Exercise Fact Sheet
How can physical activity improve my health?

The new 2008 Physical Activity Guidelines for Americans state that an active lifestyle can lower your risk of early death from a variety of causes. There is strong evidence that regular physical activity can also lower your risk of:

Body Mass IndexYou can get an idea of whether you are obese, overweight, or of normal weight by figuring out your body mass index (BMI). BMI is a number calculated from your weight and height. Women with a BMI of 25 to 29.9 are considered overweight. Women with a BMI of 30 or more are considered obese. All adults (aged 18 years or older) with a BMI of 25 or higher are considered at risk for serious health problems. These health risks increase as your BMI rises. Your doctor or nurse can help you figure out your BMI, or you can use this online BMI calculator from the Centers for Disease Control and Prevention (CDC).

Regular activity can help prevent unhealthy weight gain and also help with weight loss, when combined with lower calorie intake. If you are overweight or obese, losing weight can lower your risk for many diseases. Being overweight or obese increases your risk of heart disease, high blood pressure, stroke, type 2 diabetes, breathing problems, osteoarthritis, gallbladder disease, sleep apnea (breathing problems while sleeping), and some cancers.

Regular physical activity can also improve your cardiorespiratory (heart, lungs, and blood vessels) and muscular fitness. For older adults, activity can improve mental function.

Physical activity may also help:
•Improve functional health for older adults
•Reduce waistline size
•Lower risk of hip fracture
•Lower risk of lung cancer
•Lower risk of endometrial cancer
•Maintain weight after weight loss
•Increase bone density
•Improve sleep quality

How much physical activity should I do?

Health benefits are gained by doing the following each week:
•2 hours and 30 minutes of moderate-intensity aerobic physical activity
or•1 hour and 15 minutes of vigorous-intensity aerobic physical activity
or•A combination of moderate and vigorous-intensity aerobic physical activity
and •Muscle-strengthening activities on 2 or more days

This physical activity should be in addition to your routine activities of daily living, such as cleaning or spending a few minutes walking from the parking lot to your office.

Moderate activity
During moderate-intensity activities you should notice an increase in your heart rate, but you should still be able to talk comfortably. An example of a moderate-intensity activity is walking on a level surface at a brisk pace (about 3 to 4 miles per hour). Other examples include ballroom dancing, leisurely bicycling, moderate housework, and waiting tables.
Vigorous activity
If your heart rate increases a lot and you are breathing so hard that it is difficult to carry on a conversation, you are probably doing vigorous-intensity activity. Examples of vigorous-intensity activities include jogging, bicycling fast or uphill, singles tennis, and pushing a hand mower.

How much physical activity do I need to do to lose weight?

If you want to lose a substantial (more than 5 percent of body weight) amount of weight, you need a high amount of physical activity unless you also lower calorie intake. This is also the case if you are trying to keep the weight off. Many people need to do more than 300 minutes of moderate-intensity activity a week to meet weight-control goals.

Does the type of physical activity I choose matter?

Yes! Engaging in different types of physical activity is important to overall physical fitness. Your fitness routine should include aerobic and strength-training activities, and may also include stretching activities.

Aerobic activities
These activities move large muscles in your arms, legs, and hips over and over again. Examples include walking, jogging, bicycling, swimming, and tennis.

Strength-training activities
These activities increase the strength and endurance of your muscles. Examples of strength-training activities include working out with weight machines, free weights, and resistance bands. (A resistance band looks like a giant rubber band. You can buy one at a sporting goods store.) Push-ups and sit-ups are examples of strength-training activities you can do without any equipment. You also can use soup cans to work out your arms.

Aim to do strength-training activities at least twice a week. In each strength-training session, you should do 8 to 10 different activities using the different muscle groups throughout your body, such as the muscles in your abdomen, chest, arms, and legs. Repeat each activity 8 to 12 times, using a weight or resistance that will make you feel tired. When you do strength-training activities, slowly increase the amount of weight or resistance that you use. Also, allow one day in between sessions to avoid excess strain on your muscles and joints.

Stretching
Stretching improves flexibility, allowing you to move more easily. This will make it easier for you to reach down to tie your shoes or look over your shoulder when you back the car out of your driveway. You should do stretching activities after your muscles are warmed up — for example, after strength training. Stretching your muscles before they are warmed up may cause injury.

How can I prevent injuries when I work out?

Being physically active is safe if you are careful. Take these steps to prevent injury:
•If you’re not active at all or have a health problem, start your program with short sessions (5 to 10 minutes) of physical activity and build up to your goal. (Be sure to ask a doctor before you start if you have a health problem.)
•Use safety equipment such as a helmet for bike riding or supportive shoes for walking or jogging.
•Start every workout with a warm-up. If you plan to walk at a brisk pace, start by walking at an easy pace for 5 to 10 minutes. When you’re done working out, do the same thing until your heart rate returns to normal.
•Drink plenty of fluids when you are physically active, even if you are not thirsty.
•Use sunscreen when you are outside.
•Always bend forward from the hips, not the waist. If you keep your back straight, you’re probably bending the right way. If your back “humps,” that’s probably wrong.
•Stop your activity if you feel very out of breath, dizzy, nauseous, or have pain. If you feel tightness or pain in your chest, or you feel faint or have trouble breathing, stop the activity right away and talk to your doctor.

Exercise should not hurt or make you feel really tired. You might feel some soreness, a little discomfort, or a bit weary. But you should not feel pain. In fact, in many ways, being active will probably make you feel better.

Can I stay active if I have a disability?

A disability may make it harder to stay active, but it shouldn’t stop you. In most cases, people with disabilities can improve their flexibility, mobility, and coordination by becoming physically active. Getting regular physical activity can also help you stay independent by preventing illnesses, such as heart disease, that can make caring for yourself more difficult.

Even though you have a disability, you should still aim to meet the physical activity goals listed in How much physical activity should I do? Work with a doctor to develop a physical activity plan that works for you.

What are some tips to help me get moving?

Fit it into a busy schedule
•If you can’t set aside one block of time, do short activities throughout the day, such as three 10-minute walks.
•Create opportunities for activity. Try parking your car farther away from where you are headed. If you ride the bus or train, get off one or two stops early and walk.
•Walk or bike to work or to the store.
•Use stairs instead of the elevator or escalator.
•Take breaks at work to stretch or take quick walks, or do something active with coworkers at lunch.
•Walk while you talk, if you’re using a cellphone or cordless phone.
•Doing yard work or household chores counts as physical activity. Turn on some upbeat music to help you do chores faster and speed up your heart rate.

Make it fun
•Choose activities that you enjoy.
•Vary your activities, so you don’t get bored. For instance, use different jogging, walking, or biking paths. Or bike one day, and jog the next.
•Reward yourself when you achieve your weekly goals. For instance, reward yourself by going to a movie.
•If you have children, make time to play with them outside. Set a good example!
•Plan active vacations that will keep you moving, such as taking tours and sightseeing on foot.

Make it social
•Join a hiking or running club.
•Go dancing with your partner or friends.
•Turn activities into social occasions — for example, go to a movie after you and a friend work out.

Overcome challenges
•Don’t let cold weather keep you on the couch. You can find activities to do in the winter, such as indoor fitness classes or exercising to a workout video.
•If you live in a neighborhood where it is unsafe to be active outdoors, contact your local recreational center or church to see if they have indoor activity programs that you can join. You can also find ways to be active at home. For instance, you can do push-ups or lift hand weights. If you don’t have hand weights, you can use canned foods or bottles filled with water or sand.

Don’t expect to notice body changes right away. It can take weeks or months before you notice some of the changes from being physically active, such as weight loss. And keep in mind, many benefits of physical activity are happening inside you and you cannot see them.

Do I need to talk to my doctor before I start?

