Pregnancy and Sexually Transmitted Infections (STIs) - What Do I Need to Know?

This week I want to answer concerns regarding complications of STI's (Sexually Transmitted Infections) in pregnancy. Pregnancy brings on many changes, and causes most of us to worry about our diet, exercise and everything that touches our bodies. So finding out about an STI can be especially concerning to women.

In fact, what may seem like an STI may not be. Pregnancy changes your body so quickly that you may notice an increase in vaginal moisture & discharge, irritation or even a different odor than you're used to. Of course you may worry that something is very wrong.

During your first or second prenatal visit, your OB doctor will do several tests on you, including vaginal cultures and blood tests for the most common STI/STD's. This list may include: HPV (human papilloma virus), bacterial vaginosis (BV), herpes (HSV), chlamydia, trichomoniasis, gonorrhea(GC), hepatitis B, HIV and Syphillis. Often herpes is left off the prenatal panel, but it can be requested as an add on. This is because most women are already aware of having had an outbreak, so they have already been diagnosed. Herpes will generally only interfere with pregnancy if lesions appear at the time of delivery, and in that case a cesarean section would likely be performed.

Women who are pregnant can become infected with the same sexually transmitted diseases as women who are not pregnant. Pregnancy does not provide any protection for women or their babies. But, during pregnancy a woman's immune system has a harder time fighting off infection. The only way to be sure you are protected is to use latex condoms with each act of intercourse, unless you are sure you are in a monogamous relationship with a partner with no STI’s.

Women can become infected with an STI like herpes, HPV and condyloma, years before they meet their current sexual partner. When they become pregnant and their immune system is weaker, they can begin having herpes outbreaks, condyloma overgrowth and abnormal pap smears due to HPV infection, without ever being aware they were carrying these viruses. It can be very shocking to wake up with clusters of warts growing around the vaginal, labial and anal areas, or to find red, hot herpes blisters having never been aware you were harboring a virus. But remember, this does not necessarily mean your partner is being unfaithful.

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Beside Pregnancy, What Could Cause Me to Miss a Period?

Most of us feel that if our menstrual cycles are normal and regular then our health must be OK, right? All it takes is to miss a period, or for them to become very irregular, for an alarm to go off. Then, we hurry to our gynecologist. It's truly amazing to me how regular most women are. So, suddenly missing a period or having a big change in frequency should not be ignored. Judging by the tears and anxiety in your voices, it can be a significant event.

Most women have between 11 and 13 periods a year. You may be different as you may have more or fewer cycles. Every woman is a little different. Menstrual periods are often irregular in puberty, when our cycles first begin. It may take several years for a woman's hormones to balance, so that ovulation and cycles become regular. Hormone imbalance is what also causes menstrual irregularities when peri-menopause and menopause occur. What surprises many women is that, with menopause, our cycles can become less frequent with less bleeding or more frequent with heavy bleeding and passage of blood clots.

If menopause comes before age 40, it is known as premature ovarian failure. This needs to be checked by your doctor because a special test called an FSH can be done to confirm early menopause. Early menopause can cause many health problems including osteoporosis, strokes, heart disease and emotional and cognitive deficits. It should not be taken lightly.

But, of the many reasons for menstrual irregularities and missed periods, the most common is pregnancy. If you might be pregnant, you are naturally excited, and you should treat yourself as if you are pregnant until you see your doctor and have a pregnancy test. There are several symptoms that are suggestive of pregnancy. These include breast tenderness, nausea and bloating.

But, since these can also be premenstrual symptoms, it can still be confusing until a pregnancy test or an ultrasound are done. If you recently went off the Pill, Depo-Provera injections or just stopped breast-feeding and want to get pregnant, it can take a few months for your periods to return to normal. You will not be able to get pregnant until you start ovulating again. A good sign that you are ovulating again (and are fertile) is when your cycles return and are regular.

Pregnancy is detected by a missed period and through taking a home pregnancy test. Sometimes tests will show up negative if they are done too soon. Home pregnancy tests check for the HCG hormone in our urine, so it is important that they are not done until you miss a period. Only certain kinds of blood tests called Quantitative not Qualitative Beta-HCG can test accurately before a missed period.

