Women’s Center of Winchester

Long-Term: Depending on what you choose, long-term birth control can be permanent or last for years at a time.

• Sterilization (Tubal Ligation) 
• A safe and effective surgical procedure that permanently prevents pregnancy
• 99% effective
• Does not protect against STIs
• Non-Uterine Implant/Nexplanon 
• A thin plastic rod, about the size of a match, is inserted into the arm and releases hormones to prevent pregnancy. 
• 99% effective
• Lasts up to 3 years
• Does not protect against STIs
• Inserted and removed by your doctor
• IUD
• A tiny, T shaped device inserted into the uterus to prevent pregnancy
• 99% effective
• Two kinds:
• Copper: causes an inflammatory reaction that prevents sperm from reaching your egg and can last up to 10 years
• Hormonal: causes your cervical mucus to thicken, makes periods lighter, and can last from 3-5 years
• Does not protect against STIs
• Inserted and removed by your doctor
• Birth Control Shot/Depo Shot
• A preventative shot given once every three months or four times each year
• 94% effective
• Does not protect against STIs

Short-Term: Depending on what you choose, short-term birth control can work for up to three weeks before you need to replace it.

• Birth Control Pill
• Monthly pack of pills taken once daily at the same time each day. 
• 91% effective
• Does not protect against STIs
• Prescription required
• Vaginal Ring
• A small, flexible ring you wear inside your vagina
• 91% effective
• Place the ring inside your vagina and leave it for three weeks. You remove it the week of your period and replace it with a new one.
• If you’d like to skip your period, replace the ring every 21 days (skipping periods may increase risk of spotting)
• Does not protect against STIs
• Prescription required
• Birth Control Patch
• A patch that is placed on your stomach, upper arm, buttocks, or upper body like a sticker. 
• 91% effective
• Replace patch every week for three weeks, then leave it off for the fourth week for your period
• To skip your period, replace the patch every seven days without leaving a gap week (skipping periods may increase risk of spotting)
• Does not protect against STIs
• Prescription required

Barrier Methods: Very short-term, since they must be put in place every time you have intercourse.

• Diaphragm & Cervical Cap
• A Diaphragm is a shallow cup you put in your vagina that covers the cervix to prevent pregnancy. A Cervical Cap is a small, plastic cup that looks like a thimble that you put in the vagina to cover the cervix. 
• Used with spermicide (a cream or gel that kills sperm)
• Used every time you have intercourse and leave in for at least 6 hours after intercourse but no longer than 24 hours (Cervical Cap can be left in for no longer than two days)
• Does not protect against STIs
• Prescription required: Your doctor will give you a pelvic exam to determine your size
• Sponge
• A soft, disc-shaped object filled with spermicide
• Place in your vagina one hour before intercourse
• Must stay in place for at least 6 hours after intercourse, but no more than 30 hours
• Does not protect against STIs
• Does not need a prescription
• Female Condom
• Thin pouch made of rubber that you place inside your vagina
• Can protect against some STIs
• Can be inserted up to eight hours before having intercourse
• Does not need a prescription
• Male Condom
• Condoms are made of rubber (latex), plastic or natural/lambskin material
• They fit snugly over a man’s erect penis to prevent sperm from entering the body.
• Most effective way to prevent STIs, except for natural/lambskin condoms which do not
• Does not need a prescription

