Irregular Menstrual Cycles/Uterine Bleeding

Q: What causes long or irregular periods?
A: Periods can be longer than average for many reasons, including hormonal imbalances due to irregular or skipped ovulation, medications you are taking, weight changes (both up and down), stress, problems with the cervix and uterine growths like fibroids.

Missed periods must first be addressed by ruling out pregnancy. If you’re not pregnant, then the most likely cause of a skipped period is an ovulation irregularity. You simply skipped a month. Taking birth control pills can also cause such light bleeding that it may seem you skip bleeding all together some months.

Spotting outside of your menstrual cycle should be checked by your doctor. It is usually nothing serious but could indicate a cervical problem that a pap smear would detect, or it could be an infection you are unaware of having.

Any menstrual irregularity — too much blood, too long a flow, too little blood, absent blood, spotting — should be reported to your gynecologist and based upon your history and duration of symptoms, you will be advised accordingly. Just make the call and don’t be afraid.

Fibroids

Q: What are fibroids?
A: Fibroids are benign growths in the uterus that may cause a variety of symptoms. Scientists do not know why fibroids grow, but it has been established that fibroid tissue is identical to the muscle tissue of the rest of the uterus. An unknown factor seems to “turn on” one unique muscle cell and that muscle cell multiplies at a much quicker rate than the other muscle cells of the uterus and forms the fibroid.

Q: Do all fibroids require treatment?
A: Some fibroids require absolutely no treatment while others require surgery. Most patients who end up with surgery are very much aware there is a problem, usually due to heavy or prolonged periods, pain, or difficulty in conceiving. Patients with no symptoms usually are not aware that they even have fibroids. They are often found during a regular checkup.

Q: Who gets fibroids?
A: All women are susceptible to fibroids. They are very common. African-American women have the highest rates when compared to Caucasian and Hispanic women.

Q: What can I do to prevent fibroids?
A: There is nothing you can do to completely avoid getting fibroids. There’s is no way to test for susceptibility.

Q: What are the most effective types of treatment?
A: Treatments range from watchful waiting to surgery. Surgery may involve simply removing the fibroid itself (a procedure called a myomectomy) or removal of the entire uterus (hysterectomy). Less invasive procedures designed to shrink or cut off the blood supply to the fibroid may be used as well. The best treatment will depend on many factors including a woman’s age, whether or not she is experiencing severe symptoms, such as heavy bleeding, and whether she still wants to have children.

Menopause

Q: What is menopause and how do I know when it has occurred?
A: Menopause is the time in a woman’s life when her periods cease and she is no longer able to become pregnant. Menopause is defined as one year without a period. It occurs because the ovaries have stopped producing a monthly cycle. Menopause typically occurs between ages 50-52. Some women go through menopause at younger ages than others. Family history can be helpful in identifying these patients. Unless there has been surgery to remove the ovaries, radiation therapy to the pelvis or serious insult to the pelvis via trauma, the timetable for menopause is set by genetics.

Q: What are the most common symptoms of menopause and the best forms of treatment?
A: Many women experience hot flashes, night sweats, sleeplessness and vaginal dryness, as well as an increasing loss of bone density due to lowered estrogen levels. Hormone Replacement Therapy, HRT, is considered the only viable treatment, but recent studies show it can contribute to your risk of ovarian and breast cancer and possible heart disease. The best way to determine if HRT is right for you is to discuss the therapy with your physician.

Birth Control

Q: What’s the best way to select birth control?
A: Have a long talk with your gynecologist about your options. Be sure to weigh all important factors, including potential health risks, effectiveness, your lifestyle, any health problems you may have and whether you are planning to start a family in the near future.

It is pretty safe to say that all forms of hormonal contraception can have side effects, although most patients do quite well. The barrier methods tend to have minimal side effects. Other methods include birth control pills, as well as newer pills that are designed to make you completely skip your period for a month or several months.

The most important thing to remember is that no form of birth control is 100 percent effective, so follow instructions carefully. There is no side-effect free form of birth control for every woman; even condoms may trigger latex allergies in some women. Diaphragms can cause urinary tract infections. Hormonal forms — pills, Depo-Provera shots, patches, IUDs with progesterone — can cause menstrual irregularities, headache, weight gain and bloating initially and other problems. IUDs may also cause cramping and heavy periods.