It is a good habit to track your cycles, so you know when to expect them, because miscalculation is a common reason for women to think they have a delayed or missed period. Tracking makes it easy to look back and see if you had sex during your fertile time, and it helps keep track of ovulation too. This is beneficial whether you are or are not trying to get pregnant right now. Nothing strikes fear into the heart of any woman like a missed period, and if you are not pregnant, there are other possible causes for missed or irregular periods that need to be looked into.

• Stress can affect all the messages to our female organs - like GnRh rhythms and hormone balance that can cause menstrual irregularities.
• Any sudden or chronic illness can also temporarily cause cycle irregularities.
• Even the stress of traveling is enough to throw off our bodies’ delicate cycles and messenger systems.
• Problems with our female organs or genitalia, such as a hymen that is closed off or imperforate (which closes the opening of the vagina and prevents the blood from coming out).
• Asherman's syndrome is a complication that occurs after having surgery in the uterus like a D & C (dilation and curette) which is done in pregnancy terminations. Asherman's syndrome can leave severe intra-uterine scarring, which prevents the uterine lining from thickening each month and causes little or no period.
• Changing schedules can really throw off your body clock. This is particularly true if you go from days to nights at work or vice versa. If you frequently change shifts, then this may be the reason. Isn't that amazing how sensitive our bodies are?
• Perhaps you're trying a new medication and realize it is having an effect on your cycles. Then it's important to let your doctor know how it is affecting you. We see the same with women who abuse illegal drugs.
• Carrying around too much weight can hormonally shift your cycles and even stop them. Most women will see a big change and a return to regular cycles with ovulation even with a 5-10 pound weight loss - even if they are still overweight.
• Being underweight can cause just as many problems with your cycles. If you do not have enough body fat you will not have regular periods, and sometimes you can even cause your periods to stop altogether. This is called amenorrhea. This is a frequent cause of a missed period in women who work out to an extreme or who are professional athletes. Typically a little weight gain will bring back your periods.

It is a good idea to relax and try to reduce worry and stress. This will help your body recover.

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Can I Get Pregnant or Contract an STD in the Hot Tub?

For some reason, many women have been told, or somehow believe, that if they have sex in water, it will somehow work to prevent pregnancy - like a natural contraceptive. But, water will not prevent a pregnancy from possibly happening (even if the man pulls out before ejaculating) once any sperm have been released into the vagina.

Of course, some women also worry that, if a man even ejaculates into the water, a woman would be at risk for getting pregnant. There are many explanations as to why women cannot get pregnant just by swimming in a pool or Jacuzzi where sperm may be present. If ejaculation takes place in hot water (like a hot tub or Jacuzzi), or water filled with pool chemicals like chlorine, sperm would not be able to survive for more than a few seconds.

Also, the water in a regular pool is too cold for sperm to live, and sperm could last for only a few minutes if a man ejaculates in warm water even with no chemicals (like a bath tub). It would also be so difficult for sperm to swim through the water in a bath tub, pool or Jacuzzi and find the vagina open enough to even get in.

Sexually transmitted infections, HIV, and additional bacterial infections can still be spread while having sex in a pool, ocean, lake or in a hot tub. This means that it is important to use birth control during water sex that can provide STD protection. Although hormonal methods may protect against pregnancy, they do not provide any defense against STDs, like using condoms does.

Even though condoms are effective at preventing pregnancy and STDs, they may be somewhat risky to use during underwater sex. They can possibly rupture from decreased lubrication and possibly deteriorate from heat, chlorine, or oil-based substances in the water like tanning lotion, sun screen and bubble bath. There is also the added threat that the condom can slip off if water gets into it, and a man may be unaware of this happening.

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How Stress Lowers the Chance of Getting Pregnant

Did you know that scientists currently studying chemical stress biomarkers in our bodies are finding that stress can really make it harder to get pregnant?  What does that mean?  Well, just like rising cortisol levels associated with stress can have effects on our body, including weight gain, we are finding more and more that lifestyle, diet, and genetics can play a big role in how our body functions.

Just because we can keep track of menstrual cycles, estimate when we ovulate and time sex for the appropriate moment….we expect the egg to be available.  But that doesn't mean we will be successful in getting pregnant.  This is something you have all experienced over and over.  In fact, most couples find that once they stop trying, give up, go on vacation, relax, forget about it, they get pregnant.  Now why is that?  Well, there truly is a lot more to it than you may think.

We know that smoking, alcohol intake, and diet can affect ovulation and sperm count.  Just like certain foods can increase sperm count, so can abstaining from alcohol, tobacco and marijuana use increase sperm count and help with ovulation.  