You should talk to your doctor before you begin any physical activity program if you:
•Have heart disease, had a stroke, or are at high risk for these diseases
•Have diabetes or are at high risk for diabetes
•Are obese (BMI of 30 or greater)
•Have an injury or disability
•Are pregnant
•Have a bleeding or detached retina, eye surgery, or laser treatment on your eye
•Have had recent hip surgery

More information on physical activity (exercise)

For more information about physical activity (exercise), call womenshealth.gov at 800-994-9662 (TDD: 888-220-5446) or contact the following organizations:
•American Council on Exercise
Phone: (888) 825-3636
•Division of Nutrition, Physical Activity, and Obesity, NCCDPHP, CDC, HHS
Phone: 800-232-4636 (TDD: 888-232-6348)
•Food and Nutrition Information Center, NAL, USDA
Phone: 301-504-5414
•Healthfinder.gov, HHS
•Office of Disease Prevention and Health Promotion, HHS
Phone: 240-453-8280
•The President’s Council on Fitness, Sports, and Nutrition, HHS
Phone: 240-276-9567
•Weight-control Information Network, NIDDK, NIH, HHS
Phone: 877-946-4627 or 202-828-1025

Source: Office on Women’s Health in the Office of the Assistant Secretary for Health at the U.S.Department of Health and Human Services

©2012 Women's Health First. All Rights Reserved.

Physical Activity and Weight Control — What you need to know

Regular physical activity may help you reach and maintain a healthy weight. Being physically active may also make you more energetic, improve your mood, and reduce the risk of developing some chronic diseases.

Calories in Food > Calories Used = Weight Gain

Calories in Food < Calories Used = Weight Loss

Calories in Food = Calories Used = Weight Control

How much physical activity do I need for general health?

Experts recommend at least 150 minutes (2 hours and 30 minutes) of moderate-intensity physical activity, or 75 minutes (1 hour and 15 minutes) of vigorous-intensity aerobic physical activity per week. This amount of physical activity may reduce your risk for some chronic diseases. Aerobic physical activities make your heart beat faster for a sustained period of time.

Examples of moderate-intensity activity include:

■ brisk walking
■ general gardening
■ water aerobics

Examples of vigorous-intensity activity include:

■ bicycling (at least 10 miles per hour)
■ heavy gardening
■ jogging or running
■ racewalking
■ rock climbing
■ swimming laps
■ training to run a 10K

They also require your body to use more oxygen. Examples include bicycling, dancing, and walking.

You do not need to do all of your exercise at once to be physically active. In fact, experts recommend spreading physical activity throughout the week.

• You may break up your activity into shorter segments of 10 minutes or more.

• Moderate- or vigorous-intensity physical activities that last for at least 10 minutes count toward meeting the weekly recommendation.

How much physical activity do I need to control my weight?

People need different amounts of physical activity to lose and control weight. You may find that you need to do more or less than others.

The amount of activity needed for weight loss may differ greatly between people. Some people who are not very active may be able to achieve and maintain a healthy weight by doing the minimum amount of activity recommended by experts.

However, many adults need to do more activity to control their weight

• Some adults need 300 minutes (5 hours) or more of moderate-intensity aerobic physical activity, or 150 minutes of vigorous-intensity aerobic physical activity, per week.

• These adults should build up to this level of activity, adding time each week until they reach their goal.

In order to maintain a healthy weight after weight loss, adults may need to further increase their physical activity. Studies show that physical activity is very important to successful long-term weight control.

How can my eating habits help me achieve a healthy weight?

Health Benefits of Physical Activity
Regular physical activity may help you control your weight, and it may also help:

■ Reduce your risk for type 2 diabetes, high blood pressure and cholesterol, heart disease, osteoporosis, arthritis, and some cancers.
■ Build strong muscles, bones, and joints.
■ Improve flexibility.
■ Increase energy levels.
■ Improve mood and sense of well-being.

The number of calories you eat is important. In addition to being physically active, all adults should follow a healthy eating plan. Try to consume fewer calories than you burn each day. Remember that your weight may be affected by the balance of “calories-in” and “calories-out.”

You may wish to speak with your health care provider, a fitness specialist, or a registered dietitian about the amount of activity and calories suitable for you.

You can also use interactive tools on the “ChooseMyPlate” website of the U.S. Department of Agriculture (USDA) to find out how much activity and how many calories you need. See the USDA listing under the Additional Resources section at the end of this fact sheet for a web link.

Becoming Physically Active

Physical activity may include structured activities such as walking, jogging, strength training, or sports. It may also include daily activities such as household chores, yard work, or walking the dog. Pick a combination of structured and daily activities that fits your schedule.

If you have been inactive for a while, start slowly and work up to at least 150 minutes per week at a pace that is comfortable for you. Remember that you may build up activity over the course of the day in sessions of 10 minutes or more if you are unable to be active for longer periods. For example, whether you take three 10-minute walks or one 30-minute walk, you will achieve the same health benefits.

If you want to lose weight, you may need to do more than 150 minutes of moderate-intensity aerobic activity per week. Remember that you can be active in several shorter sessions, and that your daily activities count toward calories used.

Aerobic Activity

Get Started!Here are some ideas to help you get started:

■ Take a brisk walk around the block with family, friends, or coworkers.
■ Walk up the stairs instead of taking the elevator when it is safe to do so.
■ Mow the lawn.
■ Take an activity break at work or home. Get up, stretch, and walk around.
■ Park your car farther away from entrances of stores, movie theaters, or your home, and walk the extra distance when it is safe to do so.
■ Take a beginner’s level low-impact aerobics or step class.

One way to meet your physical activity goals is by participating in aerobic activities. Aerobic exercise includes any activity that makes you breathe hard and increases your heart rate for a sustained period of time.

Common aerobic activities include:

• brisk walking
• cycling
• dancing
• playing basketball
• running
• swimming

Experts recommend moderate- to vigorous-intensity exercise. Moderate-intensity aerobic activity may make you breathe harder and make it more difficult to talk, but you should still be able to carry on a conversation. If you are just beginning, slowly work up to moving at a moderate-intensity pace.

Strength Training

Muscle-strengthening activities also provide health benefits. Experts recommend that adults do muscle-strengthening activities on 2 or more days per week

in addition to meeting recommendations for aerobic physical activity.

However, muscle-strengthening activities can provide another way for you to meet the recommended aerobic physical activity each week. Moderate- to vigorous-intensity muscle-strengthening activities count toward the weekly physical activity recommendation if they involve one or more of the major muscle groups, such as those in the legs, hips, back, chest, abdomen, shoulders, or arms.

Strength training will help you:

• Burn extra calories.
• Build strong muscles, bones, and joints.
• Improve how your body works and moves.

Keep Moving!

Move at your own pace while you enjoy some of these activities:

■ aerobic exercise classes (step aerobics, kick boxing, high- or low-impact aerobics)

■ bicycling

■ brisk walking

■ dancing (square dancing, salsa, African dance, swing)

■ jogging

■ playing sports (tennis, basketball, soccer)

■ swimming

Experts recommend 1 full day of rest between workouts to allow your muscles to recover.

If you are new to strength training or physical activity in general, consider hiring a certified personal trainer who can create a program that is fun and safe, and will help you meet your physical activity goals. A personal trainer who has a degree in exercise physiology or is certified through a national certification program, such as the American College of Sports Medicine or National Strength and Conditioning Association, may be able to help you reach your physical activity goals. You may need to contact your health insurer to make sure such services are covered by your plan.

Mind and Body Exercise

In addition to aerobic activity and strength training, you may wish to include other forms of exercise in your physical activity program. Alternatives to traditional exercise provide variety and fun. They may also help reduce stress, increase muscular strength and flexibility, and increase energy levels. Examples of these exercises include yoga, Pilates, and tai chi.

Tips for a Safe and Successful Physical Activity Program

Check with your health care provider. If you have a chronic health problem such as obesity, diabetes, heart disease, or high blood pressure, ask your health care provider about what type and amount of physical activity is right for you.

