in, you have researched the bleeding on the Internet. Of course the first thing it says is, 'Abnormal Vaginal bleeding can be caused by cancer, especially if it happens after sex, after menopause or in between your periods.

But, this statement does not take into any number of important factors, such as: Did the bleeding occur with ovulation? Are you menopausal and on hormones? Did you miss a birth control pill? Do you always have regular cycles? Are you under a lot of stress? Rather, it just carelessly throws out a blanket statement about cancer which scares many of you.

Vaginal bleeding is considered to be abnormal if it occurs when you are not expecting your menstrual period, if your menstrual flow is lighter or heavier than what is normal for you, or if it occurs at any time in life when it is not expected, such as before age 9, during pregnancy, or after menopause. Abnormal bleeding is very common, and even though it can cause alarm, most of the time it does not indicate a serious condition.

In women of childbearing age, early pregnancy should always be considered, even in women on birth control pills or with an IUD in place. Also, ovulation can cause mid-cycle bleeding. Hormone imbalance, such as occurs during menopause, or Polycystic Ovarian Syndrome (PCOs) - the most common hormone imbalance in young women - can also be the cause.

Medications such as birth control pills, antibiotics, oral or IV steroids that are used in asthma or severe allergies, and various allergy medications could also be a factor. Any Infection of the vagina, cervix, uterus, fallopian tubes, or ovaries may also cause vaginal bleeding, especially after intercourse or douching (which is not recommended at any time for any reason). Of course, Pelvic Inflammatory Disease (PID) which causes inflammation or infection of the uterus, fallopian tubes, or ovaries could also be the cause.

The possibility of a tampon or other object left or put into the vagina and then forgotten can also cause bleeding, and therefore the vagina should be inspected. An ultrasound is useful to see if there are other causes like uterine fibroids or ovarian cysts. Extreme emotional stress and excessive exercise can cause frequent, excessive bleeding or absence and irregular bleeding.

Lastly, tests may be conducted to evaluate for female cancers like cervical, vaginal, uterine, Fallopian tube or ovarian cancer. Most of the time this will take a number of exams and tests to confirm. It is important to go see your doctor if you have abnormal bleeding so you can be reassured and evaluated properly.

I hope you have a wonderful week and be safe out there.

Dr. Susan L. Boyd, MD


Confident You, Confident Sex!

>> Wednesday, March 25, 2015

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Good Morning Everyone! I always look forward to this time we have to learn and figure things out together. You all have been so awesome and brave with your questions that it has really provided a way for you to help each other. Each time you put it out there and voice your concerns, it opens a way for others to see they weren't alone.

This week was no exception. I had three of you, plus several patients in the office, ask me the same question:

"Dr. Boyd how can I feel more confident with myself during sex?"

I think this may depend on different things for everyone, right? First of all, it is so important that you feel comfortable with your partner and that your partner makes you feel comfortable sexually (and likes your body, so you feel good about yourself during sex). If you don't feel free to express yourself naturally during sex, or sense that your partner is uncomfortable, it can help a lot to talk to each other. Often when there is tension during sex, and you can't talk about it, you will feel less confident and it will prevent you from initiating new things.

Often couples fall into habits due to busy schedules and forget to make time for each other. Both may work all day and, once home, the evenings are filled with family, homework and dinnertime. Sex may be left for the middle of the night or early morning awakenings with a nudge, and, even though you are thoroughly exhausted, you give in. It just feels like one more thing to do before you can have a few hours of peaceful sleep.

Another very common reason for women to feel less confident can be the extra weight that is slow to leave after childbirth. Seriously, who are those women that lose all their baby weight in 3-4 weeks? For most of us, it took nine months to put it on and it's going to take another 6-9 months afterwards to get it back off - and that's if we work at it. Geezz!!

There aren't very many of us who feel sexy at 8-9 months pregnant, with a black lace nighty on, milk dripping from our nipples, swollen feet and ankles and a belly so big we can't even shave ourselves properly. And, it just doesn't feel much better after either, when your belly is still big because the uterus hasn't returned to normal size, our nipples are really leaking now, and our hormones are completely messed up.

