University of Pennsylvania Health System

ObGyn Update | Penn Medicine

Friday, May 8, 2015

Feeling Well, Healing Well After Pregnancy

The bra that fit perfectly before the baby might not be as flattering now. And your bathroom habits? Well, they may be different, too.

“Urinary incontinence during pregnancy is not uncommon. and makes sense given the changes that take place during pregnancy,” says Uduak Andy, MD. Dr. Andy is a urogynecologist at Penn Medicine, an ob/gyn that specializes in treating women with pelvic floor disorders.

“You have this baby growing in your uterus pushing down on your bladder and urethra. For some women, incontinence will increase as the pregnancy progresses.”

Childbirth can lead to urinary incontinence, too. As your baby makes its way down the birth canal, your pelvic floor muscles may be stretched and, in some cases, even damaged. Even women who have a C-section are not without risk.

Dr. Andy says that because of all the changes a woman may experience throughout her pregnancy and childbirth, it may take anywhere from six weeks to a year to fully recover.

“If a woman is still experiencing pain, painful sex, or urinary incontinence six months after she’s given birth, she may want to see a urogynecologist, who can offer her treatment options and exercises to improve the pelvic floor,” says Dr. Andy. 

Bladder and Pelvic Floor Issues

Women with stress urinary incontinence may leak urine while coughing, sneezing, laughing or exercising.

According to urogynecologist Pam Levin, stress incontinence occurs when the urethra and surrounding muscles of the bladder lose their strength and support.

“Urinary incontinence and pelvic floor disorders don’t have to be a rite of passage for women, or something we just have to deal with as we age," she says.

That's why she created the Feeling Well, Healing Well Program.

Treatments for Urinary Incontinence

Penn's Feeling Well, Healing Well Program focuses on pelvic floor disorders women may experience as a result of pregnancy and childbirth.

“The post-partum time period can be challenging for new moms,” says Dr. Levin. “They might not feel comfortable talking about the issues they are experiencing. We want them to know that we specialize in these disorders and are here to help.”

It’s estimated that nearly 50 percent of women suffer from bladder and pelvic floor disorders at some point in their lifetime; however, there are options so that women don't have to live with their symptoms.

Stress incontinence can be treated with physical therapy, including Kegel exercises, physical therapy, or the use of a pessary, a removable appliance similar to a diaphragm that is inserted into the vagina or rectum to strengthen the pelvic muscles. Collagen injections may also be used to help minimize urine leakage from the bladder.

“In some cases, we recommend surgery during which a hammock or sling is placed under the urethra to provide more permanent support,” says Dr. Levin. During the operation, a sling created from FDA-approved mesh is inserted behind the urethra to support the weakened pelvic muscles.

Women who have vaginal pain after delivery or pain with intercourse may experience muscle spasms or have painful scar tissue that narrows the opening of the vagina.

“Once we learn what is causing the pain, we can determine if a woman needs surgery, physical therapy or both to address the issue,” says Dr. Andy.

Depending on the issue, surgery may be deferred until a woman decides not to have any more children. This decision would be made in collaboration with the patient after a full consultation and discussion about the risks and benefits.

Friday, April 24, 2015

When Should You See a Doctor for Irregular Periods?

Maybe you’re in your mid-to-late 20s and and suddenly—after having regular periods for more than a decade—your cycle suddenly stops behaving like clockwork. You’re not pregnant, and you’re nowhere near menopause, so what’s the deal?

Here’s what you should know about how to identify irregular periods, what causes them and when to see a doctor.

What Are Irregular Periods, Anyway?

During a normal menstrual cycle, an egg is released from one of your ovaries during ovulation. If the egg is not fertilized by a sperm, then changing hormone levels signal for your body to shed the blood and tissues that line your uterus, says the Office on Women’s Health (OWH).

This bleeding typically lasts about five days. Then, the monthly cycle repeats itself.

But some women have what is called abnormal uterine bleeding—another term for irregular periods, the OWH explains.

What is abnormal uterine bleeding?
  • Bleeding or spotting between periods
  • Bleeding after sexual intercourse
  • Heavy bleeding during your period
  • Menstrual bleeding that lasts longer than normal
  • Bleeding after you’ve reached menopause
According to the American Academy of Family Physicians (AAFP), between nine and 14 percent of women who have already gotten their first period but haven’t yet reached menopause have irregular periods.

What Causes Irregular Periods?

There are a number of reasons why a woman has irregular periods, says the National Institute of Child Health and Human Development (NICHD). 

When a girl first starts menstruating, it may take some time time before her periods become regular. And periods may stop becoming regular up to eight years before menopause.

Common causes of irregular periods include:

Uncontrolled diabetes—Women with unmanaged diabetes may have irregular periods because the interaction between blood sugar levels and hormones can disrupt a woman’s menstrual cycle, says the American Diabetes Association.

Eating disorders—Women with conditions like anorexia or bulimia may have irregular or missed periods because their bodies are not producing and circulating enough hormones to control the menstrual cycle, according to the Hormone Health Network.