• Start slowly. Add more physical activity into your daily routine and gradually work up to 150 minutes (2 hours and 30 minutes) of moderate-intensity physical activity per week to improve health. For additional health benefits, you may choose to work up to 300 minutes (5 hours) of moderate-intensity physical activity, or 150 minutes of vigorous-intensity physical activity, per week.

• Set goals. Set both short-term and long-term goals to keep motivated.

• Set rewards. Celebrate every success—you earned it!

• Track progress. Keep an activity log to track your progress. Note when you worked out, what activity you did, how long you did the activity, and how you felt during your workout. Also, record the days that you did not work out and what may have caused you to change your routine.

Get strong!

Build strong muscles and bones with strengthening exercises. Try:

■ Lifting free weights or using weight machines.

■ Using resistance bands.

■ Using stability or medicine balls.

■ Doing push-ups and abdominal crunches.

• Think variety. Choose a variety of physical activities to help you meet your goals, prevent boredom, and keep your mind and body challenged.

• Be comfortable. Wear comfortable shoes and clothes that are appropriate to the activity you will be doing.

• Slow down if you feel out of breath. The “Talk Test” is an easy way to monitor your physical activity intensity.

■ You should be able to talk during your activity, without gasping for breath.

■ When talking becomes difficult, your activity may be too hard.

■ If talking becomes difficult for you while exercising, slow down until you are able to talk comfortably again.

• Listen to your body. Stop exercising and consult your health care provider if you feel chest discomfort or pain, dizziness, severe headache, or other unusual symptoms while you work out. If pain does not go away, get medical help right away. If you are feeling fatigued or sick, take time off from your routine to rest. You can ease back into your program when you start feeling better.

• Eat nutritious foods. Choose a variety of nutritious foods every day, such as whole-grain breads and cereals, lean meats, low-fat or fat-free milk and milk products, and a variety of fruits and vegetables, like apples, berries, carrots, and kale. Remember that your health and weight depend on both your eating plan and physical activity level. Healthful foods will give you the energy you need to be active.

• Get support. Encourage your family and friends to support you and join you in your activity. Form walking groups with coworkers, play with your children outside, or take a dance class with friends.

Regular physical activity may help you feel and move better. Whether your goal is to achieve and maintain a healthy weight or improve your health, becoming physically active is a step in the right direction. It is never too early or too late to make physical activity a part of your life!

Additional Reading From the Weight-control Information Network (WIN)

Active at Any Size.  National Institutes of Health (NIH) Publication No. 10–4352.http://win.niddk.nih.gov/publications/active.htm

Healthy Eating and Physical Activity Across Your Lifespan: Better Health and You. NIH Publication No. 08–4992 (available in English and Spanish).http://www.win.niddk.nih.gov/publications/better_health.htm

Changing Your Habits: Steps to Better Health. NIH Publication No. 08–6444.http://win.niddk.nih.gov/publications/changing-habits.htm

Walking…A Step in the Right Direction. NIH Publication No. 07–4155.http://www.win.niddk.nih.gov/publications/walking.htm

Weight Loss for Life. NIH Publication No. 04–3700.http://www.win.niddk.nih.gov/publications/for_life.htm

It is never too early or too late to make physical activity a part of your life!

Additional Resources

American College of Sports Medicine

P.O. Box 1440Indianapolis, IN 46206–1440Phone: (317) 637–9200http://www.acsm.org

National Strength and Conditioning Association

1955 N. Union BoulevardColorado Springs, CO 80909Phone: (719) 632–6722Toll-free: 1–800–815–6826http://www.nsca-lift.org 8

The President’s Council on Fitness, Sports & Nutrition

1101 Wootton Parkway, Suite 560Rockville, MD 20852Phone: (240) 276–9567http://www.fitness.gov

Websites

American Heart Association

http://www.heart.org/HEARTORG

National Heart, Lung, and Blood Institute

Aim for a Healthy Weighthttp://www.nhlbi.nih.gov/health/public/heart/obesity/lose_wt

National Institutes of Health

We Can! (Ways to Enhance Children’s Activity & Nutrition)http://www.nhlbi.nih.gov/health/public/heart/obesity/wecan/index.htm

Shape Up America!

http://www.shapeup.org

U.S. Department of Agriculture (USDA)

ChooseMyPlatehttp://www.choosemyplate.gov

U.S. Department of Health and Human Services

2008 Physical Activity Guidelines for Americans.October 2008. http://www.health.gov/PAGuidelines

Note: Publications produced by WIN are reviewed by both NIDDK scientists and outside experts. This fact sheet was also reviewed by Steven Blair, P.E.D., Professor, Department of Exercise Science, Arnold School of Public Health, University of South Carolina.

Source: National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK)

©2012 Women's Health First. All Rights Reserved.

Frequently Asked Questions About Incontinence
What is incontinence?
Incontinence (in-CONT-ti-nunce) is the loss of bladder or bowel control.

There are four basic types of incontinence:

1. Stress incontinence occurs when pelvic muscles have been damaged, causing the bladder to leak during exercise, coughing , sneezing, laughing, or any body movement which puts pressure on the bladder.
2. Urge incontinence, the urgent need to pass urine and the inability to get to a toilet in time, occurs when nerve passages along the pathway from the bladder to the brain are damaged, causing a sudden bladder contraction that cannot be consciously inhibited.
3. Mixed incontinence is very common and occurs when the quantity of urine produced exceeds the bladder’s holding capacity.
4. Overflow incontinence refers to leakage that occurs when the quantity of urine produced exceeds the bladder’s holding capacity. Incontinence from surgery follows such operations as hysterectomies, cesarean sections, prostatectomies, lower intestinal surgery, or rectal surgery. This is not considered a diagnostic category. Incontinence can also occur due to other reversible factors, often outside of the urinary tract, such as restricted mobility. Mobility aids can help remove barriers to self-toileting on a timely basis. Other factors such as arthritis, may interfere with managing zippers, buttons, and articles of clothing — or moving quickly enough to reach the toilet.

Can medications I take affect my bladder or bowel control?

Several classes of medicines affect the bladder muscle and the bladder outlet muscle. Sometimes these medicines are prescribed for conditions outside the urinary system and cause unwanted changes in bladder control.

Classes of Drugs Which May Contribute to Incontinence

• Diuretics (water pills) – examples: Esidrix®, Lasix®, Maxide®
• Sedatives, muscle relaxants, alcohol – examples: Valium®, Librium®, Ativan®
• Narcotics – examples: Percocet®, Demerol®, morphine
• Antihistamines -examples: Benadryl®
• Anticholinergics – examples: Pro-Banthine®
• Antipsychotics/Antidepressants – examples: Elavil®, Prolixin®, Haldol®
• Calcium channel blockers – examples: Calan®, Procardia®, Cardizem®

Can my diet affect my bladder control?

There is no “diet” to cure incontinence. However, there are certain dietary matters you should know about. Some foods and beverages are thought to contribute to bladder leakage. Their effect on the bladder is not always understood, but you may want to see if eliminating one or all of the items listed improves your urine control.

Common Bladder Irritants:

• Alcoholic beverages
• Carbonated beverages (with or without caffeine)
• Milk or milk products
• Coffee or Tea (even decaffeinated)
• Medicines with caffeine
• Citrus juice & fruits
• Tomatoes
• Tomato-based products
• Highly spiced foods
• Sugar
• Honey
• Chocolate
• Corn Syrup
• Artificial sweeteners

What are Kegel, or pelvic muscle, exercises?

Pelvic muscle exercises, also called Kegel exercises or pelvic floor exercises, have been shown to improve mild to moderate urge and stress incontinence. When performed correctly, these exercises help to strengthen the muscles at your bladder outlet. Through regular exercise you can build strength and endurance to help improve, regain, or maintain bladder and bowel control.