https://www.plannedparenthood.org/learn/birth-control 

• Use a second method of birth control (such as condoms and foam) during your first month on the Pill. 
• Pills work best if you take one around the same time every day in order to keep a constant level of the drug in your system.
• If you miss one pill: Take the forgotten pill (yesterday’s pill) as soon as you remember and take today’s pill at the regular time. 
• If you miss two pills: Take two pills as soon as you remember and two the next day. Example: You forget your pills on Saturday and Sunday evenings but remember Monday morning: What to do? Take two pills on Monday and two on Tuesday. You may experience some spotting, and use another means of contraception until you finish your package of pills. 
• If you miss three or more pills: The chances are high that you will ovulate and you may get pregnant. Start using a second method of birth control immediately. Throw away the old pack of pills. Start a new pack of pills the Sunday after you realize you have missed three or more pills, even if you are bleeding. Use a second method of birth control for the first two weeks after starting your new pack of pills. 
• If you miss one or more pills and skip a menstrual period, call your doctor or clinic to ask about a pregnancy. 
• If you miss no pills and skip a menstrual period, don’t worry too much. You may be pregnant, but it is very unlikely. It’s common for women taking birth control pills to miss periods occasionally. If you are worried, call the office. Otherwise, you can start a new pack of pills at the regularly scheduled time. When in doubt, continue on your pills until you see your doctor. 
• If you have spotting for two or more cycles, call the office. You may need an appointment. 
• If your pack of pills has 28 pills in it:
• You will notice that the last 4 to 7 pills are a different color than the others. You should be getting your period during this week. Don’t worry if your period does not come until the second or third pill. 
• If your pack of pills has 21 pills in it:
• After you take the last pill you wait seven days and begin your new pill pack. You will have your period the week you are not taking your pills. 
• If you want to skip your period:
• Simply do not take the last 4 to 7 pills of the 28 day pack and go right to a new pack of pills. If your pack has 21 pills in it, just go right into a new 21 day pack. This will allow you to have no period for that particular month you would like to skip. If you want to do this often, speak with your doctor or PA about “continuous” pill use. 
• If you feel sick to your stomach when you are taking your pills, try taking your pill with your evening meal or right before you go to bed.
• If you vomit within two hours of taking your pill, take an extra one because your original pill may have no effect. 
• Get a complete gynecologic examination once a year, including blood pressure, Pap smear, STD check, and breast examination. Call the office for an appointment two to three months in advance
• Make sure you make an appointment for a follow up before your pills run out.
• Five warning signals:
• Abdominal pain (severe)
• Chest pain (severe) or shortness of breath
• Headaches (severe)
• Eye problems; blurred vision, flashing lights, or blindness
• Severe leg pain (calf or thigh)
• When you are seen by a doctor for other check-ups or problems, be sure to mention you are using birth control pills. 
• Taking pills Continuously:
• Used to avoid monthly bleeding and associated problems (pain/cramps, PMS, Headaches).
• Take one hormone containing pill at around the same time everyday. 
• We recommend that you throw away the placebo tablets at the end of the pack so you will not take them by mistake
• When all the hormone containing pills are taken, immediately start a new pack. 
• If bleeding or persistent spotting occurs, stop hormone containing pills for 3 days only. (You can either punch out and throw these pills away or simply take them once you resume.) This three day break allows the lining of the uterus to be shed, so be prepared to experience bleeding when you stop the pills. Even if you are still bleeding, resume taking the pills after the three day break. 
• Never take more than a 3 day break from your pills. You must always take at least three weeks of hormone containing pills before taking a three day break. 
• If you are not having any spotting or bleeding, a 3 day break is not necessary. 
• While some patients do not experience frequent bleeding when initiating continuous pills, most will have bleeding and spotting that requires taking a 3 day break every few weeks. 
• Some patients have temporary nuisance side effects (nausea, headaches, PMS, etc.) when initiating the pill. If you have any problems or questions, call your healthcare provider. 

• Sexually Transmitted Infections are infections or diseases that are passed during unprotected intercourse or needle sharing with an infected partner. 
• Symptoms include: unusual discharge from your vagina, difficulty or pain when urinating or during intercourse, blisters, warts, lumps, bumps, or sores on your genitals, rash, cracked skin, itchy or irritated skin around your genital region. 
• Many STIs are treated with antibiotics. Others are manageable through medication.
• Prevention: Regular STI checks, limit sexual partners, and always use condoms. Vaccines:
• Hepatitis B: three or four shots given over a period of six months. 
• Gardasil: a vaccine for HPV, given between the ages of 9-45, though the ideal age would be given to children around 11 and 12 years. Helps protect those between the ages of 9 and 45 against the following diseases caused by HPV: vaginal, vulvar, and cervical cancer in women and anal cancer and genital warts in both men and women. Does not protect against all types of cervical cancer, so women should still get screenings later in life. Does not cure cancer or genital warts. 
• Truvada: PrEP (Pre-Exposure Prophylaxis), meaning that this helps protect yourself before getting in contact with HIV. This is a pill that is taken daily if you plan to have a relationship with someone who is HIV positive and must be used with safer intercourse practices. You must be HIV-negative and get screenings every three months.

https://www.acog.org/Patients/FAQs/How-to-Prevent-Sexually-Transmitted-Infections-STIs 

https://healthywa.wa.gov.au/Articles/A_E/About-sexually-transmitted-infections-STIs 