Hyperprolactinemia—Women who have too much of a protein hormone called prolactin in their blood can have irregular periods.

Certain medications, including anti-epileptics and antipsychotics—can cause irregular periods.

Polycystic ovary syndrome—PCOS is caused by imbalanced sex hormones, which can disrupt regular menstruation.

Premature ovarian failure—The ovaries of women with POF stop working before the age of 40, says the National Institutes of Health. Some women with this condition continue to have periods occasionally, however.

When Should You See A Doctor For Irregular Periods?

It may be time to talk to your doctor if:
  • You haven’t had a period for 90 days
  • Your period suddenly becomes irregular
  • You have a period more often than every 21 days
  • You have a period less often than every 35 days
  • Your period lasts for more than a week
  • Your period becomes unusually heavy
  • You bleed between periods
  • Your periods are extremely painful
Source: Office on Women’s Health

A gynecologist will be able to determine the cause of your irregular periods and help you figure out a treatment course. This may include oral contraceptives to regulate your cycle.

Thursday, March 19, 2015

Ignoring Nature's Call

Lori M. Noble, MD, a primary care physician at Spruce Internal Medicine, located at Penn Medicine Washington Square, discusses the health risks of ignoring nature’s call.

Dr. Noble
The long, grueling days of medical school and residency impart many lessons, far beyond those related to patient care. For instance, the mantra of my residency experience was "eat, sleep and pee when you can."

While I always made eating and sleeping a priority, urinating had a tendency to fall off my to-do list during a busy day.

I imagine this is not something unique to a career in medicine; I'm sure any woman who works in a demanding field can recall a time (or several) when she "held it in" a little longer than would have otherwise been comfortable. It's a pretty common sacrifice we make to get that one last thing done, typically without giving much thought to any potential consequence.

I recently came across an interesting article in a popular women's magazine that addressed the potential impact of holding it in and thought I'd share what I read and add my medical opinion.

Bladders are unique like fingerprints.

There is no real agreed upon amount of time that is considered okay to hold in urine. This is because every woman is different in terms of how hydrated she stays, how large her bladder is and how sensitive her bladder is to the stretch that happens as it fills with urine.

Bottom Line: The average woman will feel comfortable holding her urine for between three and six hours, but there's a lot of variability.

So Why Not Hold It In?

The authors downplay any consequence of holding in urine for a prolonged period of time, noting that the "worst case scenario" is a "bit more of a likelihood" of developing a urinary tract infection (UTI). As a physician and a woman, I take issue with this for a couple reasons:

1. UTIs can be dangerous. In some people, the infection can spread from the bladder up to the kidneys and even into the bloodstream if not treated quickly. Pregnant women and those with certain medical conditions that can affect bladder function (i.e., Multiple Sclerosis, Diabetes, etc.) are already at increased risk for UTIs, so they should be extra vigilant about emptying their bladders regularly to prevent infection.

2. Many women struggle as they get older with urinary incontinence (the loss of bladder control). Stress urinary incontinence is leakage when there is increased pressure applied to the bladder, like with coughing, laughing or jogging. Urge urinary incontinence is leakage because of an intense, involuntary contraction of the bladder, often described as the "I gotta go, I gotta go, I gotta go" feeling. Both can be made worse if the bladder fills up beyond a comfortable capacity.

Bottom Line: There are potential consequences of holding in urine for a prolonged period of time. Listen to your body and take time to go when you feel the urge.

Are There Benefits to Holding It In?

There is some evidence that holding urine can "train" the bladder to be less sensitive to the urge to go, and thus allow a woman to wait a bit longer between bathroom trips. In my opinion, the risks of holding it as outlined above, outweigh this potential benefit.

Bottom Line: When it comes to holding in urine, the risks of infection, leakage and pain outweigh the potential benefit of a modest increase in bladder capacity.

So next time you feel the urge to go, try to fight the instinct to just cross your legs and hold it in for a bit longer – your bladder will thank you for it later!

Concerns about bladder and pelvic floor health? Speak to a Penn urogynocologist.

Tuesday, September 30, 2014

Marisa's Story: Defying the Odds in the Intensive Care Nursery

Marisa Mackintosh and her husband were ecstatic to learn they were expecting twins. But when Marisa was three months along, an ultrasound revealed that the babies were having growth problems. Here, she shares the story of her family's difficult journey and the neonatal intensive care team that saved her babies' lives.

When my husband and I learned I was pregnant with twins, we were overwhelmed with surprise, immense joy and anticipation. We dreamt of welcoming them home and introducing them to our beautiful daughter, who was 16 months old at the time. The twins were due August 28, 2013, and we believed we would soon have three healthy and happy children nestled safely under our roof.

Our vision quickly came to a halt at 15 weeks after an emergency ultrasound revealed that one of our babies wasn’t growing well. We were asked to prepare for the unimaginable possibility of losing one or even both babies.