Of course, if you've had an episiotomy, vaginal tear, or a c-section scar that has to heal, this can be not only physically painful, delaying the ability and desire to reconnect intimately with your partner, but it can also have a profound psychological and emotional effect on sexual intimacy.

I have met so many wonderful husbands and partners of the women for whom I have cared, that have amazed me with the love and compassion they have. Especially in childbirth, realizing that just because a woman's body is built to have babies, it doesn't make it easy or painless. They admire the strength and courage it took. I have watched as they work with their partners and wait with patience. Hats off to you, guys.

Just like with menopause, I have tried to explain to the men when they come in with their wives wondering, "What happened? She's not the same person anymore. I think she hates me! Help her Doc!" I tell them, "Now just imagine that all of a sudden you were castrated, or for some reason your testicles, right now, today, just stopped making testosterone?" "How do you think you would feel? A little weird? Crazy? Like crying? Well, that's what's going on with her. Her ovaries just stopped making all her female hormones." Men understand that, you know? Menopause is another reason women can lose confidence sexually, just like the others we talked about.

Women lose their sexual desire and experience vaginal dryness, abnormal vaginal discharge and odors due to hormone changes and generally feel as though they are not as desirable as when they were younger. Hormones help with emotional stability and confidence (true for men as well), so it is important to have a physical and blood tests to check for overall health at this time to evaluate for hormonal imbalance.

It's like the joke someone told me, ‘When you're young and you're going into puberty, everyone tells you, ‘Girl you are becoming a woman now.’
But when you reach menopause and go through the ‘change of life,’ no one can tell you what you're going to change in to!” That's for sure - women can feel like they are losing their mind. That's why it's called a HYSTERectomy and not a UTERectomy, because years ago, they thought if they removed the uterus, they would remove a woman's hysteria!

We've come a long way since then, and we don't use the term "she's hysterical" or "nervous breakdown" much anymore. Now we understand a lot more about hormones and hormone balance, which has helped so many women over the past 50 yrs.

The last thing I want to say on this question, and one I really do get asked about a lot, concerns my patients’ most significant worries and causes of lost confidence: The battle with vaginal odor and excessive discharge.

Most of you have had problems with this since your early teens or 20's and have seen multiple doctors who all say the same thing, "Don't douche. It will make it worse and it will keep coming back because you will destroy the natural vaginal flora." Then they give you a script for the same vaginal gel or pills you've taken your whole life, and it goes on and on.

Of course, it was your big sister, mom, cousin, or grandma who showed you about douching anyway a long, long time ago, and how else should we clean out up there anyway? Old blood from your period, semen from sex, smelly discharge…you certainly don't want to smell during sex and especially with oral sex! How embarrassing. We all can relate to that.

That's why when I learned about WaterWorks, after 17 years of working as an Ob/Gyn, I was so excited. Finally, an all natural way for women to have good feminine hygiene and cleanse inside the vagina without destroying the natural flora. The natural flora is necessary to maintain a low pH in the vagina and allows it to be self-cleaning.

This is something that women could use everyday in the privacy of their own homes, and it requires no chemicals, pharmaceuticals, and no
. It is FDA-cleared and it looks like a reusable douche, but it uses only natural tap water and a patented, medical grade stainless steel nozzle.

When the stainless steel reacts with the vaginal mucosa, a reaction takes place that destroys vaginal odor. Most women have results the first time they use it and never have odor again. You hang it in your shower; it is reusable; and you can use it to rinse out old blood, semen, or excess discharge or simply use it as part of your daily cleansing routine.

I know this will go a long way to helping you feel more confident sexually, as you won't be worried about vaginal odor. I hope this information helps you and your family and friends. Have a wonderful week. You all deserve it!

Dr. Susan Boyd


Vaginal Lumps and Bumps - Causes and Cures

>> Wednesday, March 18, 2015

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We have talked about the common lumps and bumps we get on our labial and vaginal area in recent blogs, but I want to talk about the difference and describe for you the sores and rashes that can be a sign of something worse.