Zinc plays a positive role in female fertility by promoting proper cell division, a process critical to the earliest stages of conception and fetal development. Similarly, in male reproduction, zinc may well be necessary for adequate testosterone levels and sperm counts. Oysters, chicken, beef, crab, cashews and turkey are all good sources of zinc. And avocados are a great source of folic acid, which has been recognized as being important in healthy pregnancy for years.

But I suggest you look up all the different foods and how they can improve your chances of getting pregnant.  The newest breakthrough has been a saliva test that tests for alpha-amylase which, like cortisol, can be a stress biomarker in our bodies.  When this is present in high amounts, women are unable to achieve pregnancy.  In fact, it decreased their chances more than 31%. 

I know it's hard to be calm when you are wanting to get pregnant and start a family, but honestly I think there is just way too much information out there for young women today. Most of us were conceived by accident, but now with our high tech world, we seem to make even getting pregnant high tech.  We think if we follow a certain formula, push these certain buttons, we should get pregnant.  When it doesn't happen, our disappointment comes and we start to worry and begin to think we must be doing something wrong……or maybe something is wrong with us.  

So our stress levels rise and that causes chemicals in our body to release and further interfere with our ability to get pregnant.   That is why, once we stop trying and relax, most couples do get pregnant and some couples even adopt a baby and then get pregnant after years of infertility treatments!!

There might be something to all this, and our bodies have been trying to tell us this for a while - as we see a lot of disease that comes from stress like ulcers and headaches.

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Can You Get Pregnant During Your Period?

A woman CAN become pregnant if she has intercourse during her menstrual cycle. This topic has been debated for many years, and most of us have heard stories from relatives or friends about someone getting pregnant during a period. In fact, I believe my own mother said she got pregnant with me during her cycle - I obviously was not planned!

While menstruation may be the least likely time of the cycle for conceiving, many studies, including one funded by the NIH (National Institute of Health), suggest that women have the potential to get pregnant at virtually any time during menstruation. Just like every woman is different, so are her hormonal balances and timing of her menstrual cycles. Any women using 'natural' birth control, like the rhythm method or checking basal body temperatures, knows how varied one’s own physiology can be from month to month. The basic rule is that there is no predictable time during the month when the risk of pregnancy is totally absent.

So let's talk about the menstrual cycle. A woman's cycle begins on the first day of menstruation, which is counted as day 1. Most cycles that are discussed are calculated on a 28-day cycle. A woman is typically most fertile on days 10-17, with ovulation usually occurring on day 14. However, only 30% of all women fit this model, and even fewer have regular periods. Even the women with the most predictable cycles do not always ovulate at the same time each month.

The fertile period in a woman lasts for about 4-6 days each month. Men are always fertile, as they have sperm readily available, and sperm can survive inside the woman's cervix for up to 4-5 days. The egg is viable for 48-72 hours after ovulation. All of these variables can create a wide range of days for pregnancy to occur. If the sperm is deposited early, it can wait around as the period finishes and conditions become perfect for conception. During lower fertile periods, a woman is most likely to become pregnant if sexual intercourse occurs at the end of her cycle, just prior to ovulation.

Unfortunately, women are under more stress now than ever, which can cause irregular bleeding during menstruation and especially at ovulation. This can be mistaken for a period, causing confusion and miscalculation of cycle length and ovulation. Stress can also lengthen the duration of bleeding, and ovulation can actually happen before the bleeding stops.

So my advice for all of you is: if you do not want to become pregnant, always use a reliable form of birth control even during your period.

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Leukorrhea - What is it and Should I Be Concerned?

        Leukorrhea is a term that has been used for many years to describe vaginal discharge, whether normal or not.  It has classically been used to describe the increase in vaginal discharge that occurs during pregnancy and continues into the postpartum.  The term leukorrhea, when used now, is almost exclusive to the post-partum period, which is the 4-6 weeks right after having a baby.   

      It usually consists of a thick, whitish or yellowish discharge, or a thick, clear, blood-tinged discharge and is usually due to hormone imbalance & continued uterine involution (shrinkage). Most of the time it goes away completely after the post-partum period is over, and discharge returns to pre-pregnancy status.  For a select few, it may go away for a while, only to return from time to time.  It may even keep re-occurring for years.