The following weeks were dark and uncertain. Regular ultrasounds were both reassuring and terrifying. 17 weeks became 20 weeks, which became 24 weeks. Of course, we did not want to deliver then, but reaching 24 weeks, we learned, was a milestone. Another ultrasound at 27 weeks showed two babies, growing and defying the odds, though dangerously imbalanced in size and health.

My doctor offered us the opportunity to tour the Intensive Care Nursery (ICN) at Pennsylvania Hospital to get acquainted in the event that we would spend time there. We walked through a door labeled “CHOP Newborn Care at Pennsylvania Hospital” and were greeted warmly by a neonatologist who, with kindness and patience, gave us insight into the world of prematurity. Then a nurse manager gave us a tour, which provided a glimpse of life in the ICN.

One week later, at 28 weeks gestation, the babies decided it was time. On June 7, 2013, we welcomed our miracles William and Daniel (Will and Danny), weighing 2 lbs 12 oz and 1 lb 13 oz, respectively. At this moment, Will and Danny began the fight of their lives. But they – and we – were not alone.

Over the next four months, we witnessed neonatal intensive care at Pennsylvania Hospital's ICN and the Children's Hospital of Philadelphia at its absolute finest. The doctors made decisions that were simultaneously life-saving and delicately mindful of long-term health. The nurses were by our boys’ sides, 24 hours a day, 7 days a week, providing expert care and love when we – with terrible pain – had to leave at night.

It is immensely difficult to think about those days. It conjures up images of our tiny sons connected to devices, separated from us – and each other – by technology. But when reflecting on that time, it is impossible to forget that we were part of something truly incredible. The team at Pennsylvania Hospital became our family, who hugged us, cried with us, answered our endless questions, loved our children – and who celebrated with us when we finally brought our two babies home after 81 and 116 days.

In honor of Neonatal Intensive Care Awareness Month, we want to thank the very special people at Penn Medicine’s ICNs. They give themselves to our babies, and they provide hope to parents. For that we are truly grateful, this month and forever.

Thursday, September 5, 2013


The Department of Obstetrics and Gynecology at the University of Pennsylvania
hosted the annual NICHD Women’s Reproductive Health Research (WRHR) Symposium in
October 2012. Over 80 scholars, Ob/Gyn chairs and research program directors from 17
programs across the country attended this two-day event. Highlights included research
presentations by former and current scholars, career development panel, workshop on NIH
funding and grantsmanship and a keynote lecture by Dr. Alan Guttmacher, director of the Eunice
Kennedy Shriver National Institute of Child Health and Development (NICHD).

The WRHR program, initiated in 1998 by the NICHD, provides obstetrician-gynecologists
who recently completed postgraduate clinical training to further their education and
experience in basic, translational, and clinical research under the guidance of a senior
investigator and mentor. The goal is to create a talented pool of investigators with expertise
in women’s health. Chair of the Department of Obstetrics and Gynecology at the University of
Pennsylvania Health System, Deborah A. Driscoll, MD, is the principal investigator for the WRHR

“The WRHR program is a prestigious award, with our department being one of only 17 universities
nationwide chosen to participate,” says Dr. Driscoll. “But most importantly it enables us to
leverage our strong research infrastructure and provide research training to promising junior
faculty to prepare them for a career in academic medicine.”

Samuel Parry, MD, director of the maternal-fetal medicine division and a former WRHR scholar
explains: “Depending on their experience, scholars are chosen for two to five-year awards
and are required to devote at least 75 percent of their effort to their research program under
the guidance of an assigned mentor.”

A scholar’s research may be spent in the basic sciences, translational or clinical investigation
in a variety of fields including gamete biology, imprinting, preterm birth, maternal fetal
health and development, and gynecologic oncology.

The rest of the scholar’s time is spent in clinical and teaching activities.

The research program director, Dr. Christos Coutifaris, works with the mentor to
monitor the scholar’s academic progress and assist with future grant applications and
the transition to independent funding.

Michal Elovitz, MD, associate professor of obstetrics and gynecology, director of the
Maternal and Child Health Research Program in the Center for Research on Reproduction
and Women’s Health, is a former WRHR scholar who is currently mentoring Jamie Bastek, MD, MSCE.

“My own work as a WRHR scholar helped me obtain NIH funding, as well as the necessary research
time, resources and mentorship to be able to pursue a career in maternal-fetal medicine,” says
Dr. Elovitz. “Now, as a mentor myself, I can guide scholars to target a specific research interest,
and work with them to nurture their own research careers.”

Current Penn WRHR scholar, Dr. Bastek agrees. She is currently working on a project in
conjunction with the Penn cartographic modeling lab to research environmental exposures
within Philadelphia that may affect pre-term
birth rates.

“Being a WRHR scholar has afforded me the opportunity to perform grant-funded research, to focus my research interests with the guidance of mentors who have been successful in research, and to pursue a research-based career in maternal-fetal medicine,” says Dr. Bastek. “It’s also
given me the opportunity to make sure
I am in a place where I can do my own grant-funded research at the end of my WRHR scholarship.”