If you want to avoid pills or products altogether, the rhythm method is still a viable means of natural birth control. You must be having regular periods and be able to keep track of your cycles for this method to be most effective. This method can be utilized to help prevent pregnancy as well as maximize pregnancy chances, depending upon your situation.

And of course the most effective type of birth control is surgical — tubal ligations or vasectomies are equal in terms of their effectiveness–99 percent. Tubal ligation requires anesthesia and surgery and has more inherent risks as the female fallopian tubes lie within the pelvic cavity. The male vas deferens lie on the outside of the body, therefore less invasion is required to surgically cut them. Tubal ligation carries more health risks than a vasectomy.

AVOIDING COMMON HEALTH RISKS

Breast Exams

Q: How important is a monthly breast exam?
A: Your monthly breast exam is an important part of your breast cancer early-detection program. You should perform the test once a month, about two weeks after your period. If you no longer have a period, pick a day of the month that you will remember and mark it on your calendar. The tub or shower is the ideal place to perform your breast exam as you are already nude and the slippery texture of suds makes it easier for you to feel any irregularity of the breast. It acts as a lubricant to help your fingers glide over the tissue easily and smoothly. The recommendation is that women start doing monthly breast exams at 18 years of age. The only concern you should have about your self-breast exam is if you forget to do it every month. If you feel anything that seems unusual, or feel something new, you should call your doctor. They will make a recommendation about what you should do. You may be told to watch the area for one menstrual cycle and repeat the exam at that time, or you may need to come in to the office to be checked. Either way, isn’t it better to be safe than sorry?! Doctors do not consider these types of phone calls to be a bother.

Q: What about mammograms?
A: The latest recommendations for mammography are: one every one to two years starting at age 40, and every year starting at age 50. Of course, you should start earlier or have an exam more often if you have a higher than average risk of breast cancer that may be indicated by a family history of the disease.

There is no diet or lifestyle that uniquely maintains the health of the breasts but things that promote general health do have a positive impact upon breast health. Don’t smoke, exercise, keep your weight down, drink alcohol only in moderation, stick with a low-fat diet, and take a multivitamin.

Q: How important are pelvic exams and Pap smears?
A: Pelvic exams are recommended for all girls and women on an annual basis. They should be started no later than three years after the initiation of sexual intercourse and no later than 21 years of age. Pelvic exams screen for cervical problems (the Pap smear), uterine problems, ovarian problems, vaginal problems, outer genital problems, infections, etc.

Q: How will I know if I’ve contracted a Sexually Transmitted Disease, or STD?
A: When it comes to STDs, the best defense is a good offense, so always practice safe sex (use a condom) to protect yourself from HIV/AIDS and other risks. Most STDs are accompanied with symptoms such as vaginal discharge, growths or bumps on the external genitalia, burning with urination, sores or ulcers of the genitalia, fever, or pelvic pain. However, some STDs cause no early symptoms at all (such as HIV/AIDS). If for any reason you think you have been exposed or are at risk, talk to your physician and get tested.

One particular dangerous STD to watch for is the Human Papilloma Virus, or HPV. We now know that HPV not only causes genital warts, it causes most forms of cervical cancer. There is now a vaccine for HPV (currently only in use in young women) so ask your doctor if you or your daughter are good candidates for the vaccine. The vaccine not only prevents genital warts but 80 percent of all cervical cancers. HPV can be detected by pelvic exam if genital warts are seen or during a pelvic exam. It’s very common, more than 90 percent of the population is affected.

By Dr. Tammy McCarus

We’ve had such a great response to our general GYN FAQ’s that we’ve made “Ask Dr. Tammy” a regular feature. In this issue of Ask Dr. Tammy, we cover how to do self-breast examinations to the latest vaccines that are available for women’s health.

1. What are the early warning signs of breast cancer?
Early signs of breast cancer include small lumps or bumps that you feel when examining your breasts. Also, nipple discharge, especially if it is bloody, can be another early warning sign. All that being said, typically early breast cancer is picked up by a mammogram, when there are no signs of a problem evident to you, the patient. Examine your breasts at the same time of month every month, and just after your menstruation. Make sure you get your mammogram at the appropriate time.

2.What are the early warning signs of the various forms of pelvic cancer?
The most common forms of pelvic cancer include cervix, ovarian and uterine cancer. There are very few warning signs for these cancers, but any abnormal vaginal bleeding should be addressed by your gynecologist. Sometimes this can be the only warning sign of either cervical or uterine cancer. Ovarian cancer is the most worrisome of these malignancies, and unfortunately, it rarely gives any warning signs. Thorough annual pelvic exams are the best way to detect abnormalities, especially at an early stage.