     Now, most of us just say "vaginal discharge" to refer to any fluid coming from the vagina, whether pregnant or not.  Vaginal discharge plays an important role in maintaining a healthy vagina. The secretions are designed to flush out bacteria and other tiny organisms to prevent infection.  It is the natural defense mechanism the vagina uses to maintain its chemical and pH balance, as well as to preserve the flexibility of the vaginal tissue.  Vaginal discharge is normal for a woman and it would definitely not be normal to not have it.  Normal vaginal discharge is odorless and a clear or a pale milky color.

     Vaginal discharge does increase during pregnancy, as there is a baby growing in the uterus, which causes increased blood flow to the vagina and increased estrogen levels. Even female infants can have discharge for a short time after birth, due to their in-uterine exposure to estrogen from mom; many times it is period-like.  

     Discharge changes during the month.  It can be heavy at times and it can change to clear and watery - that's normal. Other reasons for change include infection, female malignancies, and hormonal changes. In pre-teens, an increase in discharge will happen about 2 years prior to puberty and the onset of the first period.    

     Abnormally heavy discharge (way too much flow that makes you feel wet all the time) that looks and smells normal, is caused by an increase in hormone levels, particularly estrogen, that causes excessive secretions from the cervical glands. These secretions help to clean your vaginal area, so even if they are uncomfortable, they are a sign that your body is doing what it needs to stay healthy. Some women have enough discharge that they need to wear panty liners all day long. This is the type of discharge we discussed earlier that can always come and go for no reason and would respond well to minimal treatment.

     Abnormal discharge will be thick or even cottage-cheese textured, yellow or green, or tinged with blood. It may have an unpleasant odor. You may feel itching or burning in your vaginal area. These are more likely signs of an infection or a sexually transmitted disease.  If you have a sense that your discharge is not normal, it is a good idea to check in with your doctor. Generally, your doctor can test it with a simple swab (Q-tip) test for culture.

       Chronic vaginal discharge always involves one or many parts of the reproductive organs. Whenever the body is loaded with toxins due to poor dietary habits and the eliminative organs such as  bowels, lungs, skin and kidneys are unable to eliminate the toxins, the body produces a profuse discharge or elimination through the vaginal walls and glands of the uterus.  In the case of advanced, chronic inflammatory conditions, it leads to discharge with pus, offensive odor and color varying from cream to yellow or light green.  

       Usually, what happens is you may begin feeling like you are getting a cold and find you also have an increase in vaginal discharge.  You may start to feel irritable and develop black patches under your eyes or some face discoloration, due to the skin weeping that occurs as the body rids itself of toxins.  You may feel weak and tired, a lot of pain in the lumbar region and the calves and a dragging sensation in the abdomen.  Arthritis syndromes can pop up, causing all-over body aches and pains and stiff joints, young & old alike. 

       Backaches will come on for no good reason making it difficult to get comfortable and you may have pain that shoots straight down your vagina or into your leg, especially the thigh and calf muscles.  It is common to have lower abdominal pain from the swelling and inflammation of the uterus and vagina that makes them ache and throb.  If it is an infection, then it has a very good chance of moving into the bladder due to close proximity of the vagina.  Then comes the burning during urination and frequent urge to go, but only a tiny amount of urine comes out.  MISERABLE FEELING!!  

      These are only examples of bodily malfunctions that can accompany female problems or how other organ systems can affect the female system as well.  It is so common to see women suffering with gastric reflux, heart burn, constipation, diarrhea and IBS (irritable bowel syndrome), when their struggling with pelvic pain, heavy periods and painful sex, it's like their whole body is sick because of the way their female system is all off.   So now you feel wiped out, and all you thought you were battling was a little discharge, yeast or bacterial infection.  It's amazing what our body does when it wants to flush out toxins, we usually don't think it will use our vagina and other female organs to do this along with skin and everything else.  Amazing.    

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Can I still get pregnant after a Leep procedure?

“Dear KnowYourV, ,

My husband and I have been trying to get pregnant and now with my abnormal pap results my doctor wants to do a ‘LEEP procedure’ to remove the abnormal tissue from my cervix. Will this interfere with my ability to get pregnant?”

I hear this from so many woman because, with the ‘LEEP procedure’, a very small portion of the cervix is actually removed. Therefore, many women worry that this will weaken their cervix and cause them to miscarry their pregnancies.