• Abnormal uterine bleeding (AUB). Bleeding that is abnormal in frequency, severity, or duration. Not the same as normal irregular periods during perimenopause or bleeding from menopause hormone therapy including estrogen and progestogen. Possible causes are hormone imbalance, pregnancy, fibroid tumors, uterine lining abnormalities, cancer, and other conditions of the vagina or cervix. See also Dysfunctional uterine bleeding.
• https://www.menopause.org/for-women/menopause-glossary#A 
• Hormonal birth control, such as pills, implants, patches, injections or rings, can cause you to spot between periods during the first three months of use. 
• Perimenopause: As you get closer to menopause your periods may be harder to predict. Your hormone levels change and your uterine lining gets thicker. This can cause spotting.
• Normal bleeding/menses: A menstrual cycle is thought to begin on the first day of your menstrual period and usually lasts 28 days, though it can last from anywhere from 21 to 35 days. Bleeding usually lasts for 3-5 days, but can be as short as 2 days or last for 7. Girls normally begin periods around 12, but can begin as early as 8 or as late as 16. 

ENDOMETRIOSIS

•  A condition in which the same kind of tissue that lines the cavity of the uterus (endometrium) grows outside the uterus (eg, on the ovaries or bowel), often resulting in severe pelvic pain and infertility.
• Symptoms include: chronic pelvic pain (especially before or during your menstrual period), pain during sex, pain during urination or bowel movements, or painful periods.
• Occurs in one out of every ten women during reproductive age May be treated with medication or surgery or both
• Diagnosis does not require surgery.
• Lupron: a shot given to help manage endometriosis. It can help reduce pain and endometriotic lesions. There are two forms, one is a shot given each month and the other is a shot given once every three months.
• Estrogen levels will increase so you will see a temporary worsening of your symptoms for the first two weeks after beginning the injections.  
• It is not a form of birth control. Though you may not experience a period, you may get pregnant if you do not use contraceptives. You should not use hormonal birth control while taking the injections.
• https://www.luprongyn.com/lupron-for-endometriosis
• Myfembree: an oral pill for women from 18-49 with moderate to severe endometriosis.
• May help with painful periods, pelvic pain between periods, and pain during intercourse.
•  https://www.myfembree.com
• https://www.acog.org/Patients/FAQs/Endometriosis

• Infrequent or difficult bowel movements. Generally described as fewer than three bowel movements a week. 
• Symptoms include: Less than three bowel movements a week, straining, lumpy or hard stools, feeling as though there is a blockage in your rectum, and needing help to pass, such as using your hands to press on your abdomen or using your finger to remove stool from your rectum.
• Never strain as this causes hemorrhoids and tears up the pelvic floor.  
• Risk Factors include: being an older adult, being a woman, dehydration, not enough fiber intake, little to no physical activity, stress, medications, depression, or eating disorders
• Help For Constipation:
• Avoid caffeine
• Exercise!!!
• Drink plenty of water
• Eat fiber rich foods (fresh fruits & vegetables, whole grains)
• If that DOES NOT help, ADD:
• Fiber supplement every day (Fibercon, Metamucil)
• Stool softener twice a day (colace)
• Dr. Gibson’s remedy: 
• 2 Tablespoons at bedtime
• 1 cup of Applesauce
• ¾ cup Miller’s unprocessed bran (found in the organic section of your grocery store)
• 1 cup prune juice
• If that is NOT satisfactory, ADD:
• Miralax everyday (If no BM for 4 days)
• Milk of Magnesia 
• https://www.mayoclinic.org/diseases-conditions/constipation/symptoms-causes/syc-20354253 

• The loss of bladder control. 
• Though it becomes more common as you age, it is not a consequence of getting older. If it affects your daily life, do not hesitate to contact your doctor. Simple lifestyle changes or medical treatment can help ease discomfort or stop the incontinence. 
• Stress incontinence: Urine leaks after exerting pressure on the bladder (e.g., coughing, laughing, sneezing, exercising, or lifting something heavy).
• Urge incontinence: Having a sudden and intense urge to urinate followed by an unintentional loss of urine. This can include needing to urinate often and during the night.
• Overflow incontinence: Frequent dribbling of urine caused by a bladder that doesn’t completely empty. 
• Functional incontinence: A physical or mental incontinence that may prevent you from making it to the bathroom on time. This can include arthritis that inhibits you from unbuttoning your pants.
• Mixed incontinence: you may experience more than one type of incontinence. 
• Risk Factors include: Being a woman, being overweight, age, smoking, family history, diabetes, or a neurological disease.

