Women’s Health

At Friberg Fertility, we provide a full range of general OB/GYN care. Many of our infertility patients are so satisfied with their experience that they choose to stay on with us after completing their infertility treatments.

Understanding Irregular Menstrual Cycles

When your period comes more often than 28 days or with intervals longer than 35 days, that is considered an irregular menstrual cycle. Many women experience this at some point in their life.

Causes of Irregular Periods

Irregular periods are usually caused by an imbalance between the ovarian hormones estrogen and progesterone that are controlled by secretion of the pituitary hormones follicle-stimulating hormone (FSH) and luteinizing hormone (LH). Abnormal secretions of FSH and LH are most commonly seen when girls enter puberty and when women get close to menopause.

Additional causes of irregular periods include the following:

  • Heavy exercise
  • Stress
  • Thyroid disease
  • Hyperprolactinemia (elevated levels of prolactin — the hormone responsible for milk production)
  • Polycystic ovarian disease (POCS)
  • Congenital adrenal hyperplasia
  • Poor nutrition
  • Mechanical distortion from fibroids and polyps

Some natural approaches that can help to regulate your menstrual cycle include the following:

  • Maintain a healthy weight.
  • Engage in regular, moderate exercise.
  • Ensure proper nutrition.
  • Participate in yoga.

When to See a Doctor for Irregular Periods

You should see a doctor for your irregular periods if any of the following occur:

  • You miss three or more periods in a year.
  • Your periods have always been regular but then suddenly became abnormal.
  • You have a period more frequently than every 21 days.
  • Your menstrual intervals are longer than 35 days.
  • Your periods become unusually painful and heavy.
  • Your period lasts more than 7-9 days.

Estrogen and/or progesterone preparation is the usual treatment for irregular menstrual cycles, but many new treatments are also available.

Understanding Uterine Fibroids

Uterine fibroids, also called myomas or fibromyomas, are common, and most women have developed some by the time they reach perimenopause.

Fibroids may be so small that they are not detected by the naked eye but can also reach the size that they cover the entire abdomen. They are almost never malignant.

Symptoms of Uterine Fibroids

When fibroids become large and bulky, they often, but not always, create symptoms such as:

  • Heavy menstrual bleeding
  • Menstrual periods that last longer than 7 days
  • Pelvic pressure or pain
  • Frequent urination
  • Difficulty emptying the bladder
  • Constipation
  • Back ache and/or leg pain

Causes of Uterine Fibroids

Fibroids are caused by genetic factors and are also influenced by hormonal factors. A single cell starts to develop and grow and divide repeatedly. An individual fibroid is composed of cells with an identical genetic design. Extracellular matrix factors, called cytokines, and growth factors from stem cells are involved in the creation and stimulation of fibroids.

Vitamin D inhibits the growth of fibroids, and it is important to examine vitamin D levels in patients with fibroids. Achieving normal vitamin D levels can help prevent further growth. The pharmacologic industry is working with vitamin D analogs to inhibit the growth of fibroids and even prevent them from development.

Uterine Fibroids and Pregnancy

Fibroids tend to grow during pregnancy and if they are present in the lower uterine segment, they may prevent the baby from descending. This can be a cause for a cesarean section.

If the fibroid is located next to the placenta, it may interfere with the placental function, and special supervision of the pregnancy is needed. Fibroids interfere with the normal uterine contraction and frequently lead to irregular, prolonged and heavy bleeding that can result in anemia and the need for iron therapy. Blood transfusions are rarely needed.

Treatment for Uterine Fibroids

For a long time, surgery was the primary treatment for fibroids. However, over the last few years, LH agonist and antagonist treatments have been developed.

Estrogen deficiency caused by the treatment and negative effects on bone development were prominent disadvantages in the early LH inhibiting medical treatment. Now, however, effective add-back estrogen and progesterone treatments have been developed.

In addition, two new orally active LH antagonists have come on the market — Elagolix (Orilissa®), which needs dosing morning and night, and relugolix (Myfembree®) that is only dosed once a day.

Uterine Fibroids and Fertility

Fibroids interfere with fertility. Large fibroids with a diameter over 5 cm and fibroids within the uterine cavity have for a long time been known to result in infertility and should be removed.