3. What criteria should a woman use in selecting an OB/GYN?
When choosing an OB/GYN, take your age into consideration. Are you still of childbearing years or are you beyond that? Are you perimenopausal or menopausal? Many OB/GYNs have dropped obstetrics as a part of their practice. Calling the physician’s office and asking some pointed questions may help you narrow the field. Ask how much time is allotted to a new patient appointment. Also, ask if the physician will be taking your history and performing your examination, or is that passed on to an associate or other type of allied health practitioner?

Your lifestyle may also play a role in choosing a GYN. Finding a doctor with office hours that can accommodate your work and family schedule is important. Lastly, don’t forget about insurance. You will want a doctor within your plan, so you can make the most of your coverage. If you are not satisfied with the choice of physicians on your plan, you may want to call your insurance provider and ask about options for going “out of plan.”

Remember your OB/GYN may be the only physician you see on a routine basis. You will be confiding in this individual all aspects of your personal life, and so being comfortable with him or her is important.

4. What are some accurate, current research tools that a woman can use to find out information on her body?
The best available research information is found on the Internet, where most of the major medical publications post their findings. Most subjects can be easily searched by typing in the subject matter or medical problem. For patient resources or surgical information try www.mayoclinic.org or www.ethiconendo.com.

5. When a woman decides upon elective surgery such as breast augmentation, what advice would you give?
Any and all surgeries must be discussed thoroughly and completely with the surgeon who will perform the operation. All questions about the procedure and the recovery should be answered. Weigh all the risks and benefits. Never be afraid to seek another opinion if you are unsure. Remember all surgery involves risk, and although very rare, serious complications, even death, can occur with the simplest of operations.

6. When major surgery is needed, how do you ask your doctor about the latest technologies and their abilities regarding these new technologies?
If you are told you need a procedure, for example a hysterectomy, you should ask your physician about the various methods available to perform that operation. You should ask your doctor what method he or she would prefer for you and why. If you feel you need more information, go to the Internet and type in hysterectomy options.” You will be given a list of the methods currently available.You can then share that information with your doctor.

Most surgeons are accustomed to having patients ask them “How many of these have you done?” or “What have your results been?” This is no time to be shy, so speak up and ask the important questions.

7. Are men as susceptible to human papillomavirus, or HPV, as women?
Yes. The only difference is since men do not have a cervix, HPV cannot cause cervical cancer. They may only develop genital warts.

8. In the event that a woman has not gone for a GYN checkup in years, what should motivate her to get it done?
How will we be able to take care of our loved ones, how will we be able to enjoy doing the activities that bring us joy, how will we be able to enjoy seeing our children grow and succeed in life if we are ill, or worse? Could we ever forgive ourselves if an illness proved to be very serious, even life threatening, knowing that early detection and treatment could have cured us, maybe even with only minor inconvenience to our lifestyles? I think not! Those things should be motivation enough. If we take good care of ourselves, we are then able to continue to provide good care for others.

9. How do you know if a surgery did not go well?
As a patient, you should feel a little bit better each day after surgery until finally you are back to normal, or even better than before. Persistent pain, fever, swelling or bleeding are all signs that something could be wrong. Your surgeon needs to investigate.

10. How does a woman know which medical issues can wait and which need immediate attention?
Unless you went to medical school, don’t hesitate to call your doctor’s office with a question. Queries like this occur every day and are not a bother. This way, you can feel confident in waiting, if that is the advice you are given. Conversely, you may head off more serious problems if you are advised to come in and get checked out.

11. How real is the new vaccine for HPV?
This vaccine is akin to a miracle. If administered before a female becomes sexually active, it will prevent most cases of genital warts and the majority of all cancers of the cervix. Never before have we had a vaccine available that can stop a form of cancer or completely prevent it.

12. Are there any other cutting-edge GYN vaccines, treatments or procedures that women should be aware of?
There are countless new forms of birth control (pills, intrauterine devices, new methods of tubal ligation). There are wonderful new procedures for urinary incontinence, most of which are performed as an outpatient. New forms of hormone replacement therapy also are available.

