Common problems

1. Low Libido in Women
2. Amenorrhea (absence of period)
3. Dysmenorrhea (cramps)
4. Menopause and Osteoporosis
5. PMS
6. Female Infertility
7. Pregnancy & Post-Partum Support
8. Breast-Feeding Support

Low Libido in Women

The decrease in female libido is mainly related to the reduction in naturally produced estrogen. It certainly seems that female libido is more linked to the quality of relationships than is the male libido and it may be that you need to regain intimacy with your partner. Loss of the female libido (sexual desire) can lead to decreased intimacy for women with their partner, anxiety about sex and of course the loss of one of life's potentially most enjoyable experiences.

Women may notice a slight to extreme change in their desire to engage in sexual acts when their hormones are fluctuating like during pregnancy or even menopause. In recent years science has made breakthroughs in the understanding of sexual dysfunction and low libido in women. Recent research from a prominent medical journal reports that up to 48% of women experience difficulty when it comes to the ability to achieve orgasm and feel sexually aroused. It is normal for females to have less sexual desire; therefore, this reality should not be viewed as dysfunctional or stemming from a lack of desire. Fortunately, nature offers traditional wisdom in the form of nutrients and botanicals, used for years to support healthy sexual function and desire.

Women have been engineering their biology for years so that they will fit more comfortably into a patriarchal society. Women all over the world suffer from low female libido, they tend to think that this is the norm and that they should just live with a poor or have a sex life which simply does not exist. Women should feel free and comfortable to discuss changes in their libido with their doctor as female libido is an internal message board from your body. Women can also increase libido and their bodies' responses naturally using herbal supplements, as has been done in native cultures for hundreds of years. Fortunately there are now herbal supplements for women that effectively address the neglected issue of female libido enhancement.

Before purchasing any female libido enhancers or libido supplements you need to be very careful to select the best and highest quality product available on the store. It is always better to make sure that the female libido enhancement product you have selected is developed by professionals or naturopaths who have experience in helping women attain ideal sexual and reproductive health. Most products require regular use - like the pills - but others like the oils and creams are supposed to work even if they are applied just hours or even minutes before the sexual act. If you are under the care of a physician, please consult your physician before using this product especially if you have heart disease or high blood pressure.

We find natural sex boosters quite effective and preferable to pharmaceutical drugs in terms of increasing female libido. If you find yourself in the position of not wanting sex at all, you may need a natural sexual enhancement to open your mind and body to intimate relations. Formulated to improve sex drive/libido and arousal response, natural sex boosters work by regulating hormonal imbalance and increasing natural vaginal lubrication.

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Amenorrhea (absence of period)

Amenorrhea is the medical name for absence of menstruation (your period). There are two types of amenorrhea, primary amenorrhea and secondary amenorrhea.
Primary amenorrhea:
Most girls will start their first period between the ages of 11 and 14. A female who has not had her first period by age 18 is said to have primary amenorrhea.

Secondary amenorrhea:

It is common for women to have irregular menstrual cycles and even skip a period occasionally. Therefore, secondary amenorrhea is said to occur when a women who was previously menstruating has an absence of her period for six months or longer.

Causes of amenorrhea

Primary amenorrhea should be investigated if a girl has not had her first menstrual cycle by the age of 16. Causes of primary amenorrhea include chromosomal abnormalities, congenital defects and/or obstructions or the reproductive system, hormonal imbalance, syndromes such as PCOS, anorexia, bulimia, excessive exercising, and stressful life events.
Other Possible Causes of Amenorrhea

Amenorrhea occurs when there is not enough hormones in a woman’s body to stimulate menstruation. This condition is associated with malnutrition, as with anorexia nervosa, or when excessive exercise puts extreme nutritional demands on the body. Stress, rapid weight loss and a low concentration of body fat can also have a negative effect on normal menstruation. Amenorrhea can also be a sign of serious disorders of the ovaries, pituitary gland or hypothalamus.
Possible Symptoms of Amenorrhea
Symptoms of amenorrhea include absence of periods; increased facial hair; deeper voice; decreased armpit hair, pubic hair and breast size; and secretions from the breast.

Causes of Secondary Amenorrhea

Secondary amenorrhea is a primary indicator of pregnancy. When pregnancy is not the cause, there are several other common reasons for a women not to menstruate including breastfeeding, hormonal imbalance, and medications such as birth control pills and certain tranquilizers. Anorexia, bulimia, excessive exercise, weight gain or weight loss, and stress can also cause an absence of your period.

What should I do if my child has an absent period?

Any time a child has not started menstruating by the age of 16, she should be evaluated by a doctor. Her doctor may run blood work to rule out pregnancy. She may also check for thyroid, pituitary, or adrenal disorders. She will perform a pelvic exam to check for any structural abnormalities such as imperforate hymen (hymen with no opening). She will want a thorough history including exercise and diet habits, recent stressors, current medication, and any past medical history. Her doctor may also perform an ultrasound to check for congenital birth defects such as absence of uterus or ovaries or other congenital abnormalities. Other lab work may include chromosomal studies and pap smear.

What should I do if I have amenorrhea?

If you have missed two or more periods, you will want to see your doctor. Your doctor will likely perform blood work to check for pregnancy. She may run tests to check thyroid levels, progesterone levels, and other hormones. She will want a thorough medical history including diet, exercise, medications, and diseases that might effect menstruation. She may also investigate symptoms of menopause.

Treatment of amenorrhea

Amenorrhea in and of itself is not a disease or illness. It is merely a symptom. Therefore, treatment will vary depending on the cause.
Congenital abnormalities and defects: If amenorrhea is caused by a congenital birth defect, it may not be correctable. Conditions such as imperforate hymen can be corrected by surgery.
Hormonal imbalances: Many hormonal causes of amenorrhea can be corrected with appropriate medication.
Pregnancy: Pregnancy is the most common reason for an absent period. Prenatal care should be sought out if pregnancy is determined to be the cause.
Breastfeeding: Breastfeeding can cause an absence of menstruation. The medical term for this is lactation induced amenorrhea. It is very common for menstruation to not occur during the course of breastfeeding. However, it should be noted that breastfeeding alone is not recommended for birth controls since pregnancy can occur when breastfeeding even with an absence of menstruation.
Diet, exercise, and nutrition: Women who are underweight or perform strenuous exercise regularly, such as runners and gymnasts, may experience amenorrhea. Your doctor will want to work with you on modifying your diet and exercise routine to a healthy level to ensure the return of menstruation.
Possible Lifestyle Changes for Amenorrhea: Eat a healthy diet, get an adequate amount of exercise and avoid stress. Be sure to get plenty of sleep. Smoking and substance abuse have been linked to amenorrhea, so avoid tobacco products and other stimulants.
Beneficial Dietary Supplements
Acetyl-L-carnitine is an amino acid that can improve hormone levels in women with low initial levels.
Calcium and Vitamin D prevent bone loss.
Blue Cohosh stimulates menstrual flow.
Motherwort and Yarrow stimulates absent or light periods.
Vitex Agnus-castis reduces elevated prolactin levels that can cause amenorrhea.
REFERENCES: Prescription for Nutritional Healing, 3rd Edition, Phyllis Balch, CNC; James F. Balch, M.D.

AMENORRHEA - Treatment with Homeopathic Medicines

#Pulsatilla [Puls]
Comes first to mind as the homoeopathic remedy for menstrual suppression. It is indicated where the menses flow by fits and starts, or when the suppression is due to wetting of the feet; also, in delayed first menses in chlorotic girls. It must be carefully distinguished from Dulcamara, which has menses suppressed from getting the feet wet, but whose temperament is not that of Pulsatilla. Bayes remarks that in amenorrhoea with anaemia "great judgment is required in the selection of the dilution, which ought to vary from the 30th to the 1st, according to the sensitiveness of the patient, " Jahr ranks Sulphur with Pulsatilla for insufficient pale menstruation. The Pulsatilla patient is disinclined to exertion, with poor appetite and longing for acids,is apt to faint easily and suffers from a tremulous anxiety. Senecio is useful also in amenorrhoea with chlorosis.
#Calcarea carbonic [Calc]
This remedy is also, like Pulsatilla, indicated in amenorrhoea when the first menses are delayed, but with Calcarea there is apt to result congestion to the head or chest, giving rise to lung troubles. It is typically indicated in fleshy, scrofulous girls with fair complexion, perspiring easily about the head and subject to acidity of the stomach. Menstrual suppression in those decidedly scrofulous, or with lung affection, especially indicates Calcarea. Belladonna has menstrual suppression with congestion to the head, but its chief use is in amenorrhoea appearing suddenly due to cold, with bearing down and throbbing pains in the hypogastrium and painful urination. Gelsemium. Here the drowsy apathetic state is prominent and neuralgic pains of the head and face accompany. Glonoine. Intense throbbing of head and albuminous urine occurring when the menses do not appear. It will act promptly if at all. If the menses are suppressed from fright, Aconite, Actea spicata and Lycopodium must be thought of. Opium and Veratrum also have this symptoms. Further symptoms indicating Calcarea in amenorrhoea are palpitation of the heart, dyspnoea worse ascending, cold damp feet, etc. Lilium tigrinum. Of use when amenorrhoea causes, by reflex action, heart symptoms.
#Ferrum metallicum [Ferr-m]
This is another useful remedy for delayed first menses where there is debility, languor, palpitation, sickly complexion and puffiness about the ankles. It corresponds to weakly, chlorotic women with flushed face, or pale and livid with blue margins about the eyes. It is especially useful in those who have been dosed with quinine and nervines.
#Sepia [Sep]
Insufficient or tardy menstruation occurring in the feeble and debilitated, those of dark complexion, delicate skin and who are sensitive to all impressions. In delay of first menses where a leucorrhoea occurs in their stead with determination of blood to the chest and pale face, the remedy is well indicated. Bryonia has nosebleed instead of menses frequently accompanied with bursting headache, and Phosphorus has haemoptysis and haematemesis instead of menses. Lachesis should not be forgotten here. Nosebleed and headache relieved by menstrual flow.
Graphites. Here, when the menses are suppressed, delayed or scanty, and accompanied with obstinate constipation, and indurated ovaries, it comes in especially well after Pulsatilla. It holds the same relation to the menopause that Pulsatilla does to puberty and youth. A sallow complexion, frequent paroxysms of headache, felling of abdominal emptiness and ball like constipation, which are marked Sepia symptoms, will easily distinguish this remedy. Cimicifuga. Cowperthwaite praises this remedy highly in amenorrhoea, giving it when no special indication are present, in nervous women subject to rheumatism or arthritic attacks, with aggravation of mental symptoms when the menses should appear.

Dysmenorrhea (cramps)

Definition
Dysmenorrhea is the occurrance of painful cramps during menstruation.

Description
More than half of all girls and women suffer from dysmenorrhea (cramps), a dull or throbbing pain that usually centers in the lower mid-abdomen, radiating toward the lower back or thighs. Menstruating women of any age can experience cramps.
While the pain may be only mild for some women, others experience severe discomfort that can significantly interfere with everyday activities for several days each month.

Causes and symptoms
Dysmenorrhea is called "primary" when there is no specific abnormality, and "secondary" when the pain is caused by an underlying gynecological problem. It is believed that primary dysmenorrhea occurs when hormone-like substances called "prostaglandins" produced by uterine tissue trigger strong muscle contractions in the uterus during menstruation. However, the level of prostaglandins does not seem to have anything to do with how strong a woman's cramps are. Some women have high levels of prostaglandins and no cramps, whereas other women with low levels have severe cramps. This is why experts assume that cramps must also be related to other things (such as genetics, stress, and different body types) in addition to prostaglandins. The first year or two of a girl's periods are not usually very painful. However, once ovulation begins, the blood levels of the prostaglandins rise, leading to stronger contractions.
Secondary dysmenorrhea may be caused by endometriosis, fibroid tumors, or an infection in the pelvis.
The likelihood that a woman will have cramps increases if she:

• has a family history of painful periods
• leads a stressful life
• does not get enough exercise
• uses caffeine
• has pelvic inflammatory disease

Symptoms include a dull, throbbing cramping in the lower abdomen that may radiate to the lower back and thighs. In addition, some women may experience nausea and vomiting, diarrhea, irritability, sweating, or dizziness. Cramps usually last for two or three days at the beginning of each menstrual period. Many women often notice their painful periods disappear after they have their first child, probably due to the stretching of the opening of the uterus or because the birth improves the uterine blood supply and muscle activity.

Diagnosis
A doctor should perform a thorough pelvic exam and take a patient history to rule out an underlying condition that could cause cramps.

Treatment
Secondary dysmenorrhea is controlled by treating the underlying disorder.
Several drugs can lessen or completely eliminate the pain of primary dysmenorrhea. The most popular choice are the nonsteroidal anti-inflammatory drugs (NSAIDs), which prevent or decrease the formation of prostaglandins. These include aspirin, ibuprofen (Advil), and naproxen (Aleve). For more severe pain, prescription strength ibuprofen (Motrin) is available. These drugs are usually begun at the first sign of the period and taken for a day or two. There are many different types of NSAIDs, and women may find that one works better for them than the others.
If an NSAID is not available, acetaminophen (Tylenol) may also help ease the pain. Heat applied to the painful area may bring relief, and a warm bath twice a day also may help. While birth control pills will ease the pain of dysmenorrhea because they lead to lower hormone levels, they are not usually prescribed just for pain management unless the woman also wants to use them as a birth control method. This is because these pills may carry other more significant side effects and risks.
New studies of a drug patch containing glyceryl trinitrate to treat dysmenorrhea suggest that it also may help ease pain. This drug has been used in the past to ease preterm contractions in pregnant women.