Now, smaller fibroids, 1 – 2 cm up to 4 cm, and fibroids just under the endometrial surface are suspected to interfere with the implantation of the embryo. Controversy exists, but removal is suggested. However, the risk of damage to the tissue next to the uterine cavity could create an even more pronounced problem.

Polycystic Ovarian Syndrome (PCOS)

Polycystic ovarian syndrome (PCOS) is an endocrine reproductive disorder affecting 7-15% of women in their reproductive years.

In 2016, PCOS was defined at a meeting in Rotterdam, resulting in “The Rotterdam Criteria” of PCOS, where it must meet 2 of the following 3 criteria — oligo-anovulation and/or biological hyperandrogenism or micropolycystism (ovarian volume > 10 nl or more than 12 follicles in the ovary) — in order to qualify for the diagnosis.

Diagnosing PCOS

The typical PCOS patient suffers from the following:

  • Hirsutism — excessive growth of coarse, dark hair on unexpected areas of a woman’s body, such as the face, chest, and back, caused by an increased level of androgens (male hormones)
  • Seborrhea — a condition that causes white scaly patches and red, itchy skin, often on the scalp
  • Dysfunctional menstrual cycles
  • Overweight
  • Infertility
  • Basal anomaly — a dysfunction of abdominal fat that is slowly starting to be brought to light by science
In spite of these symptoms, a long delay in the diagnosis of PCOS is not unusual. A number of other medical disorders mimic PCOS, including thyroid dysfunction, hyperprolactinemia (elevated prolactin), congenital adrenal hyperplasia (a group of genetic disorders that affect the adrenal glands) and Cushing’s syndrome (a disorder that occurs when the body makes too much cortisol over a long period of time).

On the laboratory side, LH is typically much higher than FSH in PCOS patients, and AMH (anti-müllarian hormone) is usually much higher than the normal levels of 0.7-3.5 ng/ml and can go up to 5-15 ng/ml.

PCOS Treatment

Initial treatment for PCOS is restoration of a healthy lifestyle with the following:

• Weight loss
• Proper diet
• Smoking cessation
• A regular exercise program

A 5-10% weight loss can restore normal menses and ovulation with improved fertility. If a woman’s body mass index (BMI) is over 35 kg, bariatric surgery may be recommended, especially if prolonged weight loss with other methods have failed.

Additional PCOS treatments include the following:

  • Clomid has become a first-line drug treatment for PCOS. It is an anti-estrogen that blocks the effects of estrogen on the pituitary and through negative feedback, leads to development of follicles. Cervical mucus tends to be thick under Clomid treatment, particularly if higher doses are needed. Careful attention should be paid to the cervical mucus quality during treatment.
  • Letrozole is an aromatase inhibitor that results in decreased estrogen secretion to induce development of follicles. It is less effective than Clomid in the estrogen inhibition but has the advantage of creating a lower risk of multiple pregnancies. Clomid and Letrozole are sometimes used together.
  • Gonadotropin therapy also has a place in the treatment of PCOS patients. However, ovarian hyperstimulation syndrome (OHSS) and multiple pregnancies are risks with gonadotropin treatment of PCOS patients.

If you are seeking to improve your fertility and the treatments above fail, in vitro fertilization (IVF) or even IVM (in vitro maturation of immature eggs) can be used.

Surgical procedures, including laparoscopic or transvaginal ovarian drilling as well as transvaginal hydrolaparoscopy, also improve the pregnancy rate in PCOS patients. However, the frequent development of pelvic adhesions after these procedures is a strong factor for caution.

Metformin, because of its role in PCOS-induced insulin resistance, has been a frequent add on in the treatment of PCOS patients. However, several randomized trials have failed to show an increased live birth rate with metformin, and it is no longer favored.

Instead, inositol has been recommended for PCOS treatment. Inositol is involved in intracellular insulin signaling and is a second messenger to regulate hormones like TSH, FSH, LH, and insulin. Inositol reduces insulin resistance and improves the metabolic profile in PCOS patients. When using a dose of 2 g of inositol and 200 mcg of folic acid twice daily, better fertilization rate and embryo quality has been seen in IVF treatments.