13. Does obesity have any bearing on the outcome of my surgery?
Obesity absolutely plays a role in the outcome of any surgery.Obese patients suffer far more complications and adverse events than patients who are not overweight. Additionally, they present strategic difficulties to their surgeons simply due to their larger size. Postoperative complications can include blood clots, stroke, heart attack, pulmonary embolus, difficulty breathing, infection and poor healing of wounds.

Getting into better shape prior to any operation is highly advised, but not through starvation or crash diets. Your nutritional status should be optimized prior to surgery in order to give you the best chance at a desirable outcome.

Dr. Tammy McCarus is an obstetrician and gynecologist in private practice in Orlando, Fla. She is also the president of the Florida OB/GYN Society and the Medical Director for The Healing Continuum.com.

It’s amazing how time can pass so quickly when you distract yourself. I’m a 43-year-old professor of psychology. My job is to train the counselors and therapists who guide and support people through challenges we experience in various stages of our life. The irony of my story is, I almost died because I wasn’t able to pull myself out of a downward spiral of events that I essentially caused myself.

A Series of Bad Events
They say once you have your health, you have everything. Here’s how I almost lost it all.

The first mistake I made is a common one among women who enter college. I was off my parents’ health insurance and didn’t have coverage of my own, nor enough money to pay for my own health care. I allowed 15 years to go by between GYN visits. It wasn’t until I started to develop heavy bleeding during my menstrual cycle, and at the insistence of my mother, that I went to see a doctor.

Much to my surprise, the doctor asked if I was pregnant. Since this was not the case, she told me something was wrong and I needed to see a gynecologist right away. I ended up seeing a nurse practitioner who truly was as cold as ice. She bluntly said, “You need to get a hysterectomy now.” There was no warmth, sympathy or love in her voice or her demeanor. A woman’s uterus is supposed to be the essence of her nature. Thank God I was spiritually planted or I would have lost it. The amazing thing to me is that another woman, let alone a health-care provider, couldn’t see this.

I later went to the GYN, who did an ultrasound and found that I had several fibroids, many of them calcified. She said that if this was just a matter of heavy bleeding and there was no pain involved, then I could wait. Telling me I could wait – without saying how long I could wait – was akin to telling me I could ignore it. Soon after, my internist and GYN moved out of town. This further pushed me away from the health process.

I eventually saw another GYN. She looked at my ultrasound and started to laugh, saying, “I’ve never seen fibroids this big before.” Once again, another health-care professional with ice water running through their veins. This made me even more self-conscious and hesitant to seek care. I never went back to her again.

Dueling Illnesses
Fast-forward to the middle of this year. I flew to Florida to spend some time with my mother. My dad was out of the country for his annual trip to visit his siblings. My mother never took these trips because she didn’t like to travel. A retired nurse and the love of my life, my mother started to get sick. I wasn’t much better off. I had begun to retain water, so much that I could barely walk. Things finally came to a head one evening when my mother fell out of bed and I couldn’t help her. I had to call the paramedics.

During the time my dad was away, my mother went from not feeling well to not walking well to not remembering how to walk. My dad took her to the doctor to see what was happening. It turns out my mother had cancer, and it had already started to spread. She didn’t know how sick she was. Ironically, I didn’t know how sick I was, either.

When I got back to Chicago, I got a new doctor, an African-American GYN who seemed like a breath of fresh air. He understood the systemic problem of black women hesitating to deal with their fibroids. He took the time to explain why my uterus needed to come out, and I agreed that it was time.

During that visit, I suffered a bad fall and had difficulty getting up. At that point, he noticed my shortness of breath and strongly advised that I see an anesthesiologist to get clearance for the surgery. I also realized I was becoming incontinent. The anesthesiologist sent me to the emergency room. They admitted me for four days after determining on top of everything else, I was experiencing congestive heart failure.

The Drama Continues
During my four-day stay in the hospital, I shed 30 pounds of water. When I was discharged, my shortness of breath was gone and it was a week out from my surgery. My brother, who lives in New York, called and said our mother had taken a turn for the worse and I need to fly out right away. I told him I was under strict orders not to fly or I could die on the plane. At this point, my mom couldn’t talk. I didn’t tell my dad of my condition because he was contending with my mom. I felt so alone and isolated from the two people I looked to all my life for strength!

After the surgery, things went well for a couple of days until I noticed bleeding from my bandages. I went to the emergency room and they said it was normal. Two days later, I went back to the doctor. I was still bleeding. Again, they sent me home, insisting it was normal.