How to find and recognize the muscles

Imagine that you need to hold back gas. Squeeze and lift the rectal area, and for women also the vaginal area, without tightening the buttocks or belly (abdomen). When you first begin your exercise program, check yourself frequently by looking in a mirror or by placing your hands on your abdomen and buttocks to insure that you do not feel your belly, thighs, or buttocks move. If there is movement, continue to experiment until you have isolated the correct muscles of the pelvic floor.

Another technique used only to help you identifying the correct pelvic muscles is to attempt to stop or slow the flow of urine. While urinating, partially empty your bladder then try to stop or slow the flow of urine. Remember to relax and completely empty your bladder when you have finished this test. Do not be discouraged if you are unable to stop or change the flow. Slowing the flow is a good start. Twice a month, you may try to stop the stream as a test to see if your muscle strength is improving. Do not do this start-and-stop test on a regular basis. It is not a helpful way to exercise the pelvic floor muscles.

Suggested exercises

There are two types of exercises you need to do. Doing both types of exercises is the best way to help improve your bladder control.

The first exercise, type 1, works on the holding ability of the muscles (building a strong dam to hold back urine). It is done by slowly tightening, lifting, and drawing in the pelvic floor muscles and holding them to a count of five. At first, you will probably notice that the muscles do not want to stay contracted or tightened very long. If you feel the contraction letting go, just re-tighten the muscles. In a week or two, you will probably notice an improvement in the control and holding power of the contractions. In fact, in the beginning, you may only be able to hold the contraction for 1-2 seconds. Concentrate on lifting the muscles and holding the contraction while progressing slowly over a period of weeks to a goal of 10-seconds. Rest for 10 seconds between each contraction.

The second exercise, Type 2, is a quick contraction. The muscles are quickly tightened, lifted up, and let go. This works the muscles that quickly shut off the flow of urine (like a faucet) to help prevent accidents.

If you have any questions or difficulties with these exercises, talk to a health care provider. Other behavioral treatments include pelvic weights (vaginal cones), biofeedback training to help isolate and use the correct muscles, and electrical stimulation of the muscles that may help with your exercise efforts. Sometimes a combination of all or some of these techniques is most helpful in managing and improving your incontinence. NAFC publishes a kit for both men and women, designed to assist with pelvic muscle exercises. It is most helpful for women with mild to moderate stress and urge incontinence and men experiencing urine leakage after prostate surgery. The audio recording teaches how, coaches through, and encourages continuously. The accompanying manual helps you to follow the verbal instructions with written descriptions and detailed drawings.

Can I retrain my bladder and take control again?

In 1991, a gynecologist, Dr. Andrew Fantl, announced the success of a bladder retraining program conducted at the Medical College of Virginia. More than 100 healthy women, 55 years and older, participated in the program. 12% were cured of their bladder leakage, and 75% were greatly improved. Some women had stress incontinence; some had urge incontinence; and others had symptoms of both types. (Only women tested this program in Virginia. Men with urge incontinence in other centers have benefited by it too.) Bladder retraining consists of urinating on a schedule and gradually increasing the amount of times between bathroom trips.

Can surgery help my “dropped” bladder? (women only)

An operation may be the best treatment when the bladder and/or other pelvic organs have fallen out of their normal position (a condition called pelvic organ prolapse), particularly when conservative therapy has not been successful. The goal of surgery for stress incontinence is to restore the urethra and bladder to their normal position in the pelvis up behind the pubic bone. The most durable operations are performed through an incision in the lower abdomen (the Burch or “MMK” operations). Other procedures may require a small abdominal incision and a vaginal incision. These operations are often named after the doctors who developed them – Pereyra, Stamey, Raz, etc.

Recently many newspapers have run articles about “no-incision” surgery. Although there is no vaginal incision with this technique, two small punctures are made above the pubic bone. Also, many people are now talking about laparoscopic, or percutaneous, bladder suspension surgery. This is a minimally invasive procedure usually requiring less than a 24-hour hospital stay with local anesthesia. Because these are fairly new procedures, long-term results are not yet available.

Women with severe stress incontinence or women who have previously had failed surgeries may be told that they need a “sling procedure”. In this operation a piece of fascia (the strong tissue that covers many of the body’s muscles), or some kind of synthetic material, is placed underneath the urethra like a hammock to support and compress it, preventing urine leakage.

Before agreeing to a surgical procedure, make sure you understand all of the treatment options that are available to you. Please refer to our section on Prolapse to read more about this condition.

How can periurethral injections improve bladder control?

The injection of “bulking” material into the tissues around the urethra sometimes results in a closing of the sphincter (bladder outlet muscle) and, therefore, protects against incontinence by increasing the resistance to the outflow of urine. Contigen® Bard® Collagen Implant has been used routinely for these cases since 1993 as a safe and effective treatment for sphincter malfunction. Collagen is a natural protein found in the body. Contigen Implant is a sterile, purified collagen taken from the skin of cows. It is chemically treated to prevent any allergic reaction, but a skin test is still performed to be extra safe. There are other materials used as bulking agents, and even more are being tested in clinical trials.

A doctor will perform urodynamic pressure tests on the bladder and sphincter to make certain that the incontinent patient is a good candidate for this treatment. The best results occur when the patient’s incontinence is a result of poor urethral function combined with good pelvic muscle support. The majority of patients with this type of urinary incontinence have had previous surgery. In men this is most commonly encountered following radical prostatectomy (surgical removal of a cancerous prostate). In women, the primary cause is multiple surgical bladder suspension procedures for stress incontinence which may interfere with nerve input to the sphincter and, ultimately, cause it to not function properly.

Eighty percent of women are dry or improved after three treatment sessions in properly selected patients. Seventy-seven percent will remain dry once this has been attained. Unfortunately, results in men are not so astounding, where only 40% attain dryness. When broken down as to cause of the incontinence, we see that men following resection of the prostate through the urethra (TURP) do as well as women, 88% dry. However, after radical prostatectomy, the more common problem, only 25% are dry, and after radiation therapy for prostate cancer, the results are even worse at 14% dry.

Source: National Health Information Center

©2012 Women's Health First. All Rights Reserved.

What is the thyroid?

Your thyroid (THY-roid) is a small gland found at the base of your neck, just below your Adam’s apple. The thyroid produces two main hormones called T3 and T4. These hormones travel in your blood to all parts of your body. The thyroid hormones control the rate of many activities in your body. These include how fast you burn calories and how fast your heart beats. All of these activities together are known as your body’s metabolism. A thyroid that is working right will produce the right amounts of hormones needed to keep your body’s metabolism working at a rate that is not too fast or too slow.

What kinds of thyroid problems can affect women?

Women are more likely than men to develop thyroid disorders. Thyroid disorders that can affect women include:

• Disorders that cause hyperthyroidism
• Disorders that cause hypothyroidism
• Thyroid nodules
• Thyroiditis
• Thyroid cancer
• Goiter

What is hyperthyroidism?

Some disorders cause the thyroid to make more thyroid hormones than the body needs. This is called hyperthyroidism , or overactive thyroid. The most common cause of hyperthyroidism is Graves’ disease. Graves’ disease is an autoimmune disorder, in which the body’s own defense system, called the immune system, stimulates the thyroid. This causes it to make too much of the thyroid hormones. Hyperthyroidism can also be caused by thyroid nodules that prompt excess thyroid hormones to be made.

What are the symptoms of hyperthyroidism?

At first, you might not notice symptoms of hyperthyroidism. They usually begin slowly. But over time, a speeded up metabolism can cause symptoms such as:

• Weight loss, even if you eat the same or more food
• Eating more than usual
• Rapid or irregular heartbeat or pounding of your heart
• Anxiety
• Irritability
• Trouble sleeping
• Trembling in your hands and fingers
• Increased sweating
• Increased sensitivity to heat
• Muscle weakness
• More frequent bowel movements
• Less frequent menstrual periods with lighter than normal menstrual flow

In addition to these symptoms, people with hyperthyroidism may have osteoporosis, or weak, brittle bones. In fact, hyperthyroidism might affect your bones before you have any of the other symptoms of the disorder. This is especially true of postmenopausal women, who are already at high risk of osteoporosis.