As background, vulva is the general name given to the external parts of the female genitals. It includes: the mons pubis (the pad of fatty tissue covered with pubic hair); the clitoris; labia majora (the outer lips); labia minora (the inner lips); the vestibule (area immediately surrounding the vaginal opening); the urinary opening; vaginal opening; and the perineum (area of skin between the anus and vagina). The appearance of the vulva can vary greatly between women. For example, although the labia minora are referred to as the 'inner lips', it is quite normal for them to extend outside the labia majora.

Dermatitis is the most common cause of chronic vulvar symptoms, such as painful intercourse, increased or foul-smelling vaginal discharge and painful urination. In some cases, vulva dermatitis can be caused by a genetic predisposition to allergies and hypersensitivity. This can be so embarrassing and frustrating because it causes a lumpy, bumpy feel and intense redness and rashes. This can take away all the fun and enjoyment from intimacy.

The following are good rules of thumb to follow to help with prevention and healing:

  • Wear cotton underwear for daily use (save the lace and G-strings for your intimate occasions)
  • Watch for allergies or sensitivities, especially latex in condoms or diaphragms, over-the-counter vaginal medications or soaps, laundry detergents, and lotions

Some of the most common, non-cancerous reasons for vulvar bumps are Genital herpes, Genital warts, Granuloma inguinale, Chancroid, Bechet's, Pagets of the vulva, Lichen Sclerosis (now known as Vulvar Hyperplasia) along with leukoplakia, neurodermatitis, Bowen's disease, hyperplastic vulvitis, Kraurosis vulva and erythroplasia of Queyrat.

Genital herpes is caused by the herpes simplex virus (HSV). It is transmissible through vaginal, anal or oral sex. Symptoms appear within 2-14 days of exposure and include flu-like symptoms and painful blisters in the genital area. Some people only experience one outbreak while others will have several. A minority of those infected experience frequent recurrences. There is no cure for genital herpes, but antiviral medications can help reduce the duration and severity of an outbreak and prevent transmission to a partner. Keeping the area clean and dry and bathing with a saline solution will help relieve discomfort and assist healing.

Genital warts are caused by particular types of the human papilloma virus (genital HPV). Genital HPV is also transmissible through vaginal, anal or oral sex. Warts can be found on the vulva, clitoris, cervix, inside the vagina or urethra and in or around the anus. They can be flesh coloured or pink and come in a variety of sizes and shapes, occurring singularly or in clusters. The warts do not usually cause pain. Warts can be treated with chemical applications, ablation (freezing, burning or use of laser to remove warts) or a cream that enhances the body's immune response to the viral infection. Warts DO NOT come and go. Once there, they stay until removed.

Psoriasis on the Vulva may or may not be itchy, and does not affect the vaginal mucosa. Symptoms include scaly, silvery or red plaque. Women with psoriasis of the vulva often have the skin condition elsewhere on their body as it is an autoiimmune system disorder. Treatment includes the use of topical steroids and a low dose coal tar cream.

Beh├žet's syndrome is a disease characterised by recurrent aphthous ulcers, possibly ulcers of the vulva. These usually occur on a cyclical basis related to the menstrual cycle.

Paget's disease of the vulva is a rare skin disease but can cause extreme itching along with red or white patches.

A common benign condition which can occur at any age, but that is more common in the post-menopausal patient, is lichen sclerosis. Now called squamous cell hyperplasia, it presents with intensive itching. White patches are frequently seen along with evidence of excoriation from scratching. Biopsy reveals an increase in the thickness of the top layer of the epidermis (hyperkeratosis) and irregular thickening of the Malpighian layer (acanthosis). This latter process produces a thickened Vulvar skin. It responds to the use of high strength topical cortical therapy - Clobetasol ointment appears to be the treatment of choice. If you stop the treatment, it will reoccur, as it is a lifelong treatment. If left untreated, lichen sclerosus can cause severe scarring of the vulva (including the shrinking of the labia and narrowing of the vaginal entrance). Lichen Sclerosis is known as a Vulvar dystrophy or vulvar intraepithelial neoplasia (VIN).