Treatment:

• Overactive bladder/Urge incontinence and mixed incontinence: Pelvic floor exercises such as Kegels, reaching a healthy weight, scheduled toilet trips, bladder training, surgery, electrical stimulation, vaginal inserts, medications, and bladder injections.  

https://www.mayoclinic.org/diseases-conditions/urinary-incontinence/symptoms-causes/syc-20352808 

Cancer prevention and screening

• Cancer Prevention:
• Regular check-ups every year for most women
• Regular exercise
• To maintain body weight: 150 minutes (2 and a half hours) of weekly exercise (minimum)
• To lose weight: 200 minutes (3.3 hours) of weekly exercise (minimum)
• Improving your diet and eat plenty of fruits and vegetables
• Reducing alcohol intake
• For women, it’s no more than 1 drink in a single day and no more than 7 drinks in a week. 
• Avoid smoking and tobacco products
• Protect your skin from the sun
• Screening
• It’s recommended that women over the age of 40 have an annual mammogram and breast exam
• Women between the ages of 21 and 30 should have a pap smear every other year
• Women between the ages of 30 and 65 should have a pap smear and HPV test (co-testing) every 3 years. 
• After 65 it’s recommended that women get pap smears every other year
• For average risk women, colonoscopy is recommended starting at age 50 for colon cancer screening
• If you are over 55 and a smoker, low dose chest CT screening is available for lung cancer screening
• https://myriad.com/patients-families/your-questions-about-disease/whats-my-risk/ 

• Women with dense breasts diagnosed by mammography have a modestly increased risk of breast cancer. 
• Risk Factors include: Age (women over the age of 60 are more likely to develop breast cancer), gender (more common in women), family history, obesity, not having children or having children later in life (over 35), higher breast density, menstrual history (beginning periods before the age of 12 and/or start menopause at a later age such as after 55), a sedentary lifestyle, heavy drinking, birth control, hormone replacement therapy, and radiation exposure. 
• Even though higher breast density is itself a risk for breast cancer, the higher the density, the harder it is to detect breast cancer. 
• Models for breast cancer risk:
• Gail: Used to test women who have no history of breast cancer, BRCA1, or BRCA2 genetic mutations. This model uses a woman’s personal information to help calculate her risk of developing breast cancer over a certain period of time. 
• Tyrer-Cuzick: Uses family history, personal information, and the presence of BRCA mutations to calculate risk for breast cancer. 

Risk Percentage:

• Average: 13%
• Moderate: Between 14% and 20%

Take steps to help lower your risk:

• Talk to your doctor
• Increase, or incorporate, regular physical activity into your routine
• Decrease alcohol intake
• Improve diet
• Reach and/or maintain a healthy weight
• High: >20%
• Women who have 20 or over 20% risk of developing breast cancer should consider beginning an annual MRI screening. 
• MRI screening should be in addition to mammography testing as MRIs can sometimes result in false positives. 
• Consultation with a breast cancer specialist is also recommended
• Screening:
• 3D Mammograms: Also known as tomosynthesis or simply as “tomo.” It is test that combines multiple x-ray images together to form a 3D image. The procedure for a 3D mammogram is the same as that of a 2D mammogram, though it may take a few seconds longer.
• Finding abnormalities may be easier using this type of mammogram
• A combination of 3D & 2D mammograms were more accurate than 2D mammograms on their own. Though the rate of accuracy is only slightly higher. 
• Downsides of 3D mammograms
• More expensive
• Increased exposure to radiation
• ABUS: Automated Breast Ultrasound Screening. It is an ultrasound that was designed to find cancer tissue in dense breasts that could be missed by mammography. 
• Uses sound waves to produce an image rather than radiation. 
• Usually given after a mammogram
• MRI: Not recommended as a regular screening tool, but it is recommended for women who are at high risk for breast cancer. Recommended to be in combination with mammograms and/or ultrasound.  
• More sensitive than mammograms to abnormalities. Can result in false positives which is why it is not recommended for all women. 
• https://www.acog.org/Clinical-Guidance-and-Publications/Practice-Bulletins/Committee-on-Practice-Bulletins-Gynecology/Breast-Cancer-Risk-Assessment-and-Screening-in-Average-Risk-Women 

