Weight, hormones and pregnancy

Dear Dr Mitchell,

I an 30 years old and have been married four years. I’ve been having regular intercourse for the past two years without any birth control and have not been able to get pregnant. My husband has not been checked yet, but I’m of strong belief that the problem rests with me, because since about age 14, I have had a hormone imbalance.

When I was a teenager I was put on birth controls to regularise my period because it would come, but so light that I would only have to wear panty shields. The birth control made it appear normal with regular flow and everything.

I must also tell you that I am overweight and have been from my teenage years, so that is also a contributing factor, I believe, to the hormone imbalance.

Things were good for a number of years and then I realised that I had spotting even when I was on the pill. I went back to my doctor who prescribed a birth control with a higher dosage and the problem was fixed again. Now I have been off them for the last two and a half years and recently I have been having sexual intercourse and I bleed during and sometimes a little after. My “clock work period” has also switched dates. I know it’s 14 days counting from the first day of the menstrual cycle, but if there is spotting before the heavy flow, should the spotting days be counted?

I’m now ready to be a mom and my husband is now ready to be a dad. What do you suggest we do?

The fact that you have been sexually active for two years without contraception and have not conceived is significant. On average approximately 82 per cent of women will conceive after regular sexual activity (two to three times weekly) for one year and 95 per cent will conceive after two years.

The fact that your cycles have been irregular since age 14 years suggest that you do not ovulate regularly. Regular menstrual cycles with a cycle length between 22 and 35 days, and the presence of premenstrual bloating, dysmenorrhoea (painful periods) and breast tenderness suggest the presence of ovulatory cycles. Approximately 20 per cent of women who are infertile have problems with ovulation.

The most common causes of ovulatory failure are: (1) Polycystic Ovary Syndrome (PCOS) accounting for 70 per cent of cases of ovulatory problems; (2) problems which affect the special part of the brain called the hypothalamus – this includes anorexia nervosa; (3) elevated prolactin levels; and (4) premature ovarian failure.

The presence of milk in the breast will indicate that elevated prolactin levels may be the cause. The presence of acne, hirsutism (excessive hair growth on the face, chest and abdomen) and excessive weight gain suggest a diagnosis of polycystic ovarian disease.

The fact that you have been overweight since your teenage years is significant, especially since it is associated with the scanty irregular menses. Women who have polycystic ovarian disease usually are at risk for diabetes mellitus. This condition may be diagnosed by doing a blood test which measures the hormones produced by the pituitary gland in the brain. An ultrasound may also be useful in detecting multiple small cysts in the ovaries, but the condition may be present in the absence of the classical polycystic ovaries as demonstrated on a pelvic ultrasound.

In women with polycystic ovaries, many forms of treatment are now available to induce ovulation. This includes weight loss, the use of clomiphene, clomiphene plus metformin, clomiphene plus glucocorticoids, gonadotrophin injections, ovarian surgery and in vitro fertilisation with embryo transfer (IVF-ET), if all the other form of treatment do not work.

It is advised that you go on a diet and exercise programme with the aim to lose 10 per cent of your body weight. Weight loss results in a lower level of the male hormone testosterone and resumption of ovulation with an increase chance of achieving a pregnancy.

The bloating that you experience after intercourse needs to be dealt with urgently. This may be indicative of an infection in the cervix, cervical cancer or a cervical polyp. You will definitely need a pap smear for further evaluation.

There are several methods that you can use to determine if you are ovulating. This includes doing your body temperature in the mornings before getting out of bed and looking for a rise in temperature which occurs around the time of ovulation; urine testing to check for the luteinising hormone (LH) level; a blood test to check the serum progesterone level on day 21; or a biopsy of the lining of the uterus.

Other causes of infertility include tubal occlusion or uterine problems such as adhesions within the cavity of the uterus. An x-ray of the lining of the uterus and tubes called a hystero salpingogram (HSG) will determine the status of the tubes and uterus.

Your husband will also need a detailed examination and the appropriate investigations to find out the underlying cause of your infertility. Consult your gynaecologist or family doctor who will do the appropriate examination and investigations.

Best wishes and I trust that 2007 will bless you with a wonderful child.

Dr Sharmaine Mitchell is an obstetrician and gynaecologist. Send questions and comments via e-mail to allwoman@jamaicaobserver.com or fax to 968-2025. We regret that we cannot supply personal answers.