What is hypothyroidism?

Hypothyroidism is when your thyroid does not make enough thyroid hormones. It is also called underactive thyroid. The most common cause of hypothyroidism in the United States is Hashimoto’s disease. Hashimoto’s disease is an autoimmune disease, in which the immune system mistakenly attacks the thyroid. This attack damages the thyroid so that it does not make enough hormones. Hypothyroidism also can be caused by:

• Treatment of hyperthyroidism
• Radiation treatment of certain cancers
• Thyroid removal

In rare cases, problems with the pituitary gland can cause the thyroid to be less active.

What are the symptoms of hypothyroidism?

Symptoms of hypothyroidism tend to develop slowly, often over several years. At first, you may just feel tired and sluggish. Later, you may develop other symptoms of a slowed down metabolism, including:

• Weight gain, even though you are not eating more food
• Increased sensitivity to cold
• Constipation
• Muscle weakness
• Joint or muscle pain
• Depression
• Fatigue (feeling very tired)
• Pale dry skin
• A puffy face
• A hoarse voice
• Excessive menstrual bleeding

In addition to these symptoms, people with hypothyroidism may have high blood levels of LDL cholesterol. This is the so‑called “bad” cholesterol, which can increase your risk for heart disease.

Source: U.S. Department of Health and Human Services

©2012 Women's Health First. All Rights Reserved.

What is anorexia nervosa?

A person with anorexia nervosa, often called anorexia, has an intense fear of gaining weight. Someone  with anorexia thinks about food a lot and limits the food she or he eats, even  though she or he is too thin. Anorexia is more than just a problem with food.  It’s a way of using food or starving oneself to feel more in control of life  and to ease tension, anger, and anxiety. Most people with anorexia are female. An  anorexic:

• Has a low body weight for her or his height
• Resists keeping a normal body weight
• Has an intense fear of gaining weight
• Thinks she or he is fat even when very thin
• Misses 3 menstrual periods in a row (for girls/women who have started having their periods)

Who becomes anorexic?

While anorexia mostly affects girls and women (85 – 95 percent of anorexics are female), it can also affect boys and men. It was once thought that women of color were shielded from eating disorders by their cultures, which tend to be more accepting of different body sizes. It is not known for sure whether African American, Latina, Asian/Pacific Islander, and American Indian and Alaska Native people develop eating disorders because American culture values thin people. People with different cultural backgrounds may develop eating disorders because it’s hard to adapt to a new culture (a theory called “culture clash”). The stress of trying to live in two different cultures may cause some minorities to develop their eating disorders.

What causes anorexia?

There is no single known cause of anorexia. Eating disorders are real, treatable medical illnesses with   causes in both the body and the mind. Some of these things may play a part:

• Culture. Women in the U.S. are under constant pressure to fit a certain ideal of beauty. Seeing images of flawless, thin females everywhere makes it hard for women to feel good about their bodies. More and more, women are also feeling pressure to have a perfect body.
• Families. If you have a mother or sister with anorexia, you are more likely       to develop the disorder. Parents who think looks are important, diet themselves, or criticize their children’s bodies are more likely to have a child with anorexia.
• Life changes or stressful events. Traumatic events (like rape) as well as stressful things (like starting a new job), can lead to the onset of anorexia.
• Personality traits. Someone with anorexia may not like her or himself, hate the way she or he looks, or feel hopeless. She or he often sets hard-to-reach goals for her or himself and tries to be perfect in every way.
• Biology. Genes, hormones, and  chemicals in the brain may be factors in developing anorexia.

What are signs of anorexia?

Someone with anorexia may  look very thin. She or he may use extreme measures to lose weight by:

• Making her or himself throw up
• Taking pills to urinate or have a bowel movement
• Taking diet  pills
• Not eating or eating very little
• Exercising a  lot, even in bad weather or when hurt or tired
• Weighing food and counting calories
• Eating very small amounts of only certain foods
• Moving food around the plate instead of eating it

Someone with anorexia may  also have a distorted body image, shown by thinking she or he is fat, wearing  baggy clothes, weighing her or himself many times a day, and fearing weight  gain.

Anorexia can also cause someone to not act like  her or himself. She or he may talk about weight and food all the time, not eat  in front of others, be moody or sad, or not want to go out with friends. People with anorexia may also have other psychiatric and physical illnesses,  including:

• Depression
• Anxiety
• Obsessive behavior
• Substance abuse
• Issues with the  heart and/or brain
• Problems with  physical development

What happens to your body with anorexia?

With anorexia, your body doesn’t get the energy  from foods that it needs, so it slows down. Look at the picture below to find out how anorexia affects your health.

Can someone with anorexia get better?

Yes. Someone with anorexia can get better. A  health care team of doctors, nutritionists, and therapists will help the  patient get better. They will:

• Help bring the person back to a normal weight
• Treat an psychological issues related to anorexia
• Help the person get rid of any actions or thoughts that cause the eating disorder

These three steps will prevent “relapse”  (relapse means to get sick again, after feeling well for a while).

Is it safe for young people to take antidepressants for anorexia?
It may be safe for young people to be treated with antidepressants. However, drug companies who make antidepressants are required to post a “black box” warning label on the medication. A “black box” warning is the most serious type of warning on prescription drugs.

It may be possible that antidepressants make children, adolescents, and young adults more likely to think about suicide or commit suicide.

The latest information from the FDA — including what drugs are included in this warning and things to look for — can be found on their website at http://www.fda.gov

Some research suggests that the use of medicines — such as antidepressants,  antipsychotics, or mood stabilizers — may sometimes work for anorexic patients. It is thought that these medicines help the mood and anxiety symptoms that often co-exist with anorexia. Other recent studies, however, suggest that antidepressants  may not stop some patients with anorexia from relapsing. Also, no medicine has  shown to work 100 percent of the time during the important first step of  restoring a patient to healthy weight. So, it is not clear if and how  medications can help anorexic patients get better, but research is still  happening.

Some forms of psychotherapy can help make the psychological reasons for anorexia better. Psychotherapy is sometimes known as “talk therapy.” It uses different ways of communicating to  change a patient’s thoughts or behavior. This kind of therapy can be useful for  treating eating disorders in young patients who have not had anorexia for a  long time.

Individual counseling can help someone with  anorexia. If the patient is young, counseling may involve the whole family.  Support groups may also be a part of treatment. In support groups, patients,  and families meet and share what they’ve been through.

Some researchers point out that prescribing medicines and using psychotherapy designed just for anorexic patients works better at  treating anorexia than just psychotherapy alone. Whether or not a treatment  works, though, depends on the person involved and his or her situation.  Unfortunately, no one kind of psychotherapy always works for treating adults  with anorexia.

What is outpatient care for anorexia treatment and how  is it different from inpatient care?

With outpatient care, the patient receives treatment through visits with members of their health care team. Often this  means going to a doctor’s office. Outpatients usually live at home.

Some patients may need “partial hospitalization.”  This means that the person goes to the hospital during the day for treatment,  but sleeps at home at night.

Sometimes, the patient goes to a hospital and  stays there for treatment. This is called inpatient care. After leaving the  hospital, the patient continues to get help from her health care team and  becomes an outpatient.

Can women who had anorexia in the past still get pregnant?

It depends. When a woman has “active anorexia,” meaning she currently has anorexia, she does not get her period and usually does not ovulate.  This makes it hard to get pregnant. Women who have recovered from anorexia and are at a healthy weight have a better chance of getting pregnant. If you’re having a hard time getting pregnant, see your doctor.

Can anorexia hurt a baby when the mother is pregnant?

