Fatigue and Sleep
Every week I talk to someone about fatigue. There are physical and emotional causes: but the most common cause is lack of sleep.
I have struggled with sleep myself. I have a job where I often get up in the middle of the night with phone calls or emergencies and I use to find it difficult to fall back asleep, especially after difficult or stressful situations.
Science shows that sleep is extremely important to emotional and physical well-being. Lack of sleep has a variety of side effects including, anxiety, depression, weight gain, and even cancer.
Science indicates that the following play a role in our sleep.
- Blue Light:
- Avoid computers, phones, and TVs 1 hour before bed.
- Our bodies’ circadian rhythms can get thrown off with bright lights, but just as important is these devices can increase anxiety or even excitement and that can prevent us from falling asleep.
- Exercising:
- 30 minutes of elevated heart rate helps your body rest at night.
- Exercising within 1 hour of bed can make it difficult to fall asleep.
- Meditation:
- if you are like me and have a “Monkey Mind” it is especially useful
- Even 2 minutes has been shown to help
- The more you practice the more it helps. It likely won’t help the first few times you try.
- Noises:
- Many of us don’t want to be without our phones, but even light buzzing/clicking can prevent us from falling into a deep sleep.
- Sleeping Aids:
- Can be habit-forming and make the situation worse
- Melatonin can help in adults, but most studies show it is a placebo in kids.
- Caffeine:
- Duration of action is individualized, but a good rule of thumb is Caffeine takes 6-10 hours to leave our system.
- Alcohol:
- Can prevent you from falling into a deep sleep.
- For sleep purposes, don’t drink within 3 hours of wanting a good night sleep.
Heavy Bleeding
I often have trouble summarizing “heavy bleeding” in a 30 minute appointment. This is going to be a very short summary, about a very complicated topic. Hopefully you find it helpful to start simple and we can build from there.
Often times we do not find specific reasons for heavy/irregular bleeding. We will make sure it is nothing serious (cancer, infection, ect); everything else can be treated as stated below.
Causes:
- Hormone imbalance
- Anovulation (often from hormone imbalance)
- Infection
- Unknown
- Structural problems
- Polyps
- Fibroids
- Thick endometrium
- Hyperplasia
- Endometriosis/Adenomyosis
- Cancer/precancer
Periods can change over a life time, sometimes we find the reason, sometimes we don’t. These things have been shown to cause changes in our mensural cycles: stress, change in what we are eating, weight loss, weight gain, increase in activity, decrease in activity, new sexual activity, new relationships, pregnancy, age.
Treatment:
Once we rule out hormonal problems, infection, and cancer we can start treatment. Treatment is simple.
- Hormones
- Oral birth control
- IUD, Nexplanon
- Patches, Nuvaring
- Shot-Depo-provera
- Antihormones
- Lysteada: helps your uterus clot.
- Lupron: medication that puts you into a fake/temporary menopause.
- Surgery
- Ablation
- Hysterectomy
- Uterine artery ablation (we don’t do this in Tillamook, this is something interventional radiology does not gynecologists)
Vaginal Hysterectomy
This post was made by the Mayo Clinic and it is just general information:
Overview
Female reproductive systemOpen pop-up dialog box
Vaginal hysterectomy is a surgical procedure to remove the uterus through the vagina.
During a vaginal hysterectomy, the surgeon detaches the uterus from the ovaries, fallopian tubes and upper vagina, as well as from the blood vessels and connective tissue that support it, before removing the uterus.
Vaginal hysterectomy involves a shorter time in the hospital, lower cost and faster recovery than an abdominal hysterectomy, which requires an incision in your lower abdomen. However, depending on the size and shape of your uterus or the reason for the surgery, vaginal hysterectomy might not be possible. Your doctor will talk to you about other surgical options, such as an abdominal hysterectomy.
Hysterectomy often includes removal of the cervix as well as the uterus. When the surgeon also removes one or both ovaries and fallopian tubes, it’s called a total hysterectomy with salpingo-oophorectomy (sal-ping-go-o-of-uh-REK-tuh-me). All of these organs are part of your reproductive system and are situated in your pelvis.