Over the next two days, I couldn’t hold down any liquids, and I noticed a brown balloon-like membrane coming through the staples in my stomach. I went to the doctor’s office and was rushed to the hospital in a taxi. I needed emergency surgery.

It turns out that brown protrusion was my small intestine, and I was about to die. After the surgery, the nurse came in and said, “I knew you would be back.” I asked, “Why do you say that?” She said, “Because I saw the sloppy job they did closing you up after your first surgery.” See more about potential hospital mistakes in Preventing hospital-acquired infections. I wondered why she didn’t say something then. Maybe her working environment didn’t lend itself to her being a patient’s advocate.

The Spiral Ends
After weeks of convalescence, with friends by my side, I was finally given clearance to travel. I flew to see my mom. I was able to hold her hand one last time. She died hours later. What kept me together was that my mom was very spiritual and knew that death was a part of life.

In terms of my experience, I look at it as being my fault because I betrayed my own faith in God. I let fear control my actions. Now, I am healing spiritually, for betraying my God, physically, for betraying my body, and emotionally, for losing the love of my life. I hope this story helps readers and their loved ones in this journey called life.

Dr. Gale Sargeant is a professor of Psychology at the Chicago School of Professional Psychology in Chicago Illinois. Dr. Sargeant is one of our psychologists on staff at The Healing Continuum.com.

Imagine you’re 37 years old, in a great marriage and a wonderful career. Now it seems the stage is set to begin a family. This is not an unusual scenario. Many professional women choose to get established in their careers first, then have children in their late 30s and even 40s. Now, imagine that you are one of these women and your physician tells you that you have breast cancer. Not only do your plan and your life seemingly come to a halt, but you also are forced to make some hard decisions very fast.

Let’s face it, breast cancer is no longer a disease for women in their late 60s and 70s. In my practice, I am seeing large numbers of women diagnosed with breast cancer before they even begin to have children. Some of our discussions sound like, “Have you had children yet? If not we may have to schedule an emergency embryo freezing.” We freeze the embryos because chemotherapy poses a high risk of ovarian failure in younger women. This poses as a double insult to a woman who is ready to start living her life. Now, this woman has to find a surrogate mother to carry her fertilized embryos to term. At the writing of this article, my practice is steeped in television and radio interviews, and local and national conferences to mark Breast Cancer Awareness month. But after October has ended, cancer doesn’t take an 11-month cruise to the Caribbean. Breast health and cancer awareness needs to be an everyday notion.

“Getting Breast Cancer Sucks” is the quote I often use when speaking on cancer awareness. But if you are diagnosed with breast cancer, this is the best time in the history of medicine to have it. With today’s technology, you can quickly get on the right side of treatment. Women can opt for cancer treatments that fit their medical circumstances and lifestyles. We can now examine the specific cancer gene and tailor treatment based on a patient’s gene pool. We no longer have to expose a patient to excessive levels of chemotherapy to eliminate a small cancer. In the past, we’ve known at least 30 percent of women who did not need the massive doses of chemotherapy they received. For eligible candidates, there is also another form of treatment called partial breast irradiation, where a balloon catheter is inserted into a portion of the breast for a period of five to six days, instead of five to six weeks. This is a wonderful time to practice this type of medicine because we are having great outcomes. Breast cancer is not like diseases such as pancreatic cancer, where you throw everything at it and hope and pray for the best.

For prevention, I recommend that you and your family get screened for the BRCA 1 and BRCA 2 genes. This will place you more accurately in a predisposition percentile for breast or ovarian cancer. These issues don’t just affect women. By testing positive for the gene pool for BRCA 2, men are also at increased risk for prostate, pancreatic, colon and breast cancer. More and more, you hear of men being diagnosed with and dying from breast cancer due to ignorance of the risks.

Now that we have the ability to screen for the cancer gene, a patient can make a more informed decision about treatment. Does she want a bi-lateral mastectomy or does she want to treat the cancer and see what happens? A woman can now elect to take tamoxofin, the risk-reduction pill. Having so much information almost ties the patient’s hands, because if you tell someone they have a 100 percent chance of getting breast cancer, it’s a no-brainer. They know what they need to do. But if you tell that same person that they have about a 60 percent to 80 percent chance, it becomes a more difficult decision.