The Loop Electrode Electro-cautery Procedure (LEEP) is done in the doctor’s office. It replaced the cervical cone biopsy which was performed in the OR (Operating Room) under anesthesia. The LEEP procedure removes a small, flat, nickel-sized portion of tissue. By contrast, the Cone Biopsy was developed for cervical cancer diagnosis and evaluation, so a very large, deep biopsy was taken, and often it did extend so deep that the risk was higher.

Once the tissue is removed with the LEEP procedure, it is sent to pathology to be examined by the pathologist. It is important to determine if there are any cancerous cells present and also if the margins (or edges) of the specimen are clear of any abnormality. That way, healthy new tissue can replace the diseased or infected tissue, so the next pap results should be normal.

The other popular method for cervical tissue removal is ‘cryotherapy’, where the cervix is frozen, causing the abnormal tissue to be destroyed. Again, healthy tissue will generally take its place. This is done in only mildly abnormal cases, because all the tissue is destroyed in the freezing method, leaving no specimen for the pathologist.

So, in answer to your question about pregnancy, the ‘LEEP procedure’ is not going to interfere with your body’s ability to become pregnant or maintain the pregnancy. I have had many women have successful pregnancies over and over after having this procedure done.

I hope you all stay safe, and enjoy life and work wherever you may be this week. Write to us if you have anything on your mind that we can help you with.

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Thyroid Medicine and Pregnancy

Dear KnowYourV,  

"I'm on prescription medication for my thyroid, is it safe to keep taking this or other prescriptions while I'm trying to get pregnant?"

I have gotten this question from a number of you and the answer is, "Yes!!" (but you should always check with your own healthcare professional). In fact, many prescription medications are safe to take while trying to get pregnant.

Prescription medications are put in categories A,B,C,X, with A having no affect on fetus and X being a medication or substance that is prohibited. This makes is very easy for any healthcare professional to look up a medication and know whether it is safe for pregnancy or should be changed.

If you are on medications and trying to get pregnant, it is a good idea to make and appointment with your doctor to see if any of them need to be changed.

Some medications like Sharon's thyroid medication are essential but if not correctly dosed, may cause difficulty in becoming pregnant. This should be monitored by your doctor. Also high blood pressure, seizures, or diabetes may require that you be on medications and you doctor can make sure the one you are on is safe to use during pregnancy.

Even if you do have a medical condition that requires you take medication while pregnant, you can have a normal healthy pregnancy and baby. Take care of yourself, eat a healthy diet, and make sure you have a good Ob/Gyn and a MFM specialist to monitor you closely during your pregnancy.

Before we end I need to mention herbal and vitamin supplements. Because these can be easily obtained over-the-counter, without a prescription, many people don't think about them being harmful to a pregnancy. Some herbs can cause fetal defects, or cause fetal death. Make sure you check out all the supplements you're taking with your doctor.

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I’m pregnant! What risks do Sexually Transmitted Infections (STIs) pose for my developing fetus?

Sexually Transmitted Infections cause the same problems in pregnant women as they do in non-pregnant women. But in pregnancy they pose added risks to the unborn child. These infections can cause preterm birth, preterm labor and early breaking of the water which can cause infections of the uterus. Once the uterus becomes infected, the baby can become sick and this could cause the baby to suffer brain damage, pneumonia, low birth weight, blindness, deafness, meningitis and even death.

Of course many of these problems can be prevented, as most STI/STD's (Sexually Transmitted Diseases) can be effectively treated with antibiotics. When women get routine prenatal care, routine screening can be done any time there is a suspected problem. Many STI's like chlamydia,`gonorrhea, trichomoniasis and BV (Bacterial Vaginosis) remain in the vagina, and as long as the water is not broken, can be treated without ever impacting the baby. Unfortunately, some STI’s can cross the placenta and make their way via the mother's blood to the baby. HIV and Syphilis are examples of this but studies have shown that women who are treated for syphilis do not pass it to their babies. Likewise for women who are HIV positive but treated with antiviral therapy will have only a 2% chance of passing it to their babies.

Some STD’s if untreated, can be passed to the baby via the vaginal fluids during the delivery process. So the best, safest approach to preventing STI's in pregnancy and reducing the chance of harm to the baby is to go to your doctor for prenatal care. Make sure you are checked for all the necessary STI's. Ask questions there is no such thing as a dumb question. Ask to be rechecked if you are worried. Remember it's important.  It could impact your baby's life and your ability to have more children in the future.

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