Alternative treatment
Simply changing the position of the body can help ease cramps. The simplest technique is assuming the fetal position, with knees pulled up to the chest while hugging a heating pad or pillow to the abdomen. Likewise, several yoga positions are popular ways to ease menstrual pain. In the "cat stretch," position, the woman rests on her hands and knees, slowly arching the back. The pelvic tilt is another popular yoga position, in which the woman lies with knees bent, and then lifts the pelvis and buttocks.
Dietary recommendations to ease cramps include increasing fiber, calcium, and complex carbohydrates, cutting fat, red meat, dairy products, caffeine, salt, and sugar. Smoking also has been found to worsen cramps. Recent research suggests that vitamin B supplements, primarily vitamin B6 in a complex, magnesium, and fish oil supplements (omega-3 fatty acids) also may help relieve cramps.
Other women find relief through visualization, concentrating on the pain as a particular color and gaining control of the sensations. Aromatherapy and massage may ease pain for some women. Others find that imagining a white light hovering over the painful area can actually lessen the pain for brief periods.
Exercise may be a way to reduce the pain of menstrual cramps through the brain's production of endorphins, the body's own painkillers. And orgasm can make a woman feel more comfortable by releasing tension in the pelvic muscles.

Acupuncture and Chinese herbs are another popular alternative treatments for cramps.

Prognosis
Medication should lessen or eliminate pain.

Prevention
NSAIDs (Non Steroidal Anti Inflammatory Drugs) like, Brufen, Ponstan, Voltaren, Asprin, taken a day before the period begins should eliminate cramps for some women.

Menopause and Osteoporosis

What is menopause?

Menopause is the cessation of the monthly female menstrual cycle. Women who have not had a menstrual period for a year are considered postmenopausal. Most commonly, menopause takes place when a woman is in her late forties or early fifties. Women who have gone through
menopause are no longer fertile. Menopause is not a disease and cannot be prevented. Many hormonal changes occur during menopause. Postmenopausal women are at higher risk of heart disease and osteoporosis, presumably because of a decrease in the production of estrogen or other hormones. Several unpleasant symptoms may accompany menopause. Some, such as vaginal dryness, result from the lack of estrogen. Others, such as hot flashes and decreased sex drive, are caused by more complex hormonal changes. Some women experience depression, anxiety, or insomnia during menopause.

Menopause is the time in a woman's life when her period stops. It is a normal change in a woman's body. A woman has reached menopause when she has not had a period for 12 months in a row (and there are no other causes, such as pregnancy or illness, for this change). Menopause is sometimes called, "the change of life." Leading up to menopause, a woman’s body slowly makes less and less of the hormones estrogen and progesterone. This change often happens between the ages of 45 and 55 years old.
As you near menopause, you may have symptoms from the changes your body is making. Many women wonder if these changes are normal, and many are confused about how to treat their symptoms. You will feel better by learning all you can about menopause and talking with your doctor about your health and your symptoms. If your symptoms are causing you discomfort or concern, your doctor can teach you about treatment options and help you to make wise treatment choices.

Symptoms of menopause?

Menopause affects every woman differently. Your only symptom may be your period stopping. You may have other symptoms, too. Many symptoms at this time of life are because of you getting older. But some are due to menopause. Common symptoms of menopause include:

• Change in pattern of periods (can be shorter or longer, lighter or heavier, more or less time between periods)
• Hot flashes (sometimes called hot flushes), night sweats (sometimes followed by a chill)
• Trouble sleeping through the night (with or without night sweats)
• Vaginal dryness
• Mood swings, feeling crabby, crying spells (probably because of lack of sleep)
• Trouble focusing, feeling mixed-up or confused
• Hair loss or thinning on your head, more hair growth on your face

Does menopause cause bone loss?

When a woman is young, estrogen helps to keep bone strong. When estrogen levels fall at menopause, bones weaken.  When bones weaken a lot, the condition is called osteoporosis. Weak bones can break more easily.

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How to manage menopause?

Eating a healthy diet and exercising at menopause and beyond are important to feeling your best. Most women do not need any special treatment for menopause. But some women may have menopause symptoms that need treatment. Several treatments are available. It's a good idea to talk about the treatments with your doctor so you can choose what’s best for you. There is no one treatment that is good for all women. Sometimes menopause symptoms go away over time without treatment, but there’s no way to know when.
Hormone replacement therapy (HRT) -- If used properly, hormone replacement therapy or HRT) is one way to deal with the more difficult symptoms of menopause. It's the only therapy that is approved by the government for treating more difficult hot flashes and vaginal dryness. There are many kinds of hormone replacement therapies so your doctor can suggest what's best for you. As with all treatments, HRT has both possible benefits and possible risks; it is important to talk about these issues with your doctor. If you decide to use HRT, use the lowest dose that helps and for the shortest time needed. Check with your doctor every 6 months to see if you still need HRT. HRT can help with menopause by:

• Reducing hot flashes
• Treating vaginal dryness
• Slowing bone loss
• Improving sleep (and thus decrease mood swings)

For some women, HRT may increase their chance of:

• Blood clots
• Heart attack
• Stroke
• Breast cancer
• Gall bladder disease

Who should NOT take HRT for menopause?

Women who . . .

• Think they are pregnant
• Have problems with vaginal bleeding
• Have had certain kinds of cancers (such as breast and uterine cancer)
• Have had a stroke or heart attack
• Have had blood clots
• Have liver disease
• Have heart disease

HRT can also cause these side effects:

• Vaginal bleeding
• Bloating
• Breast tenderness or swelling
• Headaches
• Mood changes
• Nausea

Be sure to see your doctor if you have any of these side effects while using HRT.

How much physical activity should I do?

A woman should first talk to her doctor to see what's best for her. The goal is to exercise regularly so you can lower the risk of serious disease (such as heart disease or diabetes), and maintain a healthy weight. This usually takes at least 30 minutes of exercise (such as brisk walking) on most days of the week.

How else can I help my symptoms?

• Hot Flashes. Some women report that eating or drinking hot or spicy foods, alcohol, or caffeine, feeling stressed, or being in a hot place can bring on hot flashes. Try to avoid any triggers that bring on your hot flashes.  Dress in layers, and keep a fan in your home or workplace. Regular exercise might also ease hot flashes, but sometimes exercise can cause a hot flash. If hot flashes continue and HT is not an option, ask your doctor about taking an antidepressant or epilepsy medicine. There is proof that these can relieve hot flashes for some women.
• Vaginal Dryness. A water-based, over-the-counter vaginal lubricant (like KY® Jelly) can be helpful if sex is painful. A vaginal moisturizer (also over-the-counter) can provide lubrication and help keep needed moisture in vaginal tissues. Really bad vaginal dryness may need HT. If vaginal dryness is the only reason for considering HT, an estrogen product for the vagina is the best choice. Vaginal estrogen products (creams, tablet, ring) treat only the vagina.
• Problems Sleeping. One of the best ways to get a good night's sleep is to get at least 30 minutes of physical activity on most days of the week. But, don’t exercise close to bedtime. Also avoid large meals, smoking, and working right before bedtime. Caffeine and alcohol should be avoided after noon. Drinking something warm before bedtime, such as herbal tea (no caffeine) or warm milk, might help you to feel sleepy. Keep your bedroom dark, quiet, and cool, and use your bedroom only for sleeping and sex. Avoid napping during the day, and try to go to bed and get up at the same times every day. If you wake during the night and can't get back to sleep, get up and read until you’re sleepy. Don't just lie there. If hot flashes are the cause of sleep problems, treating the hot flashes will usually improve sleep.
• Mood swings. Some women report mood swings or "feeling blue" as they reach menopause.  Women who had mood swings (PMS) before their periods or post-partum depression after giving birth may have more mood swings around menopause. These are women who are sensitive to hormone changes. Often the mood swings will go away with time. If a woman is using HT for hot flashes or another menopause symptom, sometimes her mood swings will get better, too. Also, getting enough sleep and staying physically active will help you to feel your best. Mood swings are not the same as depression.
• Memory problems. As people age, their memory is not as good as it once was. Some women say they have "fuzzy thinking" as they reach menopause. This may be caused by changing hormones and can improve over time. Getting enough sleep and keeping physically active can help. If memory problems are really bad, talk to your doctor right away. This is not caused by menopause.

Sometimes, younger women need a hysterectomy to treat health problems such as endometriosis or cancer. A hysterectomy is an operation to remove a woman's uterus (womb). Often one or both ovaries (the female organs that produce eggs and hormones) are removed at the same time the hysterectomy is done. If you haven’t reached menopause, a hysterectomy will stop your period. But, you will reach menopause only if both ovaries are removed, called surgical menopause. Because surgical menopause is instant menopause, it can cause more severe symptoms than natural menopause (menopause that occurs as part of the natural aging process). You should talk with your doctor about how to best manage these symptoms.
Women who have a hysterectomy but have their ovaries left in place will not reach menopause at the time of surgery because their ovaries will continue to make hormones. But, because the uterus is removed, they will no longer have their periods and they cannot become pregnant. Later on, they might reach natural menopause a year or two earlier than expected. 

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What is premature menopause?

Menopause is called "premature" if it happens at or before the age of 40--whether it is natural or brought on by medical means (induced). Some women have premature menopause because of:

• Family history (genes)
• Medical treatments, such as surgery to remove the ovaries
• Cancer treatments, such as chemotherapy or radiation to the pelvic area that damage the ovaries-- although menopause does not always occur

Having premature menopause puts a woman at more risk for osteoporosis later in her life. For women who want to have children, premature menopause can be a source of great distress. Women who still want to become pregnant can talk with their doctors about other ways of having children, such as donor egg programs or adoption.

What is postmenopause?

Postmenopause is the term for all the years beyond menopause. It begins after you have not had a period for 12 months in a row--whether your menopause was natural or medically induced.

Nutritional supplements that may be helpful

Many years ago, researchers studied the effects of vitamin E supplementation in reducing symptoms of menopause. Most, but not all, studies found vitamin E to be helpful. Many doctors suggest that women going through menopause take 800 IU per day of vitamin E for a trial period of at least three months to see if symptoms are reduced. If helpful, this amount may be continued. Using lower amounts for less time has led to statistically significant changes, but only marginal clinical improvement.

Herbs that may be helpful

Some women decide to take herbal or other plant-based products to help relieve hot flashes. Some of the most common ones are:

• Soy. Soy contains phytoestrogens (chemicals that are like estrogen). But, there is no proof that soy--or other sources of phytoestrogens--really do make hot flashes better. And the risks of taking soy--mainly soy pills and powders--are not known. The best sources of soy are foods such as tofu, tempeh, soymilk, and soy nuts. These soy products are more likely to work on mild hot flashes.
• Other sources of phytoestrogens. These include herbs such as black cohosh, wild yam, dong quai, and valerian root.

Preliminary evidence suggests that supplementation with St. John’s wort extract (300 mg three times daily for 12 weeks) may improve psychological symptoms, including sexual wellbeing, in menopausal women. A double-blind trial found that Panax Ginseng (200 mg per day of standardized extract) helped alleviate psychological symptoms of menopause, such as depression and anxiety, but did not decrease physical symptoms, such as hot flashes or sexual dysfunction, in postmenopausal women who had not been treated with hormones.
Make sure to discuss these types of products with your doctor before taking them. You also should tell your doctor about other medicines you are taking, since some plant products can be harmful when combined with other drugs.

Osteoporosis
Osteoporosis is a condition in which the normal amount of bone mass has decreased. People with osteoporosis have brittle bones, which increases the risk of bone fracture, particularly in the hip, spine, and wrist. Osteoporosis is most common in postmenopausal Asian and Caucasian women. Premenopausal women are partially protected against bone loss by the hormone called estrogen. Black women often have slightly greater bone mass than do other women, which helps protect against bone fractures. In men, testosterone partially protects against bone loss even after middle age. Beyond issues of race, age, and gender, incidence varies widely from society to society, suggesting that osteoporosis is largely preventable. Osteoporosis is a silent disease that may not be noticed until a broken bone occurs. Signs may include diminished height, rounded shoulders, dowager’s hump, and evidence of bone loss from diagnostic tests. Symptoms may include neck or back pain.

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Nutritional supplements that may be helpful

Calcium: Although insufficient when used as the only intervention, calcium supplements help prevent osteoporosis. A review of the research shows that calcium supplementation plus hormone replacement therapy is much more effective than hormone replacement therapy without calcium. Doubleblind research has found that increasing calcium intake results in greater bone mass in girls. An analysis of many trials investigating the effects of calcium supplementation in premenopausal women has also shown a significant positive effect. Most doctors recommend calcium supplementation as a way to partially reduce the risk of osteoporosis and to help people already diagnosed with the condition. In order to achieve the 1,500 mg per day calcium intake many researchers deem optimal, 800 to 1,000 mg of supplemental calcium are generally added to the 500 to 700 mg readily obtainable from the diet.