Why it’s done
Vaginal hysterectomy treats various gynecological problems, including:
- Fibroids. Many hysterectomies are done to permanently treat these benign tumors in your uterus that can cause persistent bleeding, anemia, pelvic pain, pain during intercourse and bladder pressure. For large fibroids, you might need surgery that removes your uterus through an incision in your lower abdomen (abdominal hysterectomy).
- Endometriosis. This occurs when the tissue lining your uterus (endometrium) grows outside the uterus, involving the ovaries, fallopian tubes or other organs. Most women with endometriosis have a laparoscopic or robotic hysterectomy or abdominal hysterectomy, but sometimes a vaginal hysterectomy is possible.
- Adenomyosis. This occurs when the tissue that normally lines the uterus grows into the uterine wall. An enlarged uterus and painful, heavy periods result.
- Gynecological cancer. If you have cancer of the uterus, cervix, endometrium or ovaries, or precancerous changes, your doctor might recommend a hysterectomy. Most often, treatment for ovarian cancer involves an abdominal hysterectomy, but sometimes vaginal hysterectomy is appropriate for women with cervical or endometrial cancer.
- Uterine prolapse. When pelvic supporting tissues and ligaments weaken or stretch out, the uterus can sag into the vagina, causing urine leakage, pelvic pressure or difficulty with bowel movements. Removing the uterus and repairing supportive tissues might relieve those symptoms.
- Abnormal uterine bleeding. When medication or a less invasive surgical procedure doesn’t control irregular, heavy or very long periods, hysterectomy may be needed.
- Chronic pelvic pain. If your pain is clearly caused by a uterine condition, hysterectomy might help, but only as a last resort. Chronic pelvic pain can have several causes, so an accurate diagnosis of the cause is critical before having a hysterectomy.
For most of these conditions — with the possible exception of cancer — hysterectomy is just one of several treatment options. You might not need to consider hysterectomy if medications or less invasive gynecological procedures manage your symptoms.
You cannot become pregnant after a hysterectomy. If you’re not sure that you’re ready to give up your fertility, explore other treatments.
Risks
Although vaginal hysterectomy is generally safe, any surgery has risks. Risks of vaginal hysterectomy include:
- Heavy bleeding
- Blood clots in the legs or lungs
- Infection
- Damage to surrounding organs
- Adverse reaction to anesthetic
Severe endometriosis or scar tissue (pelvic adhesions) might force your surgeon to switch from vaginal hysterectomy to laparoscopic or abdominal hysterectomy during the surgery.
How you prepare
As with any surgery, it’s normal to feel nervous about having a hysterectomy. Here’s what you can do to prepare:
- Gather information. Before the surgery, get all the information you need to feel confident about it. Ask your doctor and surgeon questions.
- Follow your doctor’s instructions about medication. Find out whether you should take your usual medications in the days before your hysterectomy. Be sure to tell your doctor about over-the-counter medications, dietary supplements or herbal preparations that you take.
- Discuss anesthesia. You might prefer general anesthesia, which makes you unconscious during surgery, but regional anesthesia — also called spinal block or epidural block — might be an option. During a vaginal hysterectomy, regional anesthesia will block the feelings in the lower half of your body. With general anesthesia, you’ll be asleep.
- Arrange for help. Although you’re likely to recover sooner after a vaginal hysterectomy than after an abdominal one, it still takes time. Ask someone to help you out at home for the first week or so.
What you can expect
Talk with your doctor about what to expect during and after a vaginal hysterectomy, including physical and emotional effects.
During the procedure
You’ll lie on your back, in a position similar to the one you’re in for a Pap test. You might have a urinary catheter inserted to empty your bladder. A member of your surgical team will clean the surgical area with a sterile solution before surgery.
To perform the hysterectomy:
- Your surgeon makes an incision inside your vagina to get to the uterus
- Using long instruments, your surgeon clamps the uterine blood vessels and separates your uterus from the connective tissue, ovaries and fallopian tubes
- Your uterus is removed through the vaginal opening, and absorbable stitches are used to control any bleeding inside the pelvis
Except in cases of suspected uterine cancer, the surgeon might cut an enlarged uterus into smaller pieces and remove it in sections (morcellation).
Laparoscopic or robotic hysterectomy
You might be a candidate for a laparoscopically assisted vaginal hysterectomy (LAVH) or robotic hysterectomy. Both procedures allow your surgeon to remove the uterus vaginally while being able to see your pelvic organs through a slender viewing instrument called a laparoscope.