• PMDD: Premenstrual Dysphoric Disorder
• Symptoms usually don’t occur until about a week before your period and only last for a few days after your period begins.
• Symptoms include: mood swings, sleep problems, depression, tension, anxiety, fatigue, headaches, joint or muscle pain, hot flashes, feeling out of control, cramps, and bloating. 
• Similar to PMS, but it is more debilitating and can affect personal life and relationships.
• Depression:
• Symptoms include: Weight loss or weight gain, mood swings, loss of interest, hopelessness, apathy, insomnia, sleep disturbances (excess sleeping, restless sleep), excessive hunger, loss of appetite, fatigue, irritability, social isolation, lack of concentration, slowness in activity, trouble remembering things, or thoughts of suicide.
• Depression is a mood disorder that causes a persistent feeling of sadness and loss of interest. 
• If you feel depressed, make an appointment with your doctor or mental health professional as soon as you can. 
• Questionnaire: https://www.mdcalc.com/phq-9-patient-health-questionnaire-9 
• Anxiety:
• Experiencing occasional anxiety is a normal part of life and is part of your body’s natural “fight or flight” response. However, those with anxiety disorders have frequent feelings of intense fear, worry, and panic over everyday things. 
• Symptoms include: Feeling nervous, anticipating the worst, trouble concentrating, frequent urination, increased heart rate, rapid breathing, trembling, sweating, headaches, insomnia, and upset stomach.
• Anxiety Attacks: Intense and sudden fear or panic that usually occurs without warning, though sometimes with an obvious trigger such as public speaking. They rarely last any more than thirty minutes. 
• Questionnaire: https://psychcentral.com/quizzes/anxiety-quiz/ 
• https://www.helpguide.org/articles/anxiety/anxiety-disorders-and-anxiety-attacks.htm 

• Menopause is the time in a woman’s life when periods naturally stop and marks the end of a woman’s reproductive years. This happens when your ovaries stop making estrogen. The average age women go through this is 51.
• Perimenopause: The years leading up to menopause, beginning in your 30s or 40s, the amount of estrogen released by the ovaries begins to fluctuate. Menstrual cycles may become longer or shorter and you may even skip a period. 
• Symptoms include: hot flashes, sleep problems, mood changes, vaginal and urinary tract changes, higher risk for osteoporosis (increased risk of bone fracture), and an increased risk of Cardiovascular disease.
• Hormone Replacement Therapy: Replacement of estrogen and progestin or only of estrogen if you have undergone a hysterectomy (removal of the uterus), this can help relieve the symptoms of perimenopause and menopause. 
• Hormone Therapy is one of the most effective treatments for hot flashes and night sweats. 
• Also treats vaginal dryness and painful intercourse associated with menopause. 
• Keeps your bones strong by preserving bone density and reduces your risk of osteoporosis and fractures. 
• Prevents colon cancer
• May prevent cardiovascular disease if started early in menopause
• Potential Side Effects include: breast tenderness, nausea, and irregular bleeding or spotting.
• HT Options
• Daily pill
• Skin patch: changed once or twice weekly
• Vaginal ring: changed only every three months. 
• HT therapy taken in non-pill forms enter your bloodstream faster with less effect on your liver. Studies suggest that this may lower the risk of blood clots in the legs and lungs compared with HT taken as a pill
• Stopping hormone therapy:
• Many women try to stop HT after 4-5 years due to a small increased risk of breast cancer. 
• Hot flashes may or may not return after you stop HT. Although not proven by studies, slowly decreasing your dose of estrogen over several months or even several years may reduce the chance that your hot flashes will come back. 
• Additional Information:
• http://www.menopause.org/for-women/menopauseflashes/menopause-symptoms-and-treatments/news-you-can-use-about-hormone-therapy 
• https://www.acog.org/Patients/FAQs/The-Menopause-Years?IsMobileSet=false 
• Vaginal Dryness
• Vaginal atrophy: the decrease in estrogen levels with menopause that is a major contributor to vaginal dryness, itching, burning, discomfort, and pain during intercourse or other sexual activity. 
• Unlike hot flashes, that get better with time, vaginal symptoms typically worsen with time because of aging and a prolonged lack of estrogen. 
• Menopause and aging can affect the vagina:
• Vaginal tissues become thin, dry, and less elastic, with decreased secretions and lubrication
• Vaginal infections increase
• Discomfort with urination and increased urinary tract infections can occur
• Fragile, dry, inflamed vaginal tissues may tear and bleed
• Aromatase inhibitors, taken by women with breast cancer, resulting in extremely low estrogen levels, often causing severe symptoms of vaginal dryness and decreased lubrication. 
• Vaginal changes often result in pain with sexual activity or pelvic exams
• Pain, narrowing of the vagina, and involuntary tightening of vaginal and pelvic muscles can point where intercourse or other sexual activity is no longer pleasurable or even possible.
• Treatment:
• Vaginal lubricants (nonprescription). Many available products
• Vaginal moisturizers (nonprescription). Many available products
• Vaginal estrogen therapy (prescription required)
• Estrace or Premarin vaginal cream (0.5-1g, placed in the vagina 2-3 times per week)
• Estring (small, flexible estradiol ring placed in vagina and changed every 3 months)
• Vagifem (estradiol tablet placed in vagina twice a week)
• Vaginal “exercise”
• Sexual activity
• Stretching exercises with lubricated vaginal dilators
• Pelvic floor physical therapy
• Ospemifene (prescription required; Osphena)
• An oral tablet that treats painful intercourse caused by vaginal atrophy
• Intravaginal dehydroepiandrosterone (Intrarosa; prescription required)
• A hormone vaginal insert that treats painful intercourse caused by vaginal atrophy.
• Additional Information:
• http://www.menopause.org/for-women/menopause-take-time-to-think-about-it/consumers/2017/01/18/vaginal-moisturizers-and-lubricants-finding-your-way-through-the-drugstore-aisles 
• Hot Flashes
• Most common and bothersome symptom of menopause. Occur both during the day and at night (night sweats). Range from mild and tolerable, moderate and troublesome, or severe and debilitating. Get better with time. Can last for a few years or decades. 
• If your hot flashes are mild or moderate, you may benefit from lifestyle changes. If your hot flashes are severe, you still may benefit from lifestyle changes, but you may also opt for a nonprescription or prescription remedy, including hormone therapy. 
• Lifestyle Changes:
• Avoid warm rooms, hot drinks, spicy foods, alcohol, caffeine, excess stress, and cigarette smoking. 
• To reduce stress and get a more restful sleep, exercise regularly, but not too close to bedtime. Meditation, yoga, qigong, tai chi, biofeedback, acupuncture, or massage will also lower stress levels. 
• When a hot flash is starting, try “paced respiration” — slow, deep, abdominal breathing, in through your nose and out through your mouth. Breathe only 5 to 7 times per minute, much more slowly than usual. 
• Nonprescription remedies: eating one or two servings of soy foods daily (tofu, tempeh, soymilk, or roasted soy nuts), taking supplements containing certain herbs like black cohosh, such as Remifemin. 
• Additional Information:
• http://www.menopause.org/for-women/menopause-faqs-hot-flashes 