Vitamin D increases calcium absorption, and blood levels of vitamin D are directly related to the strength of bones. Mild deficiency of vitamin D is common in the fit, active elderly population and leads to an acceleration of age-related loss of bone mass and an increased risk of fracture. In double-blind research, vitamin D supplementation has reduced bone loss in women who consume insufficient vitamin D from food and slowed bone loss in people with osteoporosis. However, the effect of vitamin D supplementation on osteoporosis risk remains surprisingly unclear, with some trials reporting little if any benefit. Moreover, trials reporting reduced risk of fracture have usually combined vitamin D with calcium supplementation, making it difficult to assess how much benefit is caused by supplementation with vitamin D alone. Impaired balance and increased body sway are important causes of falls in elderly people with osteoporosis. Vitamin D works with calcium to prevent some musculoskeletal causes of falls. In a double-blind trial, elderly women who were given 800 IU per day of vitamin D and 1,200 mg per day of calcium had a significantly lower rate of falls and subsequent fractures than did women given the same amount of calcium alone. Despite inconsistency in the research, many doctors recommend 400 to 800 IU per day of supplemental vitamin D, depending upon dietary intake and exposure to sunlight.

Evening Primrose Oil has long been revered for providing relief from symptoms associated with PMS and menopause such as cramps, hot flashes, breast tenderness and moodiness. Dr. Fred Pescatore, an internist in Manhattan who specializes in nutritional medicine, says evening primrose oil "works well in menopausal women or in estrogenic syndromes such as PMS, breast tenderness, menopausal changes, hot flashes and vaginal dryness." The American Botanical Council reviewed 22 clinical studies of evening primrose oil, which included a total of 1,154 participants. The studies showed the oil has a positive effect in treating PMS, dermatological conditions, diabetic neuropathy and arthritis.

Fish Oils A preliminary trial found that elderly women with osteoporosis who were given 4 grams of Fish Oil per day for four months had improved calcium absorption and evidence of new bone formation. Fish oil combined with Evening Primrose Oil (EPO) may confer added benefits. In a controlled trial, women received 6 grams of a combination of EPO and Fish Oil, or a matching placebo, plus 600 mg of calcium per day for three years. The EPO/fish oil group experienced no spinal bone loss in the first 18 months and a significant 3.1% increase in spinal bone mineral density during the last 18 months.

Vitamin K is needed for bone formation. People with osteoporosis have been reported to have low blood levels and low dietary intake of vitamin K. One study found that postmenopausal (though not premenopausal) women may reduce urinary loss of calcium by taking 1 mg of vitamin K per day. People with osteoporosis given large amounts of vitamin K2 (45 mg per day) have shown an increase in bone density after six months and decreased bone loss after one or two years. Other preliminary studies have reported that vitamin K supplementation increases bone formation in some women and that higher vitamin K intake correlates with greater bone mineral density. Some doctors recommend 1mg vitamin K1 to postmenopausal women as a way to help maintain bone mass, though optimal intake remains unknown.

Magnesium. Both bone and blood levels of magnesium have been reported to be low in people with osteoporosis. Supplemental magnesium has reduced markers of bone loss in men. Supplementing with 250 mg up to 750 mg per day of magnesium arrested bone loss or increased bone mass in 87% of people with osteoporosis in a two-year, controlled trial. Some doctors recommend that people with osteoporosis supplement with 350 mg of magnesium per day. In a preliminary study, people with osteoporosis were reported to be at high risk for magnesium malabsorption. One trial studying postmenopausal women combined hormone replacement therapy with magnesium (600 mg per day), calcium (500 mg per day), vitamin C, B vitamins, vitamin D, zinc, copper, manganese, boron, and other nutrients for an eight- to nine-month period. In addition, participants were told to avoid processed foods, limit protein intake, emphasize vegetable over animal protein, and limit consumption of salt, sugar, alcohol, coffee, tea, chocolate, and tobacco. Bone density increased a remarkable 11%, compared to only 0.7% in women receiving hormone replacement alone.

Zinc and Copper: Levels of zinc in both blood and bone have been reported to be low in people with osteoporosis, and urinary loss of zinc has been reported to be high. In one trial, men consuming only 10 mg of zinc per day from food had almost twice the risk of osteoporotic fractures compared with those eating significantly higher levels of zinc in their diets. Copper is needed for normal bone synthesis. Recently, a two year, controlled trial reported that 3 mg of copper per day reduced bone loss. Some doctors recommend 2 to 3 mg of copper per day, particularly if zinc is also being taken, in order to prevent a deficiency. Supplemental zinc significantly depletes copper stores, so people taking zinc supplements for more than a few weeks generally need to supplement with copper also. All minerals discussed so far—calcium, magnesium, zinc, and copper—are sometimes found at appropriate levels in high-potency multivitamin-mineral supplements, like Vital M, from Natural Fervor Inc.

Manganese: Interest in the effect of manganese and bone health began when famed basketball player Bill Walton’s repeated fractures were halted with manganese supplementation. A subsequent, unpublished study reported manganese deficiency in a small group of osteoporotic women. Since then, a combination of minerals including manganese was reported to halt bone loss. However, no human trial has investigated the effect of manganese supplementation alone on bone mass. Nonetheless, some doctors recommend 10 to 20 mg of manganese per day to people concerned with maintenance of bone mass.

Silicon is required in trace amounts for normal bone formation,105 and supplementation with silicon has increased bone formation in animals.106 In preliminary human research, supplementation with silicon increased bone mineral density in a small group of people with osteoporosis.107 Optimal supplemental levels remain unknown, though some multivitamin-mineral supplements now contain small amounts of this trace mineral.

Strontium may play a role in bone formation, and preliminary evidence suggests that women with osteoporosis may have reduced absorption of strontium. Strontium supplementation may inhibit bone breakdown by protecting vulnerable bone surfaces. Increased bone formation and decreased bone pain were also reported people with osteoporosis. Some doctors recommend only 1 to 3 mg per day—less than many people currently consume from their diets, but an amount that has begun to appear in some multivitamin mineral formulas like Vital M from Natural Fervor Inc. geared toward bone health.

Folic acid, vitamin B6, and vitamin B12: are known to reduce blood levels of the amino acid called homocysteine in the body, and homocysteinuria, a condition associated with high homocysteine levels, frequently causes osteoporosis. Although some healthcare practitioners have suggested these vitamins might help prevent osteoporosis by lowering homocysteine, no research has explored this relationship. For the purpose of lowering homocysteine, amounts of folic acid and vitamins B6 and B12 found in high-potency B-complex supplements, Vital Energy from Natural Fervor Inc. and multivitamins, like Vital – M, should be adequate.

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PMS (Premenstrual Syndrome)

PMS is a disorder characterized by a set of hormonal changes that trigger disruptive symptoms in a significant number of women for up to two weeks prior to menstruation. Of the estimated 40 million suffers, more than 5 million require medical treatment for marked mood and behavioral changes. Often symptoms tend to taper off with menstruation and women remain symptom-free until the two weeks or so prior to the next menstrual period. These regularly recurring symptoms from ovulation until menses typify PMS, premenstrual syndrome.
Characteristics

Over 150 symptoms have been attributed to PMS. After complaints of feeling "out-of-control", anxious, depressed and having uncontrollable crying spells, the most common complaints are headache and fatigue. But symptoms may vary from month to month and there may even be symptom-free months. No women present with all the PMS symptoms. Characteristically symptoms may be both physical and emotional. They may include physical symptoms as headache, migraine, fluid retention, fatigue, constipation, painful joints, backache, abdominal cramping, heart palpitations and weight gain. Emotional and behavioral changes may include anxiety, depression, irritability, panic attacks, tension,lack of co-ordination, decreased work or social performance and altered libido.
Originally described in 1931 by an American neurologist, the grouping of symptoms has remained the same:
Aside from the regularity of symptoms seen prior to menstruation, there are certain elements which distinguish PMS from other disorders:
*PMS may often be triggered by hormonal changes. It tends to begin at puberty, after pregnancy, after starting birth control pills, after hormone related surgery as hysterectomy or tubal ligation or around the onset of the menopause. In fact, it is not unusual for the PMS sufferer to confuse her symptoms with those of an early menopause.
*Lifting of symptoms (including headache) with pregnancy, especially in the second and third trimester.
*Heredity appears to be a factor although specific symptoms may differ between sisters or mother and daughters.
*There is often an aura of increased activity prior to the worse symptoms of PMS or migraines. At this time, the woman may clean the house, function with little sleep, and feel euphoric. This is followed by the PMS symptoms, migraine, fatigue, exhaustion, depression and the inability to function. Women typically feel “out of control” at this time and this can cause the signs and symptoms of depression.
Causes

The exact cause of PMS, headaches and depression are unknown. In fact, it is not known why some women have severe symptoms, some have mild ones, while others have none. It is generally believed that PMS, migraine and depression stem from neurochemical changes within the brain. Hormonal factors, such as estrogen levels, had not been appreciated until recent studies.
The female hormone estrogen starts to rise after menstruation and peaks around mid-cycle (ovulation). It then rapidly drops only to slowly rise and then fall again in the time before menstruation. Estrogen hold fluid and with increasing estrogen comes fluid retention: many women report weight gains of five pounds premenstrually. Estrogen has a central neurologic effect: it can contribute to increase brain activity and even seizures. Estrogen can also contribute to retention of salt and a drop in blood sugar. PMS patients and migraineurs benefit from both salt and sugar restriction and a mild diuretic.
Postpartum Depression

A special form of PMS is the severe depression experienced after delivery. Most women experience a “let down” from the high hormone levels during pregnancy. Because of this, there is a normal amount of feeling “blue” immediately after childbirth. But the depth of depression experienced with postpartum depression is much deeper. These individuals cannot tolerate the hormonal disruption to their nervous system: their actions may harm themselves or their infants. That is why the treatment of PMS in the postpartum period is first to replace the missing hormones. If unsuccessful, then other hormonal preparations can be included as well.
PMS and Migraine Diet
Depending on the patient’s individual symptoms and their severity, the doctor may recommend how one may take an active role in the management of PMS and premenstrual migraine by following these guidelines:
*Eat six small meals at regular three-hour intervals, high in complex carbohydrates and low in simple sugars. This helps to maintain a stead blood glucose level and avoid energy highs and lows.
*Substantially reduce and eliminate use of caffeine, alcohol, salt, fats, and simple sugars to reduce bloating, fatigue, tension and depression.
*Daily supplemental vitamins and minerals may be administered to relieve some PMS symptoms. A multivitamin with B6(100 mcg), B complex, magnesium (300mg), Vitamin E (400 IU) and vitamin C (1000 mg) may be recommended to alleviate irritability, fluid retention, joint aches, breast tenderness, anxiety, depression and fatigue. Be sure to check with your doctor before taking any medication for PMS.
*Exercise is helpful for PMS because it reduces stress and tension, acts as a mood elevator, provides a sense of well-being and improves blood circulation by increasing natural production of beta-endorphins. It is recommended, if your physician so advises, to exercise at least three times weekly for 20-30 minutes. Aerobics, walking, jogging, bicycling and swimming are a few of the suggested ways to exercise.
The Psychiatric Treatment of PMS
The psychiatric literature since the 1930’s has portrayed women as the weaker sex and in need of medical treatment for their “hysterical” and “hysteronic” complaints [pertaining to the uterus].
Psychotropic drugs, like tricyclic anti depressants, the tranquilizers, and the selective serotonin reuptake inhibitors, are often used to treat the symptoms. There have been many documented studies showing the benefit to the patient in taking this medication for severe P.M.S.
The problem with the treatment approach when used for more than a few cycles, is that it fails to address the underlying hormonal problems. So the result is the woman taking these medications may become sleepy, forgetful or not communicative. For this and other reasons, our primary approach has been hormonal.
Medical Treatments of PMS
Since 1953, hormonal therapies have been the mainstay of the treatment of premenstrual distress and premenstrual syndrome. So women need not feel that they are going crazy for these two weeks every month. They are experiencing an exaggeration of normal function. The physician can help the patient by first explaining the process, secondly using an anti-estrogenic hormonal medication to lower and stability the estrogen level, and lastly, using psychotropic medications for short periods of time.
PMS IS REAL-- AND THE PRESCRIPTION MEDICATION MUST ADDRESS THE WOMAN’S NEED AND THE UNDERLYING HORMONAL IMBALANCES.