Your surgeon performs most of the procedure through small abdominal incisions aided by long, thin surgical instruments inserted through the incisions. Your surgeon then removes the uterus through an incision made in your vagina.
Your surgeon might recommend LAVH or robotic hysterectomy if you have scar tissue on your pelvic organs from prior surgeries or from endometriosis.
After the procedure
After surgery, you’ll be in a recovery room for one to two hours and in the hospital overnight. Some women are able to go home the day of the surgery.
You’ll take medication for pain. Your health care team will encourage you to get up and move as soon as you’re able.
It’s normal to have bloody vaginal discharge for several days to weeks after a hysterectomy, so you’ll need to wear sanitary pads.
How you’ll feel physically
Recovery after vaginal hysterectomy is shorter and less painful than it is after an abdominal hysterectomy. A full recovery might take three to four weeks.
Even if you feel recovered, don’t lift anything heavy — more than 20 pounds (9.1 kilograms) — or have vaginal intercourse until six weeks after surgery.
Contact your doctor if pain worsens or if you develop nausea, vomiting or bleeding that’s heavier than a menstrual period.
How you’ll feel emotionally
After a hysterectomy, you might feel relief because you no longer have heavy bleeding or pelvic pain.
For most women, there’s no change in sexual function after hysterectomy. But for some women, heightened sexual satisfaction occurs after hysterectomy — perhaps because they no longer have pain during intercourse.
You might feel a sense of loss and grief after hysterectomy, which is normal. Or you might have depression related to the loss of your fertility, especially if you’re young and hoped for a future pregnancy. If sadness or negative feelings interfere with your enjoyment of everyday life, talk to your doctor.
Results
After a hysterectomy, you’ll no longer have periods or be able to get pregnant.
If you had your ovaries removed but hadn’t reached menopause, you’ll begin menopause immediately after surgery. You might have symptoms such as vaginal dryness, hot flashes and night sweats. Your doctor can recommend medications for these symptoms. Your doctor might recommend hormone therapy even if you don’t have symptoms.
If your ovaries weren’t removed during surgery — and you still had periods before your surgery — your ovaries continue producing hormones and eggs until you reach natural menopause.
Covid-Vaccine
CDC is advising all pregnant patients to get the covid-19 Vaccine. All studies to date show that Covid-19 can have life threatening consequences in pregnancy and the vaccine does not. There are side effects to the vaccine. May people have sore arm, low grade fevers, and fatigue especially 1-3 days after the vaccine.
The antibodies created by this vaccine will protect your baby after it is born. We are not offering the vaccine to babies or kids under the age of 5, so you getting the vaccine is the only way to offer your baby some immunity from a very serious virus.
Some people say “We don’t know future consequences of the vaccine” and this is true. However, we have no reason to think that there will be few to no long term consequences. The vaccine has been shown to be very safe and effective in all studies done to date (New England Journal of Medicine Article is listed below and this is the best science we have). The Corona Virus in unvaccinated people has been shown to have very serious consequences including life long chronic fatigue, heart desease, and lung disease.
Corona virus does not appear to be going away. This may be our new normal. Please get vaccinated so your baby has some protection against the Corona Virus.
We are using the Madern mRNA vaccine or the Pizer vaccine, the choice is yours.
More information:
Getting Vaccinated While Pregnant: What You Need to Know – News Moms Need (marchofdimes.org)
Information about COVID-19 Vaccines for People who Are Pregnant or Breastfeeding | CDC
Preliminary Findings of mRNA Covid-19 Vaccine Safety in Pregnant Persons | NEJM – this study shows “adverse pregnancy and neonatal outcomes in persons vaccinated against Covid-19 who had a completed pregnancy were similar to incidences reported in studies involving pregnant women that were conducted before the Covid-19 pandemic”
Breast Feeding
When your baby arrives, it is normal for us to put your baby directly on your chest so you can continue your journey together. As long as your baby is breathing and comfortable, you can try breastfeeding within the hour.
Feel fortunate if breastfeeding comes naturally. It is far more common for babies and moms to struggle, especially the first week; and there are many good reasons for this.
- Babies are tired from the birthing process, and often too tired to eat. Especially the first 24 hours.