Neoplasia (VIN) can develop in women of any age. Its frequency appears to be increasing among younger women. Today, the average age for VIN is said to be about 50 years of age. The presence of a distinct mass, bleeding or discharge, strongly suggests invasive cancer and not VIN. VIN is often asymptomatic and presents as a whitening or hyperpigmentation of what appears to be normal vulvar skin. Over half of the women have multiple lesions all thought to be related to HPV virus infection. The lesions are located in the non-hairy portion of the vulva in 85-95% of cases. Biopsy is essential to confirm the diagnosis and distinguish it from the benign lesions described above and surgical excision has been the mainstay of therapy. Symptoms of VIN may include itching and burning in a specific area of the vulva, raised brown, red, pink or white lesions, warty lesions or persistent erosions or ulcers.

The vulva can also develop skin cancers such as melanoma and basal cell and squamous cell carcinomas. HPV seems to be the main culprit in many female cancers. Treatment for vulvar cancer depends on how advanced the cancer is when diagnosed. Early detection of vulval cancer is important as it improves the chances of successful treatment. Once again, surgery is the most common treatment for vulval cancer. Radiation therapy and/or chemotherapy may also be used.

I hope this helps you. The most important thing is if you feel something is wrong or have non-healing sores, go see you doctor.

Have a wonderful week.
Dr. Susan L. Boyd, MD


What Steps do I Take if I am Thinking About Becoming Pregnant?

>> Thursday, March 12, 2015

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The most important thing prior to trying to become pregnant is making an appointment with your Ob/Gyn for a check-up, pap smear, vaginal cultures, blood tests and to get all your questions answered. Usually you will be started on prenatal vitamins with folic acid. It is important to be on prenatal vitamins for 2-3 months prior to conception to help prevent birth defects.

Blood tests can screen for anemia, diabetes, thyroid disease and liver or kidney disease that could interfere with your ability to conceive or impact your pregnancy. The pap and vaginal cultures can identify concerns that can be addressed ahead of time or identify bacterial infections that may interfere with conception.

Sometimes couples will try to conceive for months, only to find out that the sperm is dying within the upper part of the vagina before it even has a chance to enter the cervix. This can be caused by certain bacteria in the vagina, but also can be due to the consistency of the discharge. If it's too thick, the sperm may be unable to move through it. If it is due to an infection, this can be detected and cleared. If the later is the case, a post-coital test may need to be done, where a sample of cervical discharge is taken and examined under the microscope right after intercourse to determine the number of living sperm.

It is important to keep track of your cycles monthly on a calendar by noting what day they start. By doing this, you can begin to predict when you are ovulating. There are ovulation predictor kits available at drug stores that are similar to pregnancy tests. They have strips in them that are used to dip in your urine and when a color change is noted, it can indicate ovulation. This can be useful for knowing when the egg is available for fertilization - the best time to have sex.

If your periods are not regular and do not come monthly, ovulation can be impossible to predict. In fact, ovulation may not be happening at all or rarely. In these cases, it may be necessary to seek out help from a fertility specialist.

Also your doctor may want to send you for an ultrasound to make sure there are no ovarian or uterine abnormalities that could interfere with a healthy pregnancy. If you have suffered with endometriosis, you may also need an HSG (hystosalpinogram), which will determine whether your fallopian tubes are patent (open) and able to catch the egg and allow it to travel down the tube to meet the sperm to be fertilized.

It seems that many women, who have had either a miscarriage or an elective termination of an earlier pregnancy, can have worries and doubts in their minds about whether they can get even get pregnant now that they want to. If you are one of these women, what you should know is that if you did not have an infection afterward and if your periods have been normal since that time, you should have no trouble getting pregnant and having a baby now.

It is so important to try to be as healthy as you can be. Women should lose weight and stop smoking (or cut down). Men should stop or reduce tobacco, marijuana and caffeine use also, as nicotine, caffeine and THC can dramatically affect sperm count. Some of the prenatal vitamin companies are coming out with a vitamin for dads-to-be, but any complete vitamin for men will do. There are also some great diets for dads-to-be that can be looked up on the Internet. These diets can help increase sperm count. Some of which have been known to actually triple sperm count.

Getting pregnant shouldn't be so complicated, and it's not- the 'getting' part is fun! But when you try and try and it doesn't happen, it can be heartbreaking. Just don't lose hope and keep in touch with your doctor. If you feel like your doctor is not communicating properly with you, search until you find the right one.

I hope you all have a happy and safe week.

Dr. Susan Boyd


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