The next layer is preparing them for hair loss, not just on their heads, but also in their eyebrows, eye lashes, etc. In my practice, we counsel the total woman and try to address every scenario and question that could arise. As a side note, if you or someone you love is at risk for any disease, please understand that your overall health is key to the outcomes. I counsel every one of my patients about their total health, which includes how they are faring mentally, as well as other issues they might consider outside the realm of my specialty. I once had a woman and her daughter walk out of my office because I respectfully admonished the mother for smoking and how it would affect her daughter in years to come.

The case of the 37-year-old is the real-life story of a patient I am currently treating. She has a wonderful husband and a sister who has volunteered to be her surrogate mother. This story turned out to be a very happy one.

Kamy Kemp is the Medical Director of Breast Care Center of Florida in Winter Park, FL.

Visit www.floridabreastcare.com for more comprehensive information on Breast Care

You are probably ecstatic about all the exciting (and not-so exciting) changes your body will be going through during the next nine months. But what about your Pilates class? Can you still strength-train three times per week? Will starting an exercise routine now be healthier for you and your baby?
In a number of cases, pregnant moms can continue many of the same activities they did before becoming pregnant, with a few modifications. But contact sports are definitely out of the question. Before engaging in any type of workout routine, be sure to talk to your doctor.
In addition to the wonderful things we already know exercise does for us, taking part in a program during pregnancy can help you limit weight gain, have a shorter, less complicated labor and a quicker recovery. Exercising during your pregnancy may also:

• Help reduce backaches, constipation, bloating, and swelling
• Help prevent or control gestational diabetes
• Increase your energy
• Improve your mood (a plus for your family and friends)
• Improve your posture
• Promote muscle tone, strength, and endurance
• Help you sleep better

So, you have made the decision to exercise. Here are the top eight precautions you should take to ensure you will be exercising safely for you and your baby.

• MAINTAIN YOUR PHYSIQUE . Pregnancy is not an ideal time to lose weight or get ready for a 5K. Your focus is to maintain your current fitness level and keep your body healthy to grow a baby. If you are a new exerciser, start gradually with low-impact cardiovascular exercise such as swimming or riding a stationary bike. Aim for 30 minutes of activity on most days of the week.
• HOOKED ON A FEELING . Because of fluid, blood pressure and heart rate changes during pregnancy, moms-to-be won’t be able to exercise at the same rate they did in the past. Gauge your intensity on how you feel. You should be able to work out at a comfortable pace that enables you to talk to the person next to you.
• LOOK THE PART . Workout clothing should be breathable and comfortable. A supportive bra and stable shoes also are a must. If exercising outdoors, avoid peak sun hours. Don’t forget protective clothing and/or sunblock.
• WARM UP AND COOL DOWN . During pregnancy, your body doesn’t produce as much synovial fluid – a type of fluid that cushions and lubricates your joints during movement. So, it is necessary to take a longer time to warm up before exercise and cool down after activity.
• BE AWARE OF THOSE CRAZY HORMONES. Pregnant women produce two hormones called relaxin and elastin that relax the connective tissue, tendons, and ligaments. This increased range of motion in your joints can potentially lead to injury. Be sure to avoid excessive bouncing and jarring of joints, stretching to the point of maximum resistance and deep flexion of the knees.
• DRINK UP . Being well hydrated is even more important when you are pregnant and exercising. Dehydration can have detrimental effects on you and your baby. Be sure to drink water before, during and after exercise. A great way to figure out your hydration status is to look at the color of your urine – pale yellow to clear means you are drinking enough.
• NO LYING DOWN ON THE JOB. After the first trimester, you should avoid any exercises where you are in a supine position (lying down with the face up). Exercises of this type include bench presses and abdominal crunches. This position can potentially block blood flow to your baby.
• KNOW THE NO-NO’S . There are certain signs and symptoms where exercise should be stopped immediately and your physician should be notified. These conditions include:
• Pain of any kind
• Contractions
• Bleeding or other discharge
• Dizziness or faintness
• Shortness of breath
• Heart palpitations or rapid heart rate
• Nausea and vomiting
• Difficulty walking
• Generalized edema
• Decreased fetal activity

Remember to listen to your body! You can also find additional information on the American College of Obstetricians and Gynecologists’ Web site at www.acog.org.
Roseanne Breckels is a clinical fitness coordinator for The National Training Center in Clermont, Florida