• Some women experience menopause-related sleep problems, especially if hormone changes cause hot flashes or sweats during the night. 
• Most adults need between 7 and 9 hours of sleep each night. During menopause transition, you may find that you have more trouble falling asleep, staying asleep, or waking up feeling refreshed. 
• Lifestyle Changes:
• Maintain an environment that promotes sleep: quiet, cool, and dark. A white noise machine may be helpful. 
• Try relaxation techniques such as meditation or slow, deep-breathing exercises.
• Avoid blue light for at least an hour before sleep (TV, computer screens, smart phones, and electric readers)
• Follow the 15-minute rule: if you do not fall asleep within 15 minutes, get up, leave the bedroom, and do something relaxing in another room, such as reading a book or magazine or listening to quiet music. Return to bed when you are drowsy. 
• Follow a regular sleep routine. Try to wake up and go to bed around the same time each day, even on weekends. 
• Use the bedroom only for sleep and intimacy
• Avoid stimulants such as alcohol, caffeine, and nicotine throughout the entire day, not just during the evening. Although alcohol is initially a sedative, it often disrupts sleep. The stimulant effect of caffeine may last up to 20 hours. 
• Avoid eating large meals or sweets right before bedtime. This may disrupt sleep and promote weight gain. 
• Exercise almost every day. Daily exercise improves sleep, but avoid strenuous exercise close to bedtime. 
• Treatments:
• Herbs and supplements: Melatonin, valerian, chamomile, lavender, lemon balm, and passion flower may be mild sedatives. Scientific data and government oversight of herbs and supplements is limited, so purchase products made in the US under good manufacturing practices.
• Over-the-counter sleep aids. Try low doses (25 mg or less) of benadryl to reduce the risk of morning grogginess. 
• Cognitive behavioral therapy (CBT): CBT is a specific form of psychotherapy that effectively treats many sleep problems.
• Prescription sleep medications
• Treatments for night sweats: hormone therapy and non hormonal medications such as certain low-dose antidepressants. Hormone therapy has other risks and benefits, so you should speak with your healthcare provider to see whether hormones or other medications that treat night sweats are for you.