Yes. Women who have anorexia while they are  pregnant are more likely to lose the baby. If a woman with anorexia doesn’t lose the baby, she is more likely to have the baby early, deliver by C-section, deliver a baby with a lower birthweight, and have depression after the baby is born.

What should I do if I think someone I know has anorexia?

If someone you know is  showing signs of anorexia, you may be able to help.

1. Set a time to talk. Set aside a time to talk privately with your friend. Make sure you talk in a quiet place where you won’t be distracted.
2. Tell your friend about your concerns. Be honest. Tell your friend about your worries about her or his not eating or over exercising. Tell your friend you are concerned and that you think these things may be a sign of a problem that       needs professional help.
3. Ask your friend to talk to a professional. Your  friend can talk to a counselor or doctor who knows about eating issues. Offer  to help your friend find a counselor or doctor and make an appointment, and  offer to go with her or him to the appointment.
4. Avoid conflicts. If your friend won’t admit that she or he has a problem, don’t push. Be sure to tell your friend you are always there to listen if she or he wants to talk.
5. Don’t place shame, blame, or guilt on your friend.  Don’t say, “You just need to eat.” Instead, say things like, “I’m concerned about you because you won’t eat breakfast or lunch.” Or, “It makes me afraid to hear you throwing up.”
6. Don’t give simple solutions. Don’t say, “If you’d just stop, then  things would be fine!”
7. Let your friend know that you will always be there no matter what.

Adapted from “What Should I  Say? Tips for Talking to a Friend Who May Be Struggling with an Eating  Disorder” from the National Eating Disorders Association.

More information on anorexia nervosa

For more information about anorexia nervosa, call womenshealth.gov at 800-994-9662 (TDD: 888-220-5446) or contact the following organizations:

• Academy for Eating Disorders  Phone: 847-498-4274
• National Association of Anorexia Nervosa and Associated Disorders  hone: 847-831-3438
• National Eating Disorders Association  Phone: 800-931-2237
• National Institute of  Mental Health (NIMH), NIH, HHS  Phone: 866-615-NIMH (6464)
• National Mental Health Information Center, SAMHSA, HHS   Phone: 800-789-2647

Source: National Eating Disorders Association 

©2012 Women's Health First. All Rights Reserved.

Oral Contraceptives and Cancer Risk

Oral contraceptives (OCs) first became available to American women in the early 1960s. The convenience, effectiveness, and reversibility of action of birth control pills (popularly known as “the pill”) have made them the most popular form of birth control in the United States. However, concerns have been raised about the role that the hormones in OCs might play in a number of cancers, and how hormone-based OCs contribute to their development. Sufficient time has elapsed since the introduction of OCs to allow investigators to study large numbers of women who took birth control pills for many years.

This fact sheet addresses only what is known about OC use and the risk of developing cancer. It does not deal with other serious side effects of OC use, such as the increased risk of cardiovascular disease for certain groups of women. Recently, alternative methods of delivering hormones for contraception have been developed, including a topical patch, vaginal ring, and intrauterine delivery system, but these products are too new to have been tested in clinical trials (research studies) for long-term safety and other effects (1). They also are not covered in this fact sheet.

What types of oral contraceptives are available in the United States and Why do researchers believe that oral contraceptives may influence cancer risk?

Currently, two types of OCs are available in the United States. The most commonly prescribed OC contains two man-made versions of natural female hormones (estrogen and progesterone) that are similar to the hormones the ovaries normally produce. This type of pill is often called a “and progesterone.” The second type of OC available in the United States is called the minipill. It contains only a type of progesterone. Estrogen stimulates the growth and development of the uterus at puberty, causes the endometrium (the inner lining of the uterus) to thicken during the first half of the menstrual cycle, and influences breast tissue throughout life, but particularly from puberty to menopause.Progesterone, which is produced during the last half of the menstrual cycle, prepares the endometrium to receive the egg. If the egg is fertilized, progesterone secretion continues, preventing release of additional eggs from the ovaries. For this reason, progesterone is called the “pregnancy-supporting” hormone, and scientists believe that it has valuable contraceptive effects. The man-made progesterone used in OCs is called progestogen or progestin.

Because medical research suggests that some cancers depend on naturally occurring sex hormones for their development and growth, scientists have been investigating a possible link between OC use and cancer risk. Researchers have focused a great deal of attention on OC users over the past 40 years. This scrutiny has produced a wealth of data on OC use and the development of certain cancers, although results of these studies have not always been consistent. The risk of endometrial and ovarian cancers is reduced with the use of OCs, while the risk of breast and cervical cancers is increased (1). A summary of research results for each type of cancer is given in Questions 2–5.

How do oral contraceptives affect breast cancer risk?

A woman’s risk of developing breast cancer depends on several factors, some of which are related to her natural hormones. Hormonal factors that increase the risk of breast cancer include conditions that may allow high levels of hormones to persist for long periods of time, such as beginning menstruation at an early age (before age 12), experiencing menopause at a late age (after age 55), having a first child after age 30, and not having children at all.A 1996 analysis of worldwide epidemiologic data conducted by the Collaborative Group on Hormonal Factors in Breast Cancer found that women who were current or recent users of birth control pills had a slightly elevated risk of developing breast cancer. The risk was highest for women who started using OCs as teenagers. However, 10 or more years after women stopped using OCs, their risk of developing breast cancer returned to the same level as if they had never used birth control pills, regardless of family history of breast cancer, reproductive history, geographic area of residence, ethnic background, differences in study design, dose and type of hormone, or duration of use. In addition, breast cancers diagnosed in women after 10 or more years of not using OCs were less advanced than breast cancers diagnosed in women who had never used OCs. To conduct this analysis, the researchers examined the results of 54 studies. The analysis involved 53,297 women with breast cancer and 100,239 women without breast cancer. More than 200 researchers participated in this combined analysis of their original studies, which represented about 90 percent of the epidemiological studies throughout the world that had investigated the possible relationship between OCs and breast cancer (2).The findings of the Women’s Contraceptive and Reproductive Experiences (Women’s CARE) study were in contrast to those described above. The Women’s CARE study examined the use of OCs as a risk factor for breast cancer in women ages 35 to 64. Researchers interviewed 4,575 women who were diagnosed with breast cancer between 1994 and 1998, and 4,682 women who did not have breast cancer. Investigators collected detailed information about the participants’ use of OCs, reproductive history, health, and family history. The results, which were published in 2002, indicated that current or former use of OCs did not significantly increase the risk of breast cancer. The findings were similar for white and black women. Factors such as longer periods of use, higher doses of estrogen, initiation of OC use before age 20, and OC use by women with a family history of breast cancer were not associated with an increased risk of the disease (3).

In a National Cancer Institute (NCI)-sponsored study published in 2003, researchers examined risk factors for breast cancer among women ages 20 to 34 compared with women ages 35 to 54. Women diagnosed with breast cancer were asked whether they had used OCs for more than 6 months before diagnosis and, if so, whether the most recent use had been within 5 years, 5 to 10 years, or more than 10 years. The results indicated that the risk was highest for women who used OCs within 5 years prior to diagnosis, particularly in the younger group (4).

How do oral contraceptives affect ovarian and endometrial cancer risk?

Studies have consistently shown that using OCs reduces the risk of ovarian cancer. In a 1992 analysis of 20 studies of OC use and ovarian cancer, researchers from Harvard Medical School found that the risk of ovarian cancer decreased with increasing duration of OC use. Results showed a 10 to 12 percent decrease in risk after 1 year of use, and approximately a 50 percent decrease after 5 years of use (5).

Researchers have studied how the amount or type of hormones in OCs affects ovarian cancer risk reduction. One of the studies used in the Harvard analysis, the Cancer and Steroid Hormone Study (CASH), found that the reduction in ovarian cancer risk was the same regardless of the type or amount of estrogen or progestin in the pill (6). A more recent analysis of data from the CASH study, however, indicated that OC formulations with high levels of progestin reduced ovarian cancer risk more than preparations with low progestin levels (7). In another recent study, the Steroid Hormones and Reproductions (SHARE) study, researchers investigated new, lower-dose progestins that have varying androgenic properties (testosterone-like effects). They found no difference in ovarian cancer risk between androgenic and nonandrogenic pills (8).