- Your body makes minimal “mil” until 3-4 days after delivery. To start, it’s a lot of work, with little nutritional value.
- It can hurt, especially in the beginning.
- When babies are born small or early they often struggle, eating can be hard work.
This seems to be something that causes new moms a great deal of anxiety. As new parents, we get pressure and opinions from friends, families, partners, nurses, and doctors. Listen as long as you want, but after you have heard enough, do what works best for you and your baby.
My most important piece of advice is to go with the flow. Don’t try to force it or expect too much right off the bat. Babies are made to go without breast milk for the first few days and that initial substance that comes from the breast (colostrum) is good for the baby. The more the baby struggles and tries to eat, the quicker the milk will come in. Don’t feel frustrated if they are too tired to eat. Each baby does things differently.
Don’t be too quick to offer a bottle, or start pumping. The more a baby tries to eat, the faster the milk will come in.
Breast Pumps
I think breast pumps can be a double edge sword. They can make feeding time easier because you get to share the task. Keep in mind moms still have to do the lion’s share of the work as collecting the milk takes as much time as feeding, and then someone still has to clean the pump and bottles and then feed the baby. This can be a never-ending cycle if you are pumping every 2-3 hours. In addition, once you offer a bottle, some babies don’t want to breastfeed because eating from a bottle is easier.
It is important to remember: studies showing a positive effect of breastfeeding did not include solely breast milk/pumping combination.
So use your pump as a way to free yourself, but if it’s more work and less fun, put your pump in the closet and forget about it until you want a night out.
Your insurance will provide you with a breast pump thanks to Obama Care. If you visit one of the sites below you can view different types of breast pumps, chose one, and your insurance will pay for it and you can have it delivered.
Qualify Through Insurance (aeroflowbreastpumps.com)
https://insurancecoveredbreastpumps.com/
Nurses
These are just four of the amazing nurses who work at Adventist Health Tillamook Hospital.
Thanks Amanda for the cute video.
Pregnancy Nutrition
Eating healthy is hard to do. We all know what we need to do, it is the implementation that is hard. OHSU has a fun diagram that shows basic nutrition information that everyone should follow.
Everyone agrees: Eat more vegetables and less sugar.
Vaginal pH
I see people every day that are worried about vaginal irritation/odor/discharge. These people may have yeast infections or an increase in bacteria. Often times we can treat those things with the appropriate medications, only to have the same symptoms return or other ones emerge to take their place. When the vagina keeps getting infections, discharge, or irritation it is often a PH problem. The vagina likes to be very acidic, like vinegar. Blood (from menstruation) and semen (from sex) both increase the PH in the vagina and can change bacteria in the vagina. Maintaining the pH balance of the vagina is essential to keeping the vagina smelling and feeling healthy. A normal vaginal pH is usually less than 4.5.
In the vagina, a change in pH may cause infections as it can allow bacteria and yeast to thrive and once you get one of these infections, you can get rid of it with appropriate medications, but if the PH is still elevated, those infections can easily return one after another. This is incredibly frustrating, but hopefully, I can offer some suggestions to eliminate the problem.
Are bacteria normal in the vagina?
Yes, the vagina has many good bacteria. Lactobacilli bacteria are healthy vaginal bacteria and secrete lactic acid and hydrogen peroxide, which give the vagina its acidic pH level.
Bacterial vaginosis is an increase in bacteria that normally live around the vagina, but not in it. These bacteria can overpopulate the vagina. This occurs when some types of bacteria multiply and increase the vaginal pH levels and kill the good bacteria. A person with bacterial vaginosis may experience itching, burning, pain, discharge and/or odor.
Other vaginal infections The presence of infections may also increase the vaginal pH. Examples include trichomonas vaginalis, yeast and group Streptococcus (GBS), and e. coli. Sometimes we get rid of one of these infections, only to find another take its place. This is when its time to start thinking about pH.
What can I do to treat the problem on my own?
Washing or cleaning the vagina using particular solutions, such as those containing vinegar, soaps, lubricants, oils or water can help or make things worse. Some solutions claim to reduce vaginal odor, but may make the problem worse because they wash out good bacteria, which affects the vaginal balance and can make some more prone to other infections. If you use any product in the vagina make sure it is “pH balanced” FOR the vagina. This product should have a pH of 4.5 or lower.