Female Infertility

Description

Infertility is the inability to conceive and become pregnant after 12 months of regular, unprotected sex at the time of ovulation. Infertility is a common medical condition, affecting approximately 6 million people in the United States every year. It is estimated that about 10% to 15% of heterosexual couples who try to conceive are unable to do so after 1 year.
Twelve months may seem like an arbitrary length of time, but it makes sense given that most fertile couples become pregnant within a year. So if a couple does not conceive after a year of effort, it is likely that the man, the woman, or both partners are infertile.
Infertility affects men and women equally. Eighty percent of infertility cases have a known cause, and half of these are wholly or partially due to male infertility factors, most commonly azoospermia (the absence of any sperm) or oligospermia (the presence of too few sperm). Infertility in women is usually due to anovulation (absence of ovulation), blocked fallopian tubes, or uterine abnormalities, or immunological causes.
A family history of systemic lupus erythematosus (SLE), rheumatoid arthritis, stroke, or heart attack can indicate a blood clotting disorder, which may be a contributing factor in female infertility, second and third trimester miscarriages, and stillbirths. Blood clotting disorders can prevent normal nourishment of the placenta, causing intra-uterine-growth-retardation (IUGR) or intra-uterine-fetal-death (IUFD). Autoimmune factors, such as endometriosis, anti-thyroid antibodies, anti-sperm antibodies, and activated natural killer cells, also may contribute to infertility.
Conception and pregnancy are complicated processes involving many biologic factors and phases: the man needs to produce healthy sperm and the woman healthy eggs; the cervical mucus needs to be healthy and abundant so that the sperm can travel up through the cervical canal to the uterus and fallopian tubes; the fallopian tubes need to be open and accessible so that the sperm can reach the egg; the sperm has to be able to fertilize the egg when they make contact; the fertilized egg (the embryo) has to be able to implant in the woman's uterus; and, finally, both the embryo and the woman's uterine environment need to be healthy and strong for the baby to come to term. If any one of the biologic factors is impaired or damaged in any way, infertility can result. Infertility in women has been linked to aging, a history of pelvic inflammatory disease, and certain lifestyle behaviors.
Infertility is diagnosed after an infertility workup. Treatment may include medication, surgery, or in vitro fertilization (IVF). About 25–30 % of all couples who receive treatment are able to conceive.
Success with IUI or IVF is related to the patient's age—older patients have lower success rates. Sex-steroid markers that may be used to determine egg quality or ovarian reserve include FSH (normal is 6–10) and E2 (estradiol; normal range is 25–65). Other factors involved in the initial evaluation include prolactin levels, progesterone levels, LH (luteinizing hormone), and TSH (thyroid-stimulating hormone).
Any of these factors that are outside of the normal range can point the reproductive endocrinologist in the right direction for creating an appropriate and often successful treatment plan.

Alternative Names

Pelvic inflammatory disease; Polycystic ovaries

Causes

Causes of infertility can be found in about 90% of infertility cases but, despite extensive tests, about 10% of couples will never know why they cannot conceive. Between 10 - 30% of cases of infertility have more than one cause. Male or female infertility each account for about 30 - 40% of cases. In men, sperm defects (their quality and quantity) are usually responsible. Female infertility is more complex.

Pelvic Inflammatory Disease

Pelvic inflammatory disease (PID) is the major cause of female infertility worldwide. PID comprises a variety of infections caused by different bacteria that affect the reproductive organs, appendix, and parts of the intestine that lie in the pelvic area. The sites of infection most often implicated in infertility are in the fallopian tubes, a specific condition referred to as salpingitis .
Causes of PID. PID may result from many different conditions that cause infections. Among them are:

• Sexually transmitted diseases (cause of most PIDs). Chlamydia trachomatis is an infectious organism that causes 75% of infertility in the fallopian tubes. Gonorrhea is responsible for most of the remaining cases.
• Pelvic tuberculosis (a growing global problem as tuberculosis cases increase)
• Nonsterile abortions
• Ruptured appendix
• Herpesvirus (suggested for some cases, but not confirmed as a cause).

Symptoms of PID. The infection may be subclinical (occurring without any symptoms), or there may be fever, chills, or pelvic pain indicating inflammation of the entire pelvic area.
Effects of PID. Severe or frequent attacks of PID can eventually cause scarring, abscess formation, and tubal damage that result in infertility. About 20% of women who develop symptomatic PID become infertile. PID also significantly increases the risk of ectopic pregnancy (fertilization in the fallopian tubes). The severity of the infection, not the number of the infections, appears to pose the greater risk for infertility.

Endometriosis

Endometriosis may account for as many as 30% of infertility cases. Some evidence suggests that between 30 - 50% of women with endometriosis are infertile. Often, however, it is difficult to determine if endometriosis is the primary cause of infertility, particularly in women who have mild endometriosis. Endometriosis rarely causes an absolute inability to conceive, but, nevertheless, it can contribute to it both directly and indirectly.
Endometriosis is the condition in which the tissue that normally lines the uterus (endometrium) grows on other areas of the body causing pain and irregular bleeding.


Direct Effect of Endometrial Cysts. Endometrial cysts may directly cause infertility in several ways:

• If implants occur in the fallopian tubes, they may block the egg's passage.
• Implants that occur in the ovaries prevent the release of the egg.
• Severe endometriosis can eventually form rigid webs of scar tissue (adhesions) between the uterus, ovaries, and fallopian tubes, thereby preventing the transfer of the egg to the tube.

Immune Factors and the Inflammatory Response. Researchers are focusing on defects in the immune system that not only may be responsible for endometriosis in the first place but may also cause the infertility associated with endometriosis. Even in early stage endometriosis, investigators have observed increased immune system activity.
Other Conditions Linking Endometriosis and Infertility. Researchers have sometimes noted unusually low levels of specific substances that enable a fertilized egg to adhere to the uterine lining. (Such abnormalities are more often a factor in infertility in women with mild to moderate endometriosis than in those with severe cases.)
One study found that the eggs in women with endometriosis appeared to have more genetic abnormalities than those in women without the disorder.

Polycystic Ovarian Syndrome

Polycystic ovarian syndrome (PCOS) is a condition in which the ovaries produce high amounts of androgens (male hormones), particularly testosterone. PCOS occurs in about 6% of women, and amenorrhea or oligomenorrhea (infrequent menses) is quite common. According to a 2002 study, nearly 30% of obese women with PCOS had amenorrhea. (The rate was lower -- 4.7% -- in women with normal weight.)
In PCOS, increased androgen production produces high LH levels and low FSH levels, so that follicles are prevented from producing a mature egg. Without egg production, the follicles swell with fluid and form into cysts. Every time an egg is trapped within the follicle, another cyst forms, so the ovary swells, sometimes reaching the size of a grapefruit. Without ovulation, progesterone is no longer produced, whereas estrogen levels remain normal.
The elevated levels of androgens (hyperandrogenism) can cause obesity, facial hair, and acne, although not all women with PCOS have such symptoms. Other male characteristics, such as deepening voice and clitoral enlargement, are rare.
PCOS also poses a high risk for insulin resistance, particularly in women who are also obese. Insulin resistance is associated with diabetes type 2, in which insulin levels are normal or high but the body cannot use this hormone efficiently. About half of PCOS patients, in fact, also have diabetes.

Premature Ovarian Failure (Early Menopause)

Premature ovarian failure (POF) is the early depletion of follicles before age 40, which, in most cases, leads to premature menopause. It affects about 1% of women and is typically preceded by irregular periods, which might continue for years. In this condition, follicle-stimulating hormone (FSH) levels are elevated, as they are during perimenopause. Premature ovarian failure is a significant cause of infertility, and women who have this condition have only a 5 - 10% chance to conceive without fertility treatments.
Causes of Premature Ovarian Failure. There are numerous causes of POF. Often the cause of this disorder or other causes of POF is unknown. In some cases, POF may represent an acceleration of the aging process.
The following conditions may produce POF:

• Adrenal, pituitary, or thyroid gland deficiencies.
• Genetic factors related to the X chromosome. A woman needs two functioning X chromosomes for normal reproduction. When one is abnormal, ovarian function fails. The most severe example is Turner's syndrome, a genetic condition, in which one of the two X-chromosomes is missing or malfunctioning. Milder cases of ovarian failure can occur in fragile X syndrome and other rare inherited conditions that cause partial X-chromosome abnormalities.
• Cancer treatments (radiation, chemotherapy, or both). Women who are undergoing cancer treatments and who want to become pregnant should see a reproductive specialist to discuss their options. According to the American Society of Clinical Oncology’s 2006 guidelines, the fertility preservation method with the best chance of success is embryo cryopreservation. This procedure involves harvesting a woman’s eggs (oocytes), followed by in vitro fertilization and freezing of embryos for later use. Other treatments under investigation include egg preservation, collecting and freezing unfertilized eggs, removing and freezing a part of the ovary for later reimplantation, and using hormone therapy to protect the ovaries during chemotherapy. Women may be able to access these investigational approaches through enrolling in clinical trials.
• Autoimmunity. Autoimmune diseases, including diabetes type 1, systemic lupus erythematosus, autoimmune hypothyroidism, and autoimmune Addison's disease, are associated with a higher risk for early menopause. Autoimmunity, however, may also play a role in some cases of POF without the presence of specific autoimmune diseases. In such cases, antibodies specifically attack the cells that secrete reproductive hormones thus causing ovarian failure.
• Other causes of POF include sarcoidosis, mumps, some sexually transmitted diseases, and tuberculosis. Women with epilepsy are at higher risk for POF.

Idiopathic Hypogonadotropic Hypogonadism

Idiopathic hypogonadotropic hypogonadism is a rare condition in which follicle-stimulating hormone (FSH) and luteinizing hormone (LH) are underproduced and prevent the development of functional ovaries. There are no other abnormalities in the hypothalamus-pituitary axis (such as tumors or abnormal stress hormones or prolactin). In most cases, the causes of hypergonadotropic hypogonadism are unknown. Genetic factors, including Kallman's syndrome, have been identified in about 20% of these cases.

Functional Hypothalamic Amenorrhea (FHA) and Eating Disorders

Functional hypothalamic amenorrhea (FHA) is the absence of menstruation due to disturbances in the thyroid gland and hypothalamus-pituitary-adrenal (HPA) system, which regulates reproduction and other important functions. The eating disorders anorexia and bulimia are most often associated with FHA. FHA may be due to other different factors, most unknown.

Luteal Phase Defect (Implantation Failure)

Luteal phase defect is a general term referring to problems in the corpus luteum that result in inadequate production of progesterone. Because progesterone is necessary for thickening and preparing the uterine lining, the ovum fails to successfully implant in the endometrium. Between 25 - 60% of women who experience recurrent miscarriages may have a luteal phase defect. A luteal phase defect, however, can also occur in fertile women, so other factors may be responsible for implantation failure.

Benign Uterine Fibroids

Benign fibroid tumors in the uterus are extremely common in women in their 30s. The effect of fibroids on fertility is controversial. A 2002 analysis suggested that they may account for infertility in only 1 - 2.4% of women who are having trouble conceiving.
Large fibroids may cause infertility impairing the uterine lining, by blocking the fallopian tube, or by distorting the shape of the uterine cavity or altering the position of the cervix.
Some evidence suggests that even small fibroids may reduce the chances of pregnancy in women who are undergoing assisted reproductive techniques. Treatments to reduce fibroids may be helpful in such women, although there has been little research on this subject.

Elevated Prolactin Levels (Hyperprolactinemia)

Prolactin is a hormone produced in the pituitary gland that stimulates breast development and milk production in association with pregnancy. High levels of prolactin (hyperprolactinemia) reduce gonadotropin hormones and inhibit ovulation. Hyperprolactinemia in women who are not pregnant or nursing can be caused by hypothyroidism or pituitary adenomas. (These are benign tumors that secrete prolactin. They can cause headache and visual problems as well as breast secretions.) Some drugs, including oral contraceptives and some antipsychotic drugs, can also elevate levels of prolactin.
Secretions from the breast not related to pregnancy or nursing (called galactorrhea ) is a telltale symptom of high prolactin levels and should be investigated.

Structural Problems Causing Obstruction

Inborn Abnormalities. Inborn genital tract abnormalities may cause infertility. Mullerian agenesis is a specific malformation in which no vagina or uterus develops. Even in these cases, some women can become mothers by undergoing in vitro fertilization and having the fertilized egg implanted in another woman who is willing and able to carry the pregnancy (a surrogate mother).
Uterine or Abdominal Scarring. Bands of scar tissue that bind together after abdominal or pelvic surgery or infection (called adhesions) can restrict the movement of ovaries and fallopian tubes and may cause infertility. Asherman's syndrome, for example, is scarring in the uterus that can cause obstructions and secondary amenorrhea. It may be caused by surgery, repeated injury, or unknown factors. Laparoscopic surgery is less likely to cause adhesions than standard open surgery.
In some of these cases, surgery may be helpful. One technique, called pressure lavage under ultrasound guidance (PLUG), may prove to be useful for treating some cases of mild scarring in the uterus (intrauterine adhesions). This technique is based on transvaginal sonohysterography, which uses ultrasound along with saline infused into the uterus to enhance visualization. Continuous accumulation of saline in the procedure is used to break up the scars.