• A disease in which bone density is reduced and there is a greater risk of fracture. Often occurs without symptoms and is progressive. You are usually unaware you have this until a fracture occurs. 
• Calcium: Are you getting enough?
• Women (25-50) 
• 1000mg + 800IU Vitamin D3
• Postmenopausal (on estrogen)
• 1000mg + 800IU Vitamin D3
• Postmenopausal (not on estrogen)
• 1500mg + 800IU Vitamin D3
• Men and Women (65 years and older)
• 1500mg + 800IU Vitamin D3
• Calcium: Where you’ll find it:
• Milk
• Milk (skim), 8 oz 302 mg
• Milk (whole), 8 oz 291
• Low-fat choc milk, 8 oz 287
• Buttermilk, 8 oz 285
• Breast milk, 8 oz 79
• Yogurt
• Nonfat yogurt, 8 oz 452
• Low-fat yogurt, 8 oz 415
• Frozen yogurt, ½ cup 90
• Cheese
• Goat cheese (hard), 1 oz 254
• Part-skim mozzarella, 1 oz 183
• American cheese, 1 oz 174
• Low-fat cottage cheese, 1C 155
• Feta cheese, 1 oz 140
• Grated parm cheese, 1 TBSP 69
• Fish
• Sardines with bones, 3 oz 370
• Canned salmon with bones, 3 oz 180
• Vegetables
• Collards (frozen, chopped), 1C 357
• Turnip greens (cooked, frozen), 1C 200
• Kale (frozen, chopped), 1C 179
• Broccoli (cooked), 1C 178
• Okra (cooked), 1C 176
• Mustard greens (cooked), 1C 103
• Other
• Vegetable lasagna, 1 piece 450
• Calcium fortified OJ, 1C 300
• Cheese pizza, 1 slice 290
• Chocolate pudding, 1⁄2C 161
• Rice pudding, ½ C 152
• Vanilla soft-serve ice cream, ½ C 113
• Choc soft-serve ice cream, ½ C 106
• Vanilla ice cream, ½ C 85
• Calcium: which one to take?
• Calcium carbonate- 40% elemental calcium, should be taken with meals in no more than 500mg at a time, least expensive
• Calcium citrate- 21% elemental calcium, can be taken with or without food in no more than 500mg at a time, more expensive but more bioavailable. 
• Preferred for those taking a PPI (nexium , prilosec, protonix, or prevacid).
• Avoid taking calcium within several hours of taking the following medicines: thyroid medication, certain antibiotics (CIPRO or LEVAQUIN) or ACEI (lisinopril, zestril, prinivil)
• Vitamin D: 
• Cannot absorb calcium properly from the gut without proper Vitamin D levels.
• There are very few dietary sources of Vitamin D: some in fortified cow’s milk, fortified OJ, fortified cereals, egg yolks, and certain saltwater fish such as mackerel
• The sun is an excellent source of Vitamin D, but increases your risk of skin cancer.

• When there is too much bad cholesterol in your blood, it begins to build up around the walls of your arteries. Over time, this buildup causes the arteries to harden and become narrowed so blood flow to the heart slows down or can even be prevented. When the blood flow is slowed down, you may experience chest pain. When the blood flow to a part of the heart is completely cut off, you will have a heart attack. 
• High blood cholesterol itself does not have any symptoms which is why it’s important to get it checked. Everyone 20 and older should have their blood cholesterol levels tested at least once every 5 years. This test is done after a 9 to 12 hour fast.
• LDL (bad) cholesterol: This is the main cause of blockage in the arteries
• HDL (good) cholesterol: This protects against heart disease helps keep cholesterol from building in the arteries
• Reading your results:
• Total Cholesterol Level Category
• Less than 200 mg/dL Desirable
• 200-239 mg/dL Borderline high
• 240 mg/dL and above High
• LDL Cholesterol Level LDL Cholesterol Category
• Less than 100 mg/dL Optimal
• 100-129 mg/dL Near optimal/above optimal
• 130-159 mg/dL Borderline high
• 160-189 mg/dL High
• 190 mg/dL and above Very High
• HDL Cholesterol Level
• The higher the number, the better. A level less than 40 mg/dL is low and is considered a major risk factor for heart disease and heart attack. Levels of 60 mg/dL or more help lower your risk. 
• Triglycerides
• Triglycerides are another type of lipid, or fat, in your blood. This can also raise your risk of heart disease. Levels of 150-199 mg/dL are borderline high and 200 mg/dL or above are considered high. Both levels may require treatment. 
• What Affects Cholesterol Levels
• Diet: Saturated fats and cholesterol in food make your cholesterol levels increase. Reducing the amount of saturated fat and cholesterol you eat helps lower your blood cholesterol levels. 
• Weight: Being overweight is a risk of heart disease and tends to increase your cholesterol levels. Losing weight can help lower your LDL levels and increase your HDL levels. 
• Physical Activity: Not being physically active is a risk factor. Regular exercise can help lower your risk for heart disease and heart attack. 
• Risk Factors for Heart Disease
• Cigarette smoking
• High blood pressure (140/90 mmHg or higher or on blood pressure medication)
• Low HDL cholesterol (less than 40mg/dL)
• Family history of early heart disease (heart disease in father or brother before age 55; heart disease in mother or sister before 65)
• Age (men 45 years or older; women 55 years or older)
• Obesity
• Physical inactivity
• Supplements that Lower Cholesterol
• Red Yeast Rice: 1200 to 3600mg per day may reduce your LDL Cholesterol by 20%
• Phytosterols: 2000mg per day may lower your LDL by 8%, 3500mg by 12%
• Psyllium (soluble fiber): 7000mg per day may reduce your LDL by 11%
• Niacin: take in consultation with a physician, secondary to side effects 
• Treatment
• Therapeutic Lifestyle Changes (TLC): Includes a TLC diet, physical activity, and weight management
• TLC Diet: recommends only consuming enough calories to maintain a healthy weight and avoid weight gain. 
• Weight Management: If you are overweight, losing weight can help lower your LDL levels and raise your HDL levels. 
• Physical Activity: Incorporating regular physical activity (30 minutes on most days or everyday) into your schedule can help raise HDL and lower LDL 
• Drug Treatment: If cholesterol-lowering drugs are needed, they are used along with TLC to help decrease your LDL levels.

