This week, let’s talk about the hidden tool in women’s fertility arsenals that goes mostly overlooked. It’s your annual exam.
A thorough well woman exam should include a pap smear, pelvic exam, breast exam, and often basic bloodwork. For many women this is also a part of their annual wellness checkup and so everything is done at once. Doctors often tell you things that might be an issue, but as a patient, it can be hard to decode what that means. So lets start from one end and work through.
The routine blood work that your doctor should perform during your annual exam typically includes a CBC, or complete blood count, and a CMP, or complete metabolic panel. Also, a thyroid test is often included. From these blood tests there are several factors that are incredibly important to fertility including:
- Iron levels
- Thyroid levels
- Blood sugar
Your doctor should make these results available to you and also should discuss treatment options if you have anemia, low thyroid, or blood sugar abnormalities. All of these factors can interfere with your ability to get pregnant and if you’re struggling with infertility, then every factor you can normalize will matter.
All Breasts Are Not The Same
A note about breasts – breasts are NOT all the same. Ther’es an incredible amount of variability that is just completely normal and makes up the vast and beautiful canvas that is women. There are two great resources about breast shape. One is the 12 shape classifications of breasts – I like the article on healthline that goes over the shapes and also variations in nipples.
There is also the amazing “Normal breast gallery ‘ – which for a lot of us is the only time we get to see non-sexualized images of completely normal breasts in all their variability. I love this resource because so many women feel like their breasts are not normal because they don’t look like the images of breasts we see in magazines.
Your doctor should do a thorough breast exam that covers the tissue of both breasts as well as the tissue in both armpits. There are a number of things they might tell you in passing that can give you useful information about your hormone state. Some of these breast changes impact fertility, especially those that indicate hormone abnormalities, but we’re including lots of different findings just to be thorough.
- Dense breast tissue – This might be detected in a breast exam or might be on a mammogram. This can be denseness in the connective tissue or the ductal and glandular tissue. It is very common and can make mammography less effective because dense tissue and tumors look very similar. For unknown reasons, dense breast tissue also comes with a slightly higher risk of breast cancer even without the difficulty in visulaizing.
- Fibrocystic breasts or fibrocystic changes (important for fertility) – This means the breast tissue is somewhat irregular and may have soft, freely moving lumps that often become tender at different parts of your cycle. Fibrocystic breasts are a great indicator that estrogen levels are either overtly high or relatively high as compared to progesterone and that matters very much for fertility.
- Orange peel skin on your breast or breasts – Orange peel skin on your breasts shows darkened or enlarged pores that look like the pores on orange peels. This is often a sign of inflammatory breast cancer and doesn’t significantly impact fertility, but does have a big health impact.
- Nipple inversion, or skin adhesion in the breast – Inverted nipples can be normal if you’ve always had them, but if one or both nipples change shape suddenly, that is worth discussing with your doctor. It can be a sign of a suspicious lump, mastitis or a breast abcess, changes post-breastfeeding, blocked ducts, or a type of cancer called Paget’s disease. None of these have a clear link with fertility but all of them should be investigated.
- Breast discharge (important for fertility) – In a non-breastfeeding woman, breast discharge can be a sign of hormone abnormalities from the pituitary gland, a prolactin secreting tumor, infections in the breast such as mastitis or abcess, or a breast tumor such as inflammatory breast cancer or DCIS. Generally this does not affect fertility but it is again worth noting.
- Breast lump – Breast lumps are common and usually normal. This might also be called a breast cyst, or fibrocystic breasts if the breasts are generally lumpy. Again, this is often a high-estrogen symptom and that could affect fertility.
- Non-suspicious lumps – Non suspicious breast lumps are the most common kind and they feel soft, rubbery, or elastic. They are freely moveable and not stuck to the skin, often tender during parts of your cycle, regular in shape (like a circle, oval, or egg). They typically don’t change much over time or change predictably with your cycle,
- Suspicious – Suspicious breast lumps stuck to or pull on your skin causing your breast to have an overall irregular shape or movement. They are often hard or extremely firm, non-tender, and have irregular shape. They often appeared suddenly or grow quickly.