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Other Causes of Infertility

Ectopic Pregnancies. Ectopic pregnancies increase the risk for infertility, although subsequent pregnancy rates are quite variable. Ectopic pregnancies that terminate without treatment appear to pose a lower risk for future infertility. Even a ruptured tube does not appear to reduce the chance for a future pregnancy in most women. Such an event however can be dangerous and even life threatening for the woman. Laparoscopic surgery to remove a fallopian tube affected by an ectopic pregnancy may preserve fertility better than traditional abdominal surgery.
Medications. Among the medications that can cause temporary infertility are those used to treat chronic disorders, as well as antidepressants, hormones, pain killers, and antipsychotic drugs.
Inflammatory Bowel Disease. Inflammatory bowel disease (particularly Crohn's disease or surgery for ulcerative colitis) can affect fertility.
Celiac Sprue. Celiac sprue is a disease in which the patient cannot tolerate gluten, a common food chemical. The disorder is also highly associated with infertility in men and women, possibly through multiple effects on nutrition, immune factors, and hormones. The mechanisms are not altogether clear, but infertility is usually reversible with strict dietary control.
Epilepsy. In one study of women with epilepsy, fertility rates were 33% lower than among women in the general population, perhaps due to certain antiepileptic drugs that increase the risk for birth defects. The social effects of epilepsy may also lead to marriage at an older age, which can be associated with delayed attempts to get pregnant and thereby affect fertility.
Thyroid Problems. Thyroid problems, either too much thyroid hormone (hyperthyroidism) or too little (hypothyroidism), can interrupt cycles.
Metabolic Syndrome (also Called Syndrome X). Doctors diagnose this condition when at least three of the the following abnormalities are present:

• Abdominal obesity
• Low HDL (good) cholesterol levels
• High triglyceride levels
• High blood pressure
• Insulin resistance

Metabolic syndrome is a pre-diabetic condition that is significantly associated with heart disease. A 2002 study reported that, as with PCOS, women with metabolic syndrome have higher levels of male hormones and are therefore at risk for infertility. A 2002 study estimated that 24% of the population now has this condition.
Other Medical Conditions. Medical conditions associated with delayed puberty and amenorrhea (absence of periods) include Cushing's disease, sickle cell disease, HIV, kidney disease, and diabetes. Genetic mutations that affect luteinizing hormone may also be responsible for some cases of light or absent menstruation. Other rare genetic disorders, such as Kallman syndrome, cause abnormalities in the hypothalamus of the brain.

Pregnancy & Post-Partum Support

Pregnancy, the period during which a woman’s fertilized egg (embryo) gestates and becomes a fetus, lasts an average of 40 weeks from the date of the last menstrual period to delivery of the infant. 
In the first trimester (13 weeks), many pregnant women experience nausea. Usually these women report that they feel best during the second trimester. During the third (final) trimester, the increasing size of the fetus begins to place mechanical strains on the expectant mother, often causing back pain, leg swelling, and other health problems.

Medical treatments for pregnancy and postpartum support

Over the counter dimenhydrinate (Dramamine®) may be used when nausea is severe enough to require medication.
With some health problems that develop during pregnancy (e.g., preeclampsia, eclampsia), bed rest, restriction of salt intake, and medication to lower blood pressure may be recommended. Women who are pregnant are advised to avoid caffeine, alcohol, nicotine, and other drugs (including over the counter medicines) that have not been prescribed by their doctor.

Dietary changes that may be helpful for pregnancy and postpartum support

Nearly all pregnant women can benefit from good nutritional habits prior to and during pregnancy. The increased number of birth defects during times of famine attest to the adverse effects of poor nutrition during pregnancy.1 For example, in a dietary survey of pregnant women, higher dietary intake of niacin (a form of vitamin B3) during the first trimester was correlated with higher birth weights, longer length, and larger head circumference (all signs of healthier infants).2

Women who consume a standard Western diet (high in fat and sugar and low in complex carbohydrates) during pregnancy and breast-feeding may not be obtaining adequate amounts of essential vitamins and minerals; this can result in health problems for the newborn.3 Pregnant women should choose a well-balanced and varied diet that includes fresh fruits and vegetables, whole grains, legumes, and fish. Refined sugars, white flour, fried foods, processed foods, and chemical additives should be avoided.

Consumption of moderate to large amounts of caffeine while pregnant has been associated with an increased risk of miscarriage.4 5 6 7 Although some studies suggest that only very large amounts of caffeine increase the risk of miscarriage,8 an analysis of clinical trials found that women who consumed more than 150 mg of caffeine (roughly one to two cups of coffee) per day while pregnant had an increased risk of miscarriage or delivering a baby with a low birth weight.9 The FDA has advised women to avoid drinking coffee and consuming other caffeine-containing foods and beverages during pregnancy.10

Lifestyle changes that may be helpful for pregnancy and postpartum support

A woman can reduce her risk of complications during pregnancy and delivery by avoiding harmful substances, such as alcohol, caffeine, nicotine, recreational drugs, and some prescription or over-the-counter drugs.
Even minimal alcohol consumption during pregnancy can increase the risk of hyperactivity, short attention span, and emotional problems in the child.11 Pregnant women should, therefore, avoid alcohol completely.
Cigarette smoking during pregnancy causes lower birth weights and smaller-sized newborns. The rate of miscarriage in smokers is twice as high as that in nonsmokers,12 and babies born to mothers who smoke have more than twice the risk of dying from sudden infant death syndrome (SIDS).13
Weight Gain in Pregnancy

No single maternal weight gain target meets the needs of all women. The amount of weight a woman optimally gains varies with her height, age, plans to breast feed, and whether she is delivering twins. However, a few basic guidelines are generally accepted:14 Women who enter pregnancy at more than 120% of standard weight still have an obligatory weight gain of 15–25 pounds at a rate of about 0.7 pounds per week. Women who are at ideal body weight and are not going to nurse have a target of gaining about 22 pounds overall at a rate of 0.8 pounds per week. Women who enter pregnancy between 90% and 110% of ideal body weight and plan to nurse have a target weight gain of 25–35 pounds overall at a rate of 0.9 pounds per week during the second and third trimesters. Physically immature adolescents and women less than 90% of ideal body weight have a target weight gain of 32 (28–40) pounds at a rate of 1.1 pounds per week. Women who know they are going to have twins have a target weight gain of 40 (35–45) pounds with a weekly rate of 1.4 pounds during the last 20 weeks of pregnancy.

Another way to determine the appropriate weight gain for pregnancy is by using the Body Mass Index (BMI). The BMI is calculated by dividing your body weight (in kilograms) by the square of your height (in meters). (A kilogram is equal to 2.2 pounds; a meter is equal to about 39 inches.) According to the standard set in 1990 by the Institute of Medicine (IOM) of the National Academy of Sciences,15 a woman with a low BMI (less than 19.8) should gain a total of 12.5–18 kg (27.5–39.7 pounds) during pregnancy; a woman with a normal BMI (19.8–26) should gain a total of 11.5–16 kg (25.4–35.3 pounds) during pregnancy; a woman with a high BMI (greater than 26.0–29.0) should gain a total of 7–11.5 kg (15.4–25.4 pounds) during pregnancy. Adolescents and black women should strive for gains at the upper end of the recommended range. Short women (less than five feet) should strive for gains at the lower end of this range. Obese women (BMI greater than 29) have a separate recommended target weight gain of about 6 kg (13.2 pounds). Published studies suggest that only 30–40% of American women actually have weight gains within the IOM’s recommended ranges.16 17 18
Although the IOM’s national recommendations concerning pregnancy weight gain have been widely adopted, they have not been universally accepted.19 The amount of weight gain during pregnancy varies considerably among women with good pregnancy outcomes.20 21 For that reason, weight gain alone is not likely to be a perfect screening tool for pregnancy complications. Neverthele

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Nutritional supplements that may be helpful for pregnancy and postpartum support

Most doctors, many other healthcare professionals, and the March of Dimes recommend that all women of childbearing age supplement with 400 mcg per day of folic acid. Such supplementation could protect against the formation of neural tube defects (such as spina bifida) during the time between conception and when pregnancy is discovered.

The requirement for the B vitamin folic acid doubles during pregnancy, to 800 mcg per day from all sources.26 Deficiencies of folic acid during pregnancy have been linked to low birth weight27 and to an increased incidence of neural tube defects (e.g., spina bifida) in infants. In one study, women who were at high risk of giving birth to babies with neural tube defects were able to lower their risk by 72% by taking folic acid supplements prior to and during pregnancy.28 Several preliminary studies have shown that a deficiency of folate in the blood may increase the risk of stunted growth of the fetus.29 30 31 32 33 34 35 36 This does not prove, however, that folic acid supplementation results in higher birth weights. Although some trials have found that folic acid and iron, when taken together, have improved birth weights,37 38 39 40 other trials have found supplementation with these nutrients to be ineffective.41 42 43

The relationship between folate status and the risk of miscarriage is also somewhat unclear. In some studies, women who have had habitual miscarriages were found to have elevated levels of homocysteine (a marker of folate deficiency).44 45 46 47 In a preliminary study, 22 women with recurrent miscarriages who had elevated levels of homocysteine were treated with 15 mg per day of folic acid and 750 mg per day of vitamin B6, prior to and throughout their next pregnancy. This treatment reduced homocysteine levels to normal and was associated with 20 successful pregnancies.48 It is not known whether supplementing with these vitamins would help prevent miscarriages in women with normal homocysteine levels. As the amounts of folic acid and vitamin B6 used in this study were extremely large and potentially toxic, this treatment should be used only with the supervision of a doctor.

In other studies, however, folate levels did not correlate with the incidence of habitual miscarriages.49 50 51
Preliminary52 and double-blind53 evidence has shown that women who use a multivitamin-mineral formula containing folic acid beginning three months before becoming pregnant and continuing through the first three months of pregnancy have a significantly lower risk of having babies with neural tube defects (e.g., spina bifida) and other congenital defects.

In addition to achieving significant protection against birth defects, women who take folic acid supplements during pregnancy have been reported to have fewer infections, and to give birth to babies with higher birth weights and better Apgar scores. 54 (An Apgar score is an evaluation of the well-being of a newborn, based on his or her color, crying, muscle tone, and other signs.) However, if a woman waits until after discovering her pregnancy to begin taking folic

Herbs that may be helpful for pregnancy and postpartum support

Many tonic herbs, which are believed to strengthen or invigorate organ systems or the entire body, can be taken safely every day during pregnancy. Examples include dandelion leaf and root, red raspberry leaf, and nettle. Dandelion leaf and root are rich sources of vitamins and minerals, including beta-carotene, calcium, potassium, and iron. Dandelion leaf is mildly diuretic (promotes urine flow); it also stimulates bile flow and helps with the common digestive complaints of pregnancy. Dandelion root is traditionally used to strengthen and invigorate the liver.74

Red raspberry leaf is the most frequently mentioned, traditional herbal tonic for general support of pregnancy and breast-feeding. Rich in vitamins and minerals (especially iron), it is traditionally used to strengthen and invigorate the uterus, increase milk flow, and restore the mother’s system after childbirth.75
Nettle leaf is rich in the minerals calcium and iron, is mildly diuretic, and is diuretic. Nettle leaf is rich in the minerals calcium and iron, is and mildly diuretic. Nettle enriches and increases the flow of breast milk and restores the mother’s energy following childbirth.76

In one study, the addition of lavender oil to a bath was more effective than a placebo in relieving perineal pain after childbirth (the perineum is the area between the vulva and the anus.)77 The improvement was not statistically significant, however, so more research is needed to determine whether lavender oil is truly effective.

Numerous herbs, known as galactagogues, are used in traditional herbal medicine systems around the world to promote production of breast milk.78 These are known as galactagogues. Vitex is one of the best recognized herbs in Europe for promoting lactation. An older German clinical trial found that 15 drops of a vitex tincture three times per day could increase the amount of milk produced by mothers with or without pregnancy complications, as compared with mothers given vitamin B1 or nothing.79 However, vitex should not be taken during pregnancy.

Goat’s rue (Galega officinalis) has a history of use in Europe for supporting breast-feeding. Taking 1 teaspoon of goat’s rue tincture per day is considered by some European practitioners to be helpful in increasing milk volume.80 Studies to support the use of goat’s rue as a galactagogue are lacking.
Sage has traditionally been used to dry up milk production when a woman no longer wishes to breast-feed.81 It should not be taken during pregnancy.

Are there any side effects or interactions with pregnancy and postpartum support?

Refer to the individual herb for information about any side effects or interactions.