• A preconception check-up is a check-up before pregnancy to make sure you’re healthy before becoming pregnant. This can be given at any time, even a year before pregnancy.
• What can affect pregnancy? Depression, diabetes, high blood pressure, not being at a healthy weight, smoking, misuse of prescription drugs, using street drugs
• Always get a preconception check-up, but especially if you have had:
• A premature birth: A birth before 37 weeks of pregnancy
• A baby with birth defects
• Miscarriage: When the baby dies in the womb before 20 weeks
• Stillbirth: When the baby dies in the womb after 20 weeks
• What can you expect? Your doctor will check your overall health and make sure that you are ready for pregnancy. You and your doctor may discuss:
• Folic Acid: This is an acid that every cell in your body needs for proper growth and development. Taking folic acid before and early on in pregnancy can help protect your baby from brain, spine, and mouth disorders. 
• Health conditions that can affect pregnancy
• Medicines you take
• Vaccinations
• Smoking, drinking alcohol, and the use of drugs
• Unsafe chemicals at work or at home
• When to stop using birth control 
• Genetic testing to see if you have a higher risk of having a baby with a birth defect.

Your doctor may give you a physical exam, a pelvic exam, a pap smear, and blood tests.  

LOSS OF LIBIDO

• Loss of libido is the reduction of sexual desire, or lack of interest in sexual activity.

• As women begin to go through menopause, perimenopause, our testosterone levels fluctuate and begin to decrease. The symptoms of menopause can affect sexual desire.  

• When asking your doctor about loss of libido, they may perform a pelvic exam to check for vaginal dryness, thinning of genital tissues, and pain triggering areas.

Treatment:

• Your doctor will go over your medications with you to see if they have any side effects that may include a reduction of sexual desire.

• Hormone therapy to reduce bothersome hot flashes and/or night sweats

• Vaginal estrogen treatment to improve the moisture and elasticity of the vagina

• Testosterone replacement

• Lifestyle and home remedies:

• Regular exercise

• Stress reduction

• Communication with your partner

• Reduction of alcohol consumption

• Stop smoking

• Additional Information:

• https://www.menopause.org/for-women/sexual-health-menopause-online/changes-at-midlife/changes-in-hormone-levels  

• Changes in genes, called mutations, are a major contributor in the development of cancers. Only about 5% to 10% of cancer mutagens are thought to be genetic. 
• Genetic testing is the use of medical tests to determine if you carry a mutagen in your DNA
• If you have any of the following you should consider genetic testing
• First degree relatives with cancer: mother, father, siblings, and children
• Many relatives who have had the same type of cancer on one side of the family
• A cluster of cancers that are tied to a single mutagen 
• A family member with more than one type of cancer
• Relatives who have developed a cancer earlier than is normal for that particular cancer
• Ethnicity (certain ethnicities have a higher risk for some cancers)
• A physical finding that is linked to an inherited gene