OC use in women at increased risk of ovarian cancer due to BRCA1 and BRCA2 genetic mutations has been studied. One study showed a reduction in risk, but a more recent study showed no effect (9, 10).

The use of OCs has been shown to significantly reduce the risk of endometrial cancer. This protective effect increases with the length of time OCs are used, and continues for many years after a woman stops using OCs (11).

How do oral contraceptives affect cervical cancer risk?

Evidence shows that long-term use of OCs (5 or more years) may be associated with an increased risk of cancer of the cervix (the narrow, lower portion of the uterus) (12). Although OC use may increase the risk of cervical cancer, human papillomavirus (HPV) is recognized as the major cause of this disease. Approximately 14 types of HPV have been identified as having the potential to cause cancer, and HPVs have been found in 99 percent of cervical cancer biopsy specimens worldwide (12). More information about HPV and cancer is available in Human Papillomaviruses and Cancer: Questions and Answers at http://www.cancer.gov/cancertopics/factsheet/risk/HPVon the Internet.A 2003 analysis by the International Agency for Research on Cancer (IARC) found an increased risk of cervical cancer with longer use of OCs. Researchers analyzed data from 28 studies that included 12,531 women with cervical cancer. The data suggested that the risk of cervical cancer may decrease after OC use stops (13). In another IARC report, data from eight studies were combined to assess the effect of OC use on cervical cancer risk in HPV-positive women. Researchers found a fourfold increase in risk among women who had used OCs for longer than 5 years. Risk was also increased among women who began using OCs before age 20 and women who had used OCs within the past 5 years (14). The IARC is planning a study to reanalyze all data related to OC use and cervical cancer risk (12).

How do oral contraceptives affect liver cancer risk?

Several studies have found that OCs increase the risk of liver cancer in populations usually considered low risk, such as white women in the United States and Europe who do not have liver disease. In these studies, women who used OCs for longer periods of time were found to be at increased risk for liver cancer. However, OCs did not increase the risk of liver cancer in Asian and African women, who are considered high risk for this disease. Researchers believe this is because other risk factors, such as hepatitis infection, outweigh the effect of OCs (15).

What screening tests are available for the cancers described?

Studies have found that regular breast cancer screening with mammograms reduces the number of deaths from breast cancer for women ages 40 to 69.  Women who are at increased risk for breast cancer should seek medical advice about when to begin having mammograms and how often to be screened. A high-quality mammogram, with a clinical breast exam (an exam done by a professional health care provider), is the most effective way to detect breast cancer early.Abnormal changes in the cervix can often be detected by a Pap test and treated before cancer develops. Women who have begun to have sexual intercourse or are age 21 should check with their doctor about having a Pap test. Researchers are working on developing screening tests for ovarian and endometrial cancer.Women who are concerned about their risk for cancer are encouraged to talk with their health care provider. More information is also available from the Cancer Information Service (see below).

Selected References

1. Burkman R, Schlesselman JJ, Zieman M. Safety concerns and health benefits associated with oral contraception. American Journal of Obstetrics and Gynecology 2004; 190(4 Suppl):S5–22.
2. Collaborative Group on Hormonal Factors in Breast Cancer. Breast cancer and hormonal contraceptives: Collaborative reanalysis of individual data on 53,297 women with breast cancer and 100,239 women without breast cancer from 54 epidemiological studies. Lancet 1996; 347:1713–1727.
3. Marchbanks PA, McDonald JA, Wilson HG, et al. Oral contraceptives and the risk of breast cancer. New England Journal of Medicine 2002; 346(26):2025–2032.
4. Althuis MD, Brogan DD, Coates RJ, et al. Breast cancers among very young premenopausal women (United States). Cancer Causes and Control 2003; 14(2):151–160.
5. Hankinson SE, Colditz GA, Hunter DJ, et al. A quantitative assessment of oral contraceptive use and risk of ovarian cancer. Obstetrics and Gynecology 1992; 80(4):708–714.
6. Centers for Disease Control and Prevention and the National Institute of Child Health and Human Development. The reduction in risk of ovarian cancer associated with oral-contraceptive use. The Cancer and Steroid Hormone Study of the Centers for Disease Control and the National Institute of Child Health and Human Development. New England Journal of Medicine 1987; 316(11):650–655.
7. Schildkraut JM, Calingaert B, Marchbanks PA, Moorman PG, Rodriguez GC. Impact of progestin and estrogen potency in oral contraceptives on ovarian cancer risk. Journal of the National Cancer Institute 2002; 94(1):32–38.
8. Greer JB, Modugno F, Allen GO, Ness RB. Androgenic progestins in oral contraceptives and the risk of epithelial ovarian cancer. Obstetrics and Gynecology 2005; 105(4):731–740.
9. Narod SA, Risch H, Moslehi R, et al. Oral contraceptives and the risk of hereditary ovarian cancer. Hereditary Ovarian Cancer Clinical Study Group. New England Journal of Medicine 1998; 339(7):424–428.
10. Modan B, Hartge P, Hirsh-Yechezkel G, et al. Parity, oral contraceptives, and the risk of ovarian cancer among carriers and noncarriers of a BRCA1 or BRCA2 mutation. New England Journal of Medicine 2001; 345(4):235–240.
11. Emons G, Fleckenstein G, Hinney B, Huschmand A, Heyl W. Hormonal interactions in endometrial cancer. Endocrine-Related Cancer 2000; 7(4):227–242.
12. Franceschi S. The IARC commitment to cancer prevention: The example of papillomavirus and cervical cancer. Recent Results in Cancer Research 2005; 166:277–297.
13. Smith JS, Green J, Berrington de GA, et al. Cervical cancer and use of hormonal contraceptives: A systematic review. Lancet 2003; 361(9364):1159–1167.
14. Moreno V, Bosch FX, Munoz N, et al. Effect of oral contraceptives on risk of cervical cancer in women with human papillomavirus infection: The IARC multicentric case-control study. Lancet 2002; 359(9312):1085–1092.
15. Yu MC, Yuan JM. Environmental factors and risk for hepatocellular carcinoma. Gastroenterology 2004; 127(5 Suppl 1):S72–S78.

Source: National Cancer Institute

©2012 Women's Health First. All Rights Reserved.

About eating disorders

“Mirror, Mirror on the wall…who’s the thinnest one of all?” According to the National Eating Disorders Association, the average American woman is 5 feet 4 inches tall and weighs 140 pounds. The average American model is 5 feet 11 inches tall and weighs 117 pounds. All too often, society associates being “thin”, with “hard-working, beautiful, strong and self-disciplined.” On the other hand, being “fat” is associated with being “lazy, ugly, weak and lacking will-power.” Because of these harsh critiques, rarely are women completely satisfied with their image. As a result, they often feel great anxiety and pressure to achieve and/or maintain an imaginary appearance.

Eating disorders are serious medical problems. Anorexia nervosa, bulimia nervosa, and binge-eating disorder are all types of eating disorders. Eating disorders frequently develop during adolescence or early adulthood, but can occur during childhood or later in adulthood. Females are more likely than males to develop an eating disorder.

Eating disorders are more than just a problem with food. Food is used to feel in control of other feelings that may seem overwhelming. For example, starving is a way for people with anorexia to feel more in control of their lives and to ease tension, anger, and anxiety. Purging and other behaviors to prevent weight gain are ways for people with bulimia to feel more in control of their lives and to ease stress and anxiety.

Although there is no single known cause of eating disorders, several things may contribute to the development of these disorders:

• Culture. In the United States extreme thinness is a social and cultural ideal, and women partially define themselves by how physically attractive they are.