Pelvic Exam – Bimanual Exam
This is the part of your annual exam in which your doctor inserts two fingers into your vagina briefly, and often uses the other hand to feel or press gently on the skin over your pelvic area. Your doc is feeling for abnormalities in your ovaries, vagina, and uterus.
Generally, they are checking the size of the uterus, looking for tenderness, checking for unusual growths or shape of the uterus or around the cervix, and also feeling your ovaries for signs of cysts. Your doctor can tell you on the spot if there is anything unusual in this part of the exam. Your doctor will also do a quick external exam just to notice any unusual discharge, irritation or issues with the labia. This also includes an internal exam in which the cervix, vagina, and part of the uterus are looked at with the help of a speculum, and sometimes a rectovaginal exam, which means your doctor will insert a finger into your rectum.
- Enlarged uterus (sometimes important for fertility)– this can be normal after pregnancy – especially mutlitple pregnancies, it is also perfectly normal during pregnancy, but at other times it could mean fibroids or other growths within the uterus. Typically this is a high estrogen or high relative estrogen situation and it does interfere with healthy pregnancies.
- Irregular uterus (important for fertility) – This is usually a growth that isn’t supposed to be there that is distorting the shape of the uterus. Typically fibroids, cysts, or tumors. Almost always estrogenic and interfere with fertility.
- Lumpy Ovaries (sometimes important for fertility) – The lumps are called cysts and can be “functional” meaning they’re a part of your normal cycle. They can also be abnormal and there are a few different causes. Benign tumors called dermoid cysts are rare, but can be found on ovaries. Endometriomas, which is escaped endometrial tissue that grows and shrinks with the menstrual cycle can form on the ovaries. Multiple cysts can indicate polycystic ovarian syndrome, which is the most common cause of lumpy ovaries. Both endometriosis and PCOS can interfere with pregnancies.
- Abnormal tenderness in some particular part (important for fertility) – If your doctor notices abnormal tenderness in an area it could indicate an infection or growth, and they will be watchful for your reactions. Tenderness is often important to fertility because it can indicate infection, cysts or growths, or micro tears in the tissue which go along with vaginal dryness and hormone abnormalities.
Visualization Exam with a Speculum
This exam involves the doctor looking carefully at the vulva, labia, and internal vagina using a speculum. These exams are often for infectious disease to spot changes to the vaginal tissue, cervix, and discharge that might indicate common sexually transmitted infections. While these don’t have much to do with hormones, chlamydia and gonorrhea both can cause pelvic inflammatory disease, which can damage fallopian tubes and other vital structures. This affects fertility and 80% of women with chlamydia and gonorrhea have no symptoms. This exam can also show polyps or other abnormalities on the vaginal walls and cervix.
This is the part of the exam in which the doctor will use a swab to swipe the surface of your cervix, which is essentially the mouth of your uterus. It is performed while the speculum is inside of you and may feel a bit pinchy or cause a uterine cramp. The swab is to gather some cervical cells which will then be tested for signs of pre-cancerous changes and/or HPV which can increase the risk of cancer.
If you know what to listen for, your annual exam is a wealth of hidden information for you on your fertility journey.
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We’ll talk about why folic acid can be toxic, how the MTHFR enzyme is in bed with estrogen (scandalous!), why it matters to be able to turn some genes off, and why high-folate foods make some people feel depressed, and so much more
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There are lots of red flags in every day life that might indicate a hormone imbalance or other problem that could have fertility consequences. This week we’ll talk about the first ones, including:
- Skipped or missed periods
- Heavy bleeding or flooding
- Scanty bleeding (even though it makes for a nicer period)
- Abnormal hair growth
- Hair loss
Next week, we’ll go over more red flags because women’s hormones can go crazy in so many ways.
For the full show notes including a video version of Dr. Kate and Dr. Amy talking this one through, click here. If you have genetic polymorphisms and want to work on them with an amazing group of other folks with genetic polymorphisms, click here. If you’d like to take a course on MTHFR, click here.
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