Holistic approaches that may be helpful for pregnancy and postpartum support

In one preliminary study, acupuncture relieved pain and diminished disability in the low back during pregnancy better than physiotherapy.82
A controlled trial found that acupuncture significantly reduced symptoms in women with hyperemesis gravidarum, a severe form of nausea and vomiting of pregnancy that usually requires hospitalization.83 Treatment consisted of acupuncture at a single point on the forearm three times daily for two consecutive days. Acupressure (in which pressure, rather than needles, is used to stimulate acupuncture points) has also been found in several preliminary trials to be mildly effective in the treatment of nausea and vomiting of pregnancy.84 85 86
References:
1. Barnes B, Bradley SG. Planning for a Healthy Baby. London: Ebury Press, 1990.
2. Doyle W, et al. The association between maternal diet and birth dimensions. J Nutr Med 1990;1:9–17.
3. Price WA. Nutrition and Physical Degeneration, 50th anniv. Ed. New Canaan, CT: Keats Publishing, Inc., 1989.
4. Infante-Rivard C, Fernandez A, Gauthier R, et al. Fetal loss associated with caffeine intake before and during pregnancy. JAMA 1993;270:2940–3.
5. Srisuphan W, Bracken MB. Caffeine consumption during pregnancy and association with late spontaneous abortion. Am J Obstet Gynecol 1986;154:14–20.
6. Dlugosz L, Belanger K, Hellenbrand K, et al. Maternal caffeine consumption and spontaneous abortion: a prospective cohort study. Epidemiology 1996;7:250–5.
7. Fenster L, Eskenazi B, Windham GC, Swan SH. Caffeine consumption during pregnancy and spontaneous abortion. Epidemiology 1991;2(3):168–74.
8. Klebanoff MA, Levine RJ, DerSimonian R, et al. Maternal serum paraxanthine, a caffeine metabolite, and the risk of spontaneous abortion. N Engl J Med 1999;341:1639–44.
9. Fernandes O, Sabharwal M, Smiley T, et al. Moderate to heavy caffeine consumption during pregnancy and relationship to spontaneous abortion and abnormal fetal growth: a meta-analysis. Reprod Toxicol 1998;12:435–44.
10. Caffeine in pregnancy. Rockville, MD: Food and Drug Administration, 1981. (FDA 81–1081.
11. Gold S, Sherry L. Hyperactivity, learning disabilities, and alcohol. J Learn Disabil 1984;17:3–6.
12. Northrup C. Women’s Bodies, Women’s Wisdom. New York: Bantam, 1994, 613.
13. Haglund B, Cnattingius S. Cigarette smoking as a risk factor for sudden infant death syndrome. Am J Public Health 1990;80:29–32.
14. Adapted from McGanity WJ, Dawson EB, Van Hook JW. Maternal nutrition. In: Shils ME, Olson JA, Shike M, Ross AC, eds. Modern Nutrition in Health and Disease, 9th ed. Baltimore: Williams and Wilkins, 1999, 811–38.
15. Institute of Medicine. Nutrition during pregnancy, weight gain and nutrient supplements. Report of the Subcommittee on Nutritional Status and weight Gain during Pregnancy, Subcommittee on Dietary Intake and Nutrient Supplements during Pregnancy, Committee on Nutritional Status during Pregnancy and Lactation, Food and Nutrition Board. Washington, DC: National Academy Press, 1990, 1–233.
16. Caulfield LE, Witter FR, Stoltzfus RJ. Determinants of gestational weight gain outside the recommended ranges among black and white women. Obstet Gynecol 1996;87:760–6.
17. Hickey CA, Cliver SP, Goldenberg RL, et al. Prenatal weight gain, term birth weight, and fetal growth retardation among high-risk multiparous black and white women. Obstet Gynecol 1993;81:529–35.
18. Parker JD, Abrams B. Prenatal weight gain advice: an examination of the recent prenatal weight gain recommendations of the Institute of Medicine. Obstet Gynecol 1992;79:664–9.
19. Johnson JW, Yancey MK. A critique of the new recommendations for weight gain in pregnancy. Am J Obstet Gynecol 1996;174(1 Pt 1):254–8 [review].
20. Abrams B, Parker JD. Maternal weight gain in women with good pregnancy outcome. Obstet Gynecol 1990;76:1–7.
21. Carmichael S, Abrams B, Selvin S. The pattern of maternal weight gain in women with good pregnancy outcomes. Am J Public Health 1997;87:1984–8.
22. Abrams B, Altman SL, Pickett KE. Pregnancy weight gain: still controversial. Am J Clin Nutr 2000;71(5 Suppl):1233S–41S [review].
23. Galtier-Dereure F, Boegner C, Bringer J. Obesity and pregnancy: complications and cost. Am J Clin Nutr 2000;71(5 Suppl):1242S–8S [review].
24. Carmichael SL, Abrams B. A critical review of the relationship between gestational weight gain and preterm delivery. Obstet Gynecol 1997;89:865–73 [review].
25. Abrams B, Altman SL, Pickett KE. Pregnancy weight gain: still controversial. Am J Clin Nutr 2000;71(5 Suppl):1233S–41S [review].
26. Truswell AS. ABC of nutrition. Nutrition for pregnancy. Br Med J 1985;291: 263–6.
27. Scholl TO, Hediger ML, Schall JI, et al. Dietary and serum folate: their influence on the outcome of pregnancy. Am J Clin Nutr 1996;63:520–5.
28. MRC Vitamin Study Research Group. Prevention of neural tube defects: Results of the Medical Research Council Vitamin Study. Lancet 1991;338:131–7.
29. Tamura T, Goldenberg RL, Johnston KE, et al. Serum concentrations of zinc, folate, vitamins A and E, and proteins, and their relationships to pregnancy outcome. Acta Obstet Gynecol Scand Suppl 1997;165:63–70.
30. Tamura T, Goldenberg RL, Freeberg LE, et al. Maternal serum folate and zinc concentrations and their relationships to pregnancy outcome. Am J Clin Nutr 1992;56:365–70.
31. Goldenberg RL, Tamura T, Cliver SP, et al. Serum folate and fetal growth retardation: a matter of compliance? Obstet Gynecol 1992;795 (Pt 1):719–22.
32. Neggers YH, Goldenberg RL, Tamura T, et al. The relationship between maternal dietary intake and infant birthweight. Acta Obstet Gynecol Scand Suppl 1997;165:71–5.
33. Frelut ML, de Courcy GP, Christides JP, et al. Relationship between maternal folate status and foetal hypotrophy in a population with a good socio-economical level. Int J Vitam Nutr Res 1995;65:267–71.
34. Ek J. Plasma and red cell folate in mothers and infants in normal pregnancies. Relation to birth weight. Acta Obstet Gynecol Scand 1982;61:17–20.
35. Malinow MR, Rajkovic A, Duell PB, et al. The relationship between maternal and neonatal umbilical cord plasma homocyst(e)ine suggests a potential role for maternal homocyst(e)ine in fetal metabolism. Am J Obstet Gynecol 1998;178:228–33.
36. Burke G, Robinson K, Refsum H, et al. Intrauterine growth retardation, perinatal death, and maternal homocysteine levels. N Engl J Med 1992;326:69–70 [letter].
37. Iyengar L, Rajalakshmi K. Effect of folic acid supplement on birth weights of infants. Am J Obstet Gynecol 1975;122:332–6.
38. Rolschau J, Date J, Kristoffersen K. Folic acid supplement and intrauterine growth. Acta Obstet Gynecol Scand 1979;58:343–6.
39. Blot I, Papiernik E, Kaltwasser JP, et al. Influence of routine administration of folic acid and iron during pregnancy. Gynecol Obstet Invest 1981;12:294–304.
40. Baumslag N, Edelstein T, Metz J. Reduction of incidence of prematurity by folic acid supplementation in pregnancy. Br Med J 1970;1:16–7.
41. Fleming AF, Martin JD, Hahnel R, Westlake AJ. Effects of iron and folic acid antenatal supplements on maternal haematology and fetal wellbeing. Med J Aust 1974;2:429–36.
42. Fletcher J, Gurr A, Fellingham FR, et al. The value of folic acid supplements in pregnancy. J Obstet Gynaecol Br Commonw 1971;78:781–5.
43. Giles PF, Harcourt AG, Whiteside MG. The effect of prescribing folic acid during pregnancy on birth-weight and duration of pregnancy. A double-blind trial. Med J Aust 1971;2:17–21.
44. Sutterlin M, Bussen S, Ruppert D, Steck T. Serum levels of folate and cobalamin in women with recurrent spontaneous abortion. Hum Reprod 1997;12:2292–6.
45. Wouters MG, Boers GH, Blom HJ, et al. Hyperhomocysteinemia: a risk factor in women with unexplained recurrent early pregnancy loss. Fertil Steril 1993;60:820–5.
46. Steegers-Theunissen RP, Boers GH, Blom HJ, et al. Hyperhomocysteinaemia and recurrent spontaneous abortion or abruptio placentae. Lancet 1992;339:1122–3 [letter].
47. Quere I, Bellet H, Hoffet M, et al. A woman with five consecutive fetal deaths: case report and retrospective analysis of hyperhomocysteinemia prevalence in 100 consecutive women with recurrent miscarriages. Fertil Steril 1998;69:152–4.
48. Quere I, Mercier E, Bellet H, et al. Vitamin supplementation and pregnancy outcome in women with recurrent early pregnancy loss and hyperhomocysteinemia. Fertil Steril 2001;75:823–5.
49. Pietrzik K, Prinz R, Reusch K, et al. Folate status and pregnancy outcome. Ann N Y Acad Sci 1992;669:371–3.
50. Neiger R, Wise C, Contag SA, et al. First trimester bleeding and pregnancy outcome in gravidas with normal and low folate levels. Am J Perinatol 1993;10:460–2.
51. Neela J, Raman L. The relationship between maternal nutritional status and spontaneous abortion. Natl Med J India 1997;10:15–6.
52. Botto LD, Mulinare J, Erickson JD. Occurrence of congenital heart defects in relation to maternal mulitivitamin use. Am J Epidemiol 2000;151:878–84.
53. Czeizel AE. Reduction of urinary tract and cardiovascular defects by periconceptional multivitamin supplementation. Am J Med Genet 1996;62:179–83.
54. Tamura T, Goldenberg R, Freeberg L, et al. Maternal serum folate and zinc concentrations and their relationships to pregnancy outcome. Am J Clin Nutr 1992:56;365–70.
55. Mock DM, Quirk JG, Mock NI. Marginal biotin deficiency during normal pregnancy. Am J Clin Nutr 2002;75:295–9.
56. Velie EM, Block G, Shaw GM, et al. Maternal supplemental and dietary zinc intake and the occurrence of neural tube defects in California. Am J Epidemiol 1999;150:605–16.
57. Allen LH. Anemia and iron deficiency: effects on pregnancy outcome. Am J Clin Nutr 2000;71(5 Suppl):1280S–4S [review].
58. Yu SM, Keppel KG, Singh GK, Kessel W. Preconceptional and prenatal multivitamin-mineral supplement use in the 1988 National Maternal and Infant Health Survey. Am J Public Health 1996;86:240–2.
59. Romslo I, Haram K, Sagen N, Augensen K. Iron requirement in normal pregnancy as assessed by serum ferritin, serum transferrin saturation and erythrocyte protoporphyrin determinations. Br J Obstet Gynaecol 1983;90:101–7.
60. Hemminki E, Uski A, Koponen P, Rimpela U. Iron supplementation during pregnancy—experiences of a randomized trial relying on health service personnel. Control Clin Trials 1989;10:290–8.
61. al-Momen AK, al-Meshari A, al-Nuaim L, et al. Intravenous iron sucrose complex in the treatment of iron deficiency anemia during pregnancy. Eur J Obstet Gynecol Reprod Biol 1996;69:121–4.
62. Bloxam DL, Williams NR, Waskett RJD, et al. Maternal zinc during oral iron supplementation in pregnancy: a preliminary study. Clin Sci 1989;76:59–65.
63. Mukherjee MD, Sandstead HH, Ratnaparkhi MV, et al. Maternal zinc, iron, folic acid, and protein nutriture and outcome of human pregnancy. Am J Clin Nutr 1984;40:496–507.
64. Nelson MM, Forfar JO. Associations between drugs administered during pregnancy and congenital abnormalities of the fetus. Br Med J 1971;1:523–7.
65. Olsen SF, Secher NJ, Tabor A, et al. Randomised clinical trials of fish oil supplementation in high risk pregnancies. Fish Oil Trials In Pregnancy (FOTIP) Team. Brit J Obstet Gynecol 2000;107:382–95.
66. Steuerwald U, Weihe P, Jorgensen PJ, et al. Maternal seafood diet, methylmercury exposure, and neonatal neurologic function. J Pediatr 2000;136:599–605.
67. Frezza M, Centini G, Cammareri G, et al. S-adenosylmethionine for the treatment of intrahepatic cholestasis of pregnancy. Results of a controlled clinical trial. Hepatogastroenterology 1990;37 Suppl 2:122–5.
68. Frezza M, Surrenti C, Manzillo G, et al. Oral S-adenosylmethionine in the symptomatic treatment of intrahepatic cholestasis. A double-blind, placebo-controlled study. Gastroenterology 1990;99:211–5.
69. Truswell AS. ABC of nutrition. Nutrition for pregnancy. Br Med J 1985;291:263–6.
70. Villar J, Repke JT. Calcium supplementation during pregnancy may reduce preterm delivery in high-risk populations. Am J Obstet Gynecol 1990;163:1124–31.
71. Ritchie LD, King JC. Dietary calcium and pregnancy-induced hypertension: is there a relation? Am J Clin Nutr 2000;71(5 Suppl):1371S–4S [review].
72. Villar J, Belizan JM. Same nutrient, different hypotheses: disparities in trials of calcium supplementation during pregnancy. Am J Clin Nutr 2000;71(5 Suppl):1375S–9S [review].
73. Koo WWK, Walters JC, Esterlitz J, et al. Maternal calcium supplementation and fetal bone mineralization. Obstet Gynecol 1999;94:577–82.
74. Gladstar R. Herbal Healing for Women. New York: Simon and Schuster, 1993, 176.
75. Gladstar R. Herbal Healing for Women. New York: Simon and Schuster, 1993, 177.
76. Gladstar R. Herbal Healing for Women. New York: Simon and Schuster, 1993, 177.
77. Dale A, Cornwell S. The role of lavender oil in relieving perineal discomfort following childbirth: A blind randomized trial. J Adv Nursing 1994;19:89–96.
78. Bingel AS, Farnsworth NR. Higher plants as potential sources of galactagogues. Econ Med Plant Res 1994;6:1–54 [review].
79. Mohr H. [Clinical investigations of means to increase lactation.] Dtsch Med Wschr 1954;79:1513–6 [in German].
80. Weiss RF. Herbal Medicine. Gothenburg, Sweden: Ab Arcanum and Beaconsfield, UK: Beaconsfield Publishers Ltd., 1988, 318.
81. Weiss RF. Herbal Medicine. Gothenburg, Sweden: Ab Arcanum and Beaconsfield, UK: Beaconsfield Publishers Ltd., 1988, 229–30.
82. Wedenberg K, Moen B, Norling A. A prospective randomized study comparing acupuncture with physiotherapy for low-back and pelvic pain in pregnancy. Acta Obstet Gynecol Scand 2000;79:331–5.
83. Carlsson CPO, Axemo P, Bodin A, et al. Manual acupuncture reduces hyperemesis gravidarum: a placebo-controlled, randomized, single-blind, crossover study. J Pain Symptom Manage 2000;20:273–9.
84. Stainton MC, Neff EJ. The efficacy of SeaBands for the control of nausea and vomiting in pregnancy. Health Care Women Int 1994;15:563–75.
85. Belluomini J, Litt RC, Lee KA, Katz M. Acupressure for nausea and vomiting of pregnancy: a randomized, blinded study. Obstet Gynecol 1994;84:245–8.
86. Hyde E. Acupressure therapy for morning sickness. A controlled clinical trial. J Nurse Midwifery 1989;34:171–8.