• Personal characteristics. Feelings of helplessness, worthlessness, and poor self-image often accompany eating disorders.

• Other emotional disorders. Other mental health problems, like depression or anxiety, occur along with eating disorders.

• Stressful events or life changes. Things like starting a new school or job or being teased and traumatic events like rape can lead to the onset of eating disorders.

• Biology. Studies are being done to look at genes, hormones, and chemicals in the brain that may have an effect on the development of, and recovery from eating disorders.

• Families. Parents’ attitudes about appearance and diet can affect their kids’ attitudes. Also, if your mother or sister has bulimia, you are more likely to have it.

Over-exercising

For more information on exercise and healthy eating, visit our fitness and nutrition section.

Too much of a good thing can be very bad for you. Just like eating disorders, societal pressures to be thin can also push women to exercise too much. Over-exercise is when someone engages in strenuous physical activity to the point that is unsafe and unhealthy. In fact, some studies indicate that young women who are compelled to exercise at excessive levels are at risk for developing eating disorders.

Eating disorders and over-exercising go hand-in-hand — they both can be a result of an unhealthy obsession with your body. The most dangerous aspect of over-exercising is the ease with which it can go unrecognized. The condition can be easily hidden by an emphasis on fitness or a desire to be healthy. Like bulimia and anorexia, in which persons deny themselves adequate nutrition by restrictive eating behaviors, over-exercising is a controlled behavior that denies the body the energy and nutrition needed to maintain a healthy weight.

According to the American Journal of Sports Medicine, a host of physical consequences can result from over-exercising — pulled muscles, stress fractures, knee trauma, shin splints, strained hamstrings, and ripped tendons.

Remember, fitness should be done within limits and integrated into your lifestyle, done in moderation like everything else in life. If exercising is getting in the way of your daily activities or relationships, you may need to slow down.

More information on eating disorders see: womenshealth.gov
•Anorexia Nervosa Fact Sheet— This fact sheet explains anorexia’s causes, signs and symptoms, and its effects on the body. It also provides information for pregnant women who have or have had anorexia.

•Binge Eating Disorder Fact Sheet— This fact sheet provides information on binge eating disorder, including potential causes, associated risks, and possible treatments.

•Bulimia Nervosa Fact Sheet— This fact sheet answers common questions about bulimia nervosa, including its causes, warning signs, complications, and available treatment options.

Explore other publications and websites:

•50 Ways to Lose the 3 Ds: Dieting, Drive for Thinness, and Body Dissatisfaction (Copyright © National Eating Disorders Association) — This tip sheet offers advice about how you can improve your body image and make sure your children grow up with a positive body image, too.

•Binge Eating Disorder — This fact sheet describes the symptoms, causes, complications, and treatment of binge eating disorder, and gives a profile of those at risk for the disorder.

•Compulsive Exercise (Copyright © Nemours Foundation) — This publication provides information on compulsive exercise, its warning signs, and the serious effects it can have on a teenager’s health.

•Consequences of Eating Disorders (Copyright © Academy for Eating Disorders) — This Web page describes the psychosocial and medical consequences of eating disorders over the long term. It has information about what happens to the different functions of your body, and other conditions that people with eating disorders are likely to have.

•Diagnoses of Eating Disorders (Copyright © Academy for Eating Disorders) — This Web page describes the warning signs of various eating disorders and discusses how they are diagnosed. If you are worried about a friend or family member, this site can help you find out if certain behaviors could indicate an eating disorder.

•Eating Disorders — This detailed booklet describes symptoms, causes, and treatments of eating disorders. It also includes information on getting help and coping.

•Eating Disorders (Copyright © American Psychological Association) — This fact sheet describes anorexia, bulimia, and binge eating disorder, as well as who suffers from them and how a psychologist can help.

•Eating Disorders (Copyright © Mayo Foundation) — This Web page describes the signs, symptoms, and causes of eating disorders, and gives information about treatments.

•GirlsHealth.gov: Your Feelings — We have created the GirlsHealth.gov section to help adolescent girls (ages 10-16) learn more about some of the unique health issues and social situations they will encounter during the teen years. The feelings section provides resources and links to useful information to help you prepare to deal with some of the issues your girls will likely face.

•How to Afford Appropriate Treatment for an Eating Disorder: A Guide for Patients & Their Families (Copyright © National Eating Disorder Association) — This publication provides detailed information about health insurance, where to find help for eating disorders, and where to get financial assistance for treatment.

•How to Help a Friend with Eating and Body Image Issues (Copyright © National Eating Disorders Association) — This publication describes how you can help a friend who has a poor body image or an eating disorder.

•Mental Health Services Locator — This website will help you locate mental health treatment facilities and support services in your state.

•Orthorexia Nervosa (Copyright © National Eating Disorders Association) — This publication explains the symptoms of and treatment for orthorexia.

•Risk Factors of Eating Disorders (Copyright © Academy for Eating Disorders) — This fact sheet discusses the risk factors that might make someone more likely to develop an eating disorder, such as gender, ethnicity, weight, and genetic factors.

•Treatment (Copyright © Academy for Eating Disorders) — This fact sheet discusses different treatment options available for people with eating disorders. It includes information about the initial assessment, psychological treatments, medical treatments, and more.

•What’s Going On With Me? Evaluating Eating and Exercising Habits (Copyright © National Eating Disorders Association) — This fact sheet explains the difference between regular and “disordered” eating. It identifies behaviors that are common in people with disordered eating, and explains how these behaviors can take a toll on your mental and physical well-being.

Connect with other organizations

•Academy for Eating Disorders

•American Psychological Association

•Eating Disorders Anonymous

•National Association of Anorexia Nervosa and Associated Disorders

•National Association to Advance Fat Acceptance

•National Eating Disorders Association

•National Institute of Mental Health, NIH, HHS

•Overeaters Anonymous

•T.H.E. (Treatment, Healing, Education) Center for Disordered Eating

Source: U.S. Department of Health and Human Services Office on Women’s Health

©2012 Women's Health First. All Rights Reserved.

What is screening?

Screening is looking for cancer before a person has any symptoms. This can help find cancer at an early stage. When abnormal tissue or cancer is found early, it may be easier to treat. By the time symptoms appear, cancer may have begun to spread.

Cervical cancer is a disease in which malignant (cancer) cells form in the cervix.

The cervix is the lower, narrow end of the uterus (the hollow, pear-shaped organ where a fetus grows). The cervix leads from the uterus to the vagina (birth canal).

Cervical cancer usually develops slowly over time. Before cancer appears in the cervix, the cells of the cervix go through changes known as dysplasia, in which cells that are not normal begin to appear in the cervical tissue. Later, cancer cells start to grow and spread more deeply into the cervix and to surrounding areas.

The following summaries are about cervical cancer:

• Cervical Cancer Treatment
• Cervical Cancer Prevention

Screening for cervical cancer using the Pap test has decreased the number of new cases of cervical cancer and the number of deaths due to cervical cancer since 1950.

Cervical dysplasia occurs more often in women who are in their 20s and 30s. Death from cervical cancer is rare in women younger than 30 years and in women of any age who have regular screenings with the Pap test. The Pap test is used to detect cancer and changes that may lead to cancer. The chance of death from cervical cancer increases with age. Deaths from cervical cancer occur more often in black women than in white women.

Human papillomavirus (HPV) infection is the major risk factor for development of cervical cancer.

Although most women with cervical cancer have the human papillomavirus (HPV) infection, not all women with an HPV infection will develop cervical cancer. Many different types of HPV can affect the cervix and only some of them cause abnormal cells that may become cancer. Some HPV infections go away without treatment.

HPV infections are spread mainly through sexual contact. Women who become sexually active at a young age and have many sexual partners are at increased risk for HPV infections.

Other risk factors for cervical cancer include:

• Having many sexual partners.
• Giving birth to many children.
• Having first sexual intercourse at a young age.