If a person’s vaginal pH levels are routinely high without any symptoms of an infection, they can take several steps at home to reduce their pH levels. These include: Avoiding soaps and washes, but use moisturizers and lubricants: Soaps typically have a high pH, and using them to clean the vaginal area may increase vaginal pH. It is best to use warm water and a gentle cleanser to clean the vulva but to refrain from using soap inside the vagina. Moisturizers that are made for the vagina and are pH balanced, may help neutralize alkaline products.
Probiotics? Oral probiotics have not been shown to help with vaginal bacteria. Yogurt in the vagina has not been shown to help with vaginal bacteria. There are vaginal probiotics that you put in the vagina. These products have not been studied well, but you could give them a try. Natural remedies do help some people.
Changing tampons regularly. Leaving a tampon in for too long can increase the vaginal pH because the pH of blood is slightly basic. Changing tampons frequently also reduces the risk of bacterial infections, including toxic shock syndrome (TSS).
Using barrier protection during sex. Using barrier protection, such as condoms or dental dams, not only helps to prevent pregnancy and STIs but can prevent semen and other fluids from affecting pH levels in the vagina.
Apple cider vinegar. Tampons allowed to absorb some Apple Cider vinegar may help. Vinegar has a pH of 4.5, so it may help make the vagina a more welcoming place for those good bacteria. Tampons may also help clear semen, and blood out of the vagina.
Summary
Understanding normal vaginal pH can help you avoid irritating bacteria infections. If you seem to have a vaginal odor, itching, discharge that comes and goes, especially if it comes and goes around the time of your menstrual cycle or after sex, it is very likely it is a pH problem. Try some over the counter pH correctors or apple cider vinegar. This may solve the problem. Even if you correct the pH, remember that you may need yeast medication or an antibiotic to help get rid of the bad bacteria. It is important to see a doctor to rule out sexually transmitted infections as they can cause long term problems if not identified quickly. 
Birth Plan?
You don’t need a birth plan. If you and your partner fill one out, it may give you information on things to expect and ask for. -If you don’t have one, we will ask what you want when the time comes and give you the same options as a birth plan. In my experience, we do almost all the normal things requested in a birth plan.
Please know that my job as a physician is to make sure you and your baby are healthy. That is my primary goal. My secondary goal is to make you and your partner have the best experiences possible.
If you have a birth plan you are welcome to give it to the nurses and I and we will do our best to follow it. If we feel your or your baby is in harms way we will let you know, a birth plan is just a plan. You get to decide when and where we deviate from that initial plan. We are long past the time when the doctors and nurses make all the decisions.
If you want pain medications we have IV medications and epidurals.
For natural labor, we have Jacuzzi tubs, TV, Music, essential oils, and birthing balls. Plus a variety of other equipment we use for helping you to get the baby in the right position. If a natural, no medication delivery is what you want make sure to take a natural birthing class online beforehand so you have as many options as possible.
If you want to walk around, eat, drink, you should.
If you want to avoid a C-section, that’s our goal too. Our C-section rate is way below the national average.
If you want a less painful delivery we will help you with that goal too. No matter please feel free to bring music, games, or movies to help pass the time. Labor can be stressful and boring at the same time.
We have a large variety of essential oils for calming and energy. The nurses will give you a menu when you arrive. Feel free to brink any other aromatherapy you find helpful.
In natural labor you can get into any position you want. If you want suggestions on how to push effectively we will give them to you, but for the most part- do what feels most comfortable.
If your baby is crying/pink when it arrives, we will pass them directly to you so you can warm your baby with skin-to-skin contact.
We don’t cut the cord until the placentas jobs is done and your labor partner will be offered the opportunity to do this.
The nurses will always ask before giving vaccinations or antibiotics to your baby. This choice is yours. The normal things we want you to consider giving your baby is.
1. Vitamin K 2. Hepatis B vaccine 3. Antibiotics We can give you specific information on all of these, I gave my kids all three and you are welcome to pick and choose. There are good reasons for all of them.
Want more birthing plans. You can check the links below. Feel free to print out and bring in whatever plan you want.
https://www.whattoexpect.com/pregnancy/labor-and-delivery/birth-plan/