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Breast-Feeding Support

Breastfeeding is the feeding of an infant or young child with breast milk directly from a woman's breasts, not from a baby bottle or other container. Babies have a sucking reflex that enables them to suck and swallow milk. It is possible for most mothers to nourish their infant (or infants in the case of twins and multiple births) by breastfeeding for the first six months, if not longer, without the supplement of infant formula milk or solid food.
According to a 2001 World Health Organization (WHO) report,[1] alternatives to breastfeeding include:

• expressed breast milk from an infant’s own mother
• breast milk from a healthy wet-nurse or a human-milk bank
• a breast-milk substitute fed with a cup, which is a safer method than a feeding bottle and teat.

In most situations human breast milk is the best source of nourishment for human infants,[2] preventing disease, promoting health and reducing health care costs[3] (exceptions include situations where the mother is taking certain drugs or is infected with tuberculosis or HIV). Experts disagree about how long to breastfeed to gain the greatest benefit, and about the risks of using artificial formulas.[4][5][6] In both developing and developed countries, artificial feeding is associated with more deaths from diarrhoea in infants.[7]
The WHO recommends a minimum of two years of breastfeeding and exclusive breastfeeding for the first six months of life. The American Academy of Pediatrics (AAP) recommends at least one year of breastfeeding and exclusive breastfeeding for the first six months of life. Exclusive breastfeeding for the first six months of life "provides continuing protection against diarrhea and respiratory tract infection" that is more common in babies fed formula. [8] The WHO[9] and AAP[10] both stress the value of breastfeeding for mothers and children. While recognizing the superiority of breastfeeding, regulating authorities work to make artificial feeding safer when it is not used.[5]
Breast milk
Not all the properties of breast milk are understood, but its nutrient content is relatively stable. Breast milk is made from the nutrients in the mother's bloodstream and bodily stores. Some studies estimate that a woman who breastfeeds her infant exclusively uses 400 - 600 extra calories a day in producing milk.[11] The composition of breast milk depends on how long the baby nurses.
"Research shows that the milk and energy content of breastmilk actually decreases after the first year.[9] Breastmilk adapts to a toddler's developing system, providing exactly the right amount of nutrition at exactly the right time.[10] In fact, research shows that between the ages of 12 and 24 months, 448 milliliters of a mother's milk provide these percentages of the following minimum daily requirements:
Energy 29% Folate 76% Protein 43% Vitamin B12 94% Calcium 36% Vitamin C 60%10 Vitamin A 75%.[3]
Benefits for the infant
During breastfeeding nutrients and antibodies pass to the baby[12] and the maternal bond can also be strengthened.[13] Research has demonstrated a variety of benefits to breastfeeding an infant. [14] These include:

Superior nutrition

Breast milk contains the ideal ratio of the amino acids cystine, methionine, and taurine to support development of the central and peripheral nervous system. Children aged seven and eight years old who were of low birthweight who were breastfed for more than eight months demonstrated significantly higher intelligence quotient scores than comparable children breastfed for less time, suggesting breastfeeding offers long-term cognitive benefits in some populations.[15]
The quality of a mother's breast milk may be compromised by stress, bad food habits, chronic illnesses, smoking, and drinking.[16]

Less Diarrhea

Breastfeeding protects infants against diarrhea as compared to formula-fed peers;[17] compared to formula-fed peers, death rates due to diarrhea in breastfed infants are lower irrespective of the development level of the country.[7]

Greater immune health

Breast milk include several anti-infective factors such as bile salt stimulated lipase (protecting against amoebic infections), lactoferrin (which binds to iron and inhibits the growth of intestinal bacteria)[18][19] and immunoglobulin A protecting against microorganisms.[20]
Despite also being a factor in the transmission of HIV from mother to child, some constituents in Breast milk may be protective of infection. In particular, high levels of certain polyunsaturated fatty acids in breastmilk (including eicosadienoic, arachidonic and gamma-Linolenic acids) are associated with a reduced risk of child infection when nursed by HIV-positive mothers. Arachidonic acid and gamma-linolenic acid may also reduce viral shedding of the HIV virus in Breast milk.[21]
Breastfeeding does not appear to offer protection against allergies.[22]

Higher Intelligence

Babies with a specific variant of the FADS2 gene (approximately 90% of all babies) demonstrate an IQ an average of 7 points higher if breastfed.[23]

Less Diabetes mellitus

Infants exclusively breastfed have less chance of developing diabetes mellitus type 1 than peers with a shorter duration of breastfeeding and an earlier exposure to cow milk and solid foods.[24] Breastfeeding also appears to protect against diabetes mellitus type 2,[25][26] at least in part due to its effects on the child's weight.[26]

Less obesity

Breastfeeding appears to reduce the risk of extreme obesity in children aged 39 to 42 months.[27] The protective effect of breastfeeding against obesity is consistent, though small, across many studies, and appears to increase with the duration of breastfeeding.[28]

Fewer urinary tract infections

Breastfeeding reduced the risk of acquiring urinary tract infections in infants up to seven months post-partum. The protection was strongest immediately after birth, and was ineffective past seven months[29]

Fewer respiratory infections

Breastfeeding appears to reduce symptoms of upper respiratory tract infections in premature infants up to seven months after release from hospital.[30]

Fewer middle ear infections

Increased duration of certain types of middle ear infections (otitis media with effusion, OME) in the first two years of life is associated with a shorter period of breastfeeding, in addition to feeding while lying down and maternal cigarette smoking.[31] A reduced proportion and duration of any otitis media infection was associated with breastfeeding rather than formula feeding for the first twelve months of life.[17]

Less Celiac disease

A review of the association between breastfeeding and celiac disease (CD) concluded that breast feeding while introducing gluten to the diet reduced the risk of CD. The study was unable to determine if breastfeeding merely delayed symptoms or offerred life-long protection.[32]

Less Atopy

In children who are at risk for atopy (defined as at least one parent or sibling having atopy), atopic syndrome can be prevented or delayed through exclusive breastfeeding for four months, though these benefits may not be present after four months of age. [33] However, the key factor may be the age at which non-breastmilk is introduced rather than duration of breastfeeding.[34] Atopic dermatitis, the most common form of eczema, can be reduced through exclusive breastfeeding beyond 12 weeks in individuals with a family history of atopy, but when breastfeeding beyond 12 weeks is combined with other foods incidents of eczema rise irrespective of family history.[35]

Less necrotizing enterocolitis

Necrotizing enterocolitis (NC), found mainly in premature births, is six to ten times more common in infants fed formula exclusively, and three times more common in infants fed a mixture of breast milk and formula, as compared to exclusive breastfeeding. In infants born at more than 30 weeks, NC was twenty times more common in infants fed exclusively on formula.[36]

Reduced risk of Breast Cancer

A study at the University of Wisconsin found that women who were breast fed in infancy may have a lower risk of developing breast cancer than those who were not breast fed. [37]

Possible protection from sudden infant death syndrome

Breastfed babies have improved arousal from sleep, which may reduce the risk of sudden infant death syndrome.[38]

Benefits for mothers

Breastfeeding is a cost effective way of feeding an infant, and provides the best nourishment for a child at a small nutrient cost to the mother. Frequent and exclusive breastfeeding can delay the return of fertility through lactational amenorrhea, though breastfeeding is at best an imperfect means of birth control. During breastfeeding beneficial hormones are released into the mother's body.[12] and the maternal bond can be strengthened.[13] Breastfeeding is possible throughout pregnancy, but generally milk production will be reduced at some point.[39]

Cancer

Breastfeeding mothers have less risk of endometrial,[40][41] breast and ovarian cancer,[10][13] and osteoporosis.[10][13]

Other health benefits

Mothers who breastfeed longer than eight months also benefit from bone re-mineralisation[42] and breastfeeding diabetic mothers require less insulin.[43] Breastfeeding helps stabilize maternal endometriosis,[10] reduces the risk of post-partum bleeding[44] and benefits the insulin levels for mothers with polycystic ovary syndrome.[45]
Some breastfeeding women have pain from candidiasisor staphylococcus infections of the nipple[46] though these can be managed with medical attention with little concern for mother and child.

Arthritis

Women who breast feed for longer have a smaller chance of getting rheumatoid arthritis, suggests a Malmo University study published online ahead of print in the Annals of the Rheumatic Diseases (See Women Who Breast Feed for More than a Year Halve Their Risk of Rheumatoid Arthritis). The study also found that taking oral contraceptives, which are suspected to protect against the disease because they contain hormones that are raised in pregnancy, did not have the same effect. Simply having children but not breast feeding also did not seem to be protective.

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Bonding

The hormones released during breastfeeding strengthen the maternal bond. Teaching partners how to manage common difficulties is associated with higher breastfeeding rates.[47] Support for a mother while breastfeeding can assist in familial bonds and help build a paternal bond between father and child.[48]
If the mother is away, an alternative caregiver may be able to feed the baby with expressed breast milk. The various breast pumps available for sale and rent help working mothers to feed their babies breast milk for as long as they want. To be successful, the mother must produce and store enough milk to feed the child for the time she is away, and the feeding caregiver must be comfortable in handling breast milk.

Hormone release

Breastfeeding releases the hormones oxytocin and prolactin which relax the mother and make her feel more nurturing toward her baby.[49] Breastfeeding soon after giving birth increases the mother's oxytocin levels, making her uterus contract more quickly and reducing bleeding. Oxytocin is similar to pitocin, a synthetic hormone used to make the uterus contract.[44]

Weight loss

As fat accumulated during pregnancy is used to produce milk, extended breastfeeding—at least 6 months—can help mothers lose weight.[50] However, weight loss is highly variable among lactating women, and diet and exercise is a more reliable way of losing weight.[51]

Organisational endorsements

World Health Organization

The WHO recommends two years of breastfeeding and exclusive breastfeeding for the first six months of life.
“[the] vast majority of mothers can and should breastfeed, just as vast majority of infants can and should be breastfed. Only under exceptional circumstances can a mother's milk be considered as unsuitable for her infant. For those few health situations where infants cannot, or should not, be breastfed, the choice of the best alternative - expressed milk from the infant's own mother, breast milk from a healthy wet-nurse or a human-milk bank, or a breast milk substitute fed with a cup, which is a safer method than a feeding bottle or a teat - depends on individual circumstances. [52]”

American Academy of Pediatrics

AAP recommends at least one year of breastfeeding and exclusive breastfeeding for the first six months of life.
“Extensive research, especially in recent years, documents diverse and compelling advantages to infants, mothers, families, and society from breastfeeding and the use of human milk for infant feeding. These include health, nutritional, immunologic, developmental, psychological, social, economic, and environmental benefits.[10]”

Breastfeeding difficulties

Despite being a natural human activity, breastfeeding difficulties are not uncommon. Putting the baby to the breast as soon as possible after birth helps to avoid many problems. The AAP breastfeeding policy says: Delay weighing, measuring, bathing, needle-sticks, and eye prophylaxis until after the first feeding is completed.[10] Many breastfeeding difficulties can be resolved with proper hospital procedures, properly trained midwives, doctors and hospital staff, and lactation consultants.[53] There are some situations in which breastfeeding may be harmful to the infant, including infection with tuberculosis or HIV, some medications and some drugs.

Infant weight gain

Breastfed infants generally gain weight according to the following guidelines:
0–4 months: 170 grams per week†
4–6 months: 113–142 grams per week
6–12 months: 57–113 grams per week
† It is acceptable for some babies to gain 113–142 grams (4–5 ounces) per week. This average is taken from the lowest weight, not the birth weight.
The average breastfed baby doubles birth weight in 5–6 months. By one year, the typical breastfed baby will weigh about 2½ times birth weight. At one year, breastfed babies tend to be leaner than bottle fed babies.[54] By two years, differences in weight gain and growth between breastfed and formula-fed babies are no longer evident.[55];

Methods and considerations

There are many books and videos to advise mothers about breastfeeding. Lactation consultants in hospitals or private practice, and volunteer organisations of breastfeeding mothers such as La Leche League also provide advice and support.

Early breastfeeding

In the half hour after birth, the baby's suckling reflex is strongest, and the baby is more alert, so it is the ideal time to start breastfeeding. [56]. Early breast-feeding is associated with fewer nighttime feeding problems [57]

Time and place for breastfeeding

Breastfeeding at least once every two to three hours helps to maintain milk production. For most women, eight breastfeeding or pumping sessions every 24 hours keeps their milk production high.[10] Newborn babies may feed more often than this: 10 to 12 breastfeeding sessions every 24 hours is common, and some may even feed 18 times a day.[58] Feeding a baby on demand (sometimes referred to as "on cue"), may mean breastfeeding much more than the recommended minimum. Feeding when the baby shows early signs of hunger, is the best way to maintain milk production and ensure the baby's needs for milk and comfort are being met.[9] However, it may be important to recognize whether a baby is truly hungry, as breastfeeding too frequently may mean the child receives a disproportionately high amount of foremilk, and not enough hindmilk, potentially creating problems.[59].
"Experienced breastfeeding mothers learn that the sucking patterns and needs of babies vary. While some infants' sucking needs are met primarily during feedings, other babies may need additional sucking at the breast soon after a feeding even though they are not really hungry. Babies may also nurse when they are lonely, frightened or in pain.
"Comforting and meeting sucking needs at the breast is nature's original design. Pacifiers (dummies, soothers) are literally a substitute for the mother when she can't be available. Other reasons to pacify a baby primarily at the breast include superior oral-facial development, prolonged lactational amenorrhea, avoidance of nipple confusion and stimulation of an adequate milk supply to ensure higher rates of breastfeeding success.
Babies usually show they are hungry by waking up (newborns), mouthing their fists, moaning or fussing. Crying is a late indicator of hunger. When a baby's cheeks are stroked, the rooting instinct makes it move its face towards the stroking and open its mouth.
Breastfeeding can make mothers thirsty, especially at first, when both mother and baby are inexperienced and when feeding sessions can last for an hour or more (there is no time limit for breastfeeding). Having water readily available helps mothers maintain proper hydration.
Most US states now have breastfeeding laws which allow a mother to breastfeed her baby anywhere she is allowed to be. In hospitals, rooming-in care is used for breastfeeding. There are breastfeeding rooms in some places, including hypermarkets.

Latching on, feeding and positioning

When the nipple strokes the baby's cheek the baby will open its mouth and turn towards the nipple. To help the baby latch on well, tickle the baby's top lip with the nipple, wait until the baby's mouth opens wide, then bring the baby up towards the nipple quickly, so that the baby has a mouthful of nipple and areola. The nipple should be at the back of the baby's throat, with the baby's tongue lying flat in its mouth. Inverted or flat nipples can be massaged so that the baby will have more to latch onto. Resist the temptation to move towards the baby, as this can lead to poor attachment.
Many women wear nursing brassieres for easier access to the breast, but these are not always necessary and certainly not required. In the very early days, wearing a nursing bra can make breastfeeding complicated and uncomfortable. Wearing a bra at any time after birth will not affect how the breast changes with pregnancy and breastfeeding. Many women find that the size of their breasts change dramatically and so fitting a bra is better done after childbirth rather than before. An ill-fitting bra, whether designed for nursing or otherwise, can cause plugged ducts or mastitis.
Pain in the nipple or breast is linked to incorrect breastfeeding techniques. Failure to latch on is one of the main reasons for ineffective feeding and can lead to infant health concerns. A 2006 study found that inadequate parental education, incorrect breastfeeding techniques, or both were associated with higher rates of preventable hospital admissions in newborns.[60]
The baby may pull away from the nipple after a few minutes or after a much longer period of time. Normal feeds at the breast can last a few sucks (newborns), from 10 to 20 minutes or even longer (on demand). Sometimes, after the finishing of a breast, the mother may offer the other breast.
The length of feeds varies a lot. Regardless of the time taken, the breastfeeding mother should be comfortable.

• Upright: The sitting position with the back straight and leaning back comfortably.
• Mobile: The mother carries her nursling in a sling or other baby carrier while breastfeeding. Doing so permits the mother to incorporate breastfeeding into the varied work of daily life
• Lying down: Good for night feeds or for those who have had a caesarean section

• On her back: Mother is usually sitting slightly upright; particularly useful for tandem breastfeeding (nursing more than one child)
• On her side: The mother and baby lie on their sides

• Hands and knees: The mother is on all fours with the baby underneath her (not usually recommended)

While most women breastfeed their child in the cradling position, there are many ways to hold the feeding baby. It depends on the mother and child's comfort and the feeding preference of the baby. Some babies prefer one breast to the other, but the mother should offer both breasts at every nursing with her newborn.

• Cradling positions:

• Cradle hold: The baby is held with its head in the woman's elbow horizontally across the abdomen, "tummy to tummy", with the woman in an upright and supported position image
• Cross-cradle hold: As above but the baby is held with its head in the woman's hand

• Football hold: The woman is upright and the baby is held securely under the mother's arm with the head cradled in her hands. This position is especially useful for feeding twins simultaneously image
• Feeding up hill: The baby lies stomach to stomach with the mother who is lying on her back; this is helpful for babies finding it difficult to feed
• Lying down:

• On its side: The mother and baby lie on their sides
• On its back: The baby is lying on its back (cushioned by something soft) with the mother on her hands and knees above the child (not usually recommended)

When tandem breastfeeding, the mother is unable to move the baby from one breast to another and comfort can be more of an issue. As tandem breastfeeding brings extra strain to the arms, especially as the babies grow, many mothers of twins recommend the use of more supporting pillows. Favored positions include:

• Double cradle hold
• Double clutch hold
• One clutched baby and one cradled baby
• Lying down

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Exclusive breastfeeding

Exclusive breastfeeding is when an infant receives no other food or drink besides breast milk.[9] National and international guidelines recommend that all infants be breastfed exclusively for the first six months of life. It is generally accepted that newborns should be exclusively breastfed for around 6 months. Breastfeeding may continue with the addition of appropriate foods, for two years or more. Exclusive breastfeeding has dramatically reduced infant deaths in developing countries by reducing diarrhea and infectious diseases.
Exclusively breastfed infants feed anywhere from 6 to 14 times a day. Newborns consume from 30 to 90 ml (1 to 3 US fluid ounces). After the age of four weeks, babies consume about 120ml (4 US fluid ounces) per feed. Each baby is different, but as it grows the amount will increase. It is important to recognize the baby's hunger signs. It is assumed that the baby knows how much milk it needs and it is therefore advised that the baby should dictate the number, frequency, and length of each feed. The supply of milk from the breast is determined by the number and length of these feeds or the amount of milk expressed. The birth weight of the baby may affect its feeding habits, and mothers may be influenced by what they perceive its requirements to be. For example, a baby born small for gestational age may lead a mother to believe that her child needs to feed more than if it larger; they should, however, go by the demands of the baby rather than what they feel is necessary.
While it can be hard to measure how much food a breastfed baby consumes, babies normally feed to meet their own requirements.[61] Babies that fail to eat enough may exhibit symptoms of failure to thrive. If necessary, it is possible to estimate feeding from wet and soiled nappies (diapers): 8 wet cloth or 5–6 wet disposable, and 2–5 soiled per 24 hours suggests an acceptable amount of input for newborns older than 5–6 days old. After 2–3 months, stool frequency is a less accurate measure of adequate input as some normal infants may go up to 10 days between stools. Babies can also be weighed before and after feeds.

Expressing breast milk

When direct breastfeeding is not possible, a mother can express (artificially remove and store) her milk. With manual massage or using a breast pump, a woman can express her milk and keep it in freezer storage bags, a supplemental nursing system, or a bottle ready for use. Breast milk may be kept at room temperature for up to ten hours, refrigerated for up to eight days or frozen for up to four to six months. Research suggests that the antioxidant activity in expressed breast milk decreases over time but it still remains at higher levels than in infant formula.[62]
Expressing breast milk can maintain a mother's milk supply when she and her child are apart. If a sick baby is unable to feed, expressed milk can be fed through a nasogastric tube.
Expressed milk can also be used when a mother is having trouble breastfeeding, such as when a newborn causes grazing and bruising. If an older baby bites the nipple, the mother's reaction - a jump and a cry of pain - is usually enough to discourage the child from biting again. (Another possibility is responding to the bite by drawing the baby so close that his nose is covered and he cannot breathe without releasing.[63]) Babies or toddlers that are truly feeding cannot physically bite the nipple.
"Exclusively Expressing", "Exclusively pumping" and "EPing" are terms for a mother who feeds her baby exclusively on her breastmilk while not physically breastfeeding. This may arise because her baby is unable or unwilling to latch on to the breast. With good pumping habits, particularly in the first 12 weeks when the milk supply is being established, it is possible to produce enough milk to feed the baby for as long as the mother wishes. It is generally advised to delay using a bottle to feed expressed breast milk until the baby is 4-6 weeks old and is good at sucking directly from the breast.[64] Because It takes less effort to suck from a bottle, a baby might lose its desire to suck from the breast. This is called nursing strike or nipple confusion. To avoid this when feeding expressed breast milk (EBM) before 4-6 weeks of age, it is recommended that breast milk be given by other means such as feeding spoons or feeding cups. Also, EBM should be given by someone other than the breastfeeding mother (or wet nurse), so that the baby can learn to associate direct feeding with the mother (or wet nurse) and associate bottle feeding with other people.
Some women donate their expressed breast milk (EBM) to others, either directly or through a milk bank. Though historically the use of wet nurses was common, some women dislike the idea of feeding their own child with another woman's milk; others appreciate being able to give their baby the benefits of breast milk. Feeding expressed breast milk—either from donors or the baby's own mother—is the feeding method of choice for premature babies.[65] The transmission of some viral diseases through breastfeeding can be prevented by expressing breast milk and subjecting it to Holder pasteurisation.[66]

Mixed feeding

Predominant or mixed breastfeeding means feeding breast milk along with infant formula, baby food and even water, depending on the age of the child. Babies feed differently with artificial teats than from a breast. When feeding from the breast, the tongue massages the milk out rather than sucking, and the nipple does not go as far into the mouth; when feeding from a bottle, an infant will suck harder and the milk may come in more rapidly. Therefore, mixing breastfeeding and bottle-feeding (or using a pacifier) before the baby is used to feeding from its mother can induce the infant to prefer the bottle to the breast. Orthodontic teats, which are generally slightly longer, are closer to the nipple. Some mothers supplement feed with a small syringe or flexible cup to reduce the risk of artificial nipple preference.

Tandem breastfeeding

Feeding two children at the same time is called tandem breastfeeding The most common reason for tandem breastfeeding is the birth of twins, although women with closely spaced children can and do continue to nurse the older as well as the younger. As the appetite and feeding habits of each baby may not be the same, this could mean feeding each according to their own individual needs, and can also include breastfeeding them together, one on each breast.
In cases of triplets or more, it is a challenge for a mother to organize feeding around the appetites of all the babies. While breasts can respond to the demand and produce large quantities of milk, it is common for women to use alternatives. However, some mothers have been able to breastfeed triplets successfully [67][68] [69].
Tandem breastfeeding may also occur when a woman has a baby while breastfeeding an older child. During the late stages of pregnancy the milk will change to colostrum, and some older nurslings will continue to feed even with this change, while others may wean due to the change in taste or drop in supply. Feeding a child while being pregnant with another can also be considered a form of tandem feeding for the nursing mother, as she also provides the nutrition for two.[70]

Extended breastfeeding

Breastfeeding past two years is called extended breastfeeding or "sustained breastfeeding" by supporters and those outside the U.S.[71]) Supporters of extended breastfeeding believe that all the benefits of human milk, nutritional, immunological and emotional, continue for as long as a child nurses. Often the older child will nurse infrequently or sporadically as a way of bonding with the mother.[citation needed]

Shared breastfeeding

It used to be common worldwide, and still is in developing nations such as those in Africa, for more than one woman to breastfeed a child. Shared breastfeeding is a risk factor for HIV infection in infants.[72] A woman who is engaged to breastfeed another's baby is known as a wet nurse. Islam has codified the relationship between this woman and the infants she nurses, and also between the infants when they grow up, so that milk siblings are considered as blood siblings and cannot marry. Shared breastfeeding can incur strong negative reactions in the Anglosphere[73]; American feminist activist Jennifer Baumgardner has written about her experiences in New York with this issue[74].

Weaning

Weaning is the process of introducing the infant to other food and reducing the supply of breast milk. The infant is fully weaned once it relies on other food for all its nutrition and it no longer receives any breast milk. Most mammals stop producing the enzyme lactase at the end of weaning, and become lactose intolerant. Many humans have a mutation that allows the production of lactase throughout life and can drink milk - usually cow or goat milk - well beyond the age of weaning.[75]
In the past, bromocriptine was sometimes used to reduce the engorgement experienced by many women during weaning. However, it was discovered that when used for this purpose, this medication posed serious health risks to women, such as stroke, and the U.S. FDA withdrew this indication for the drug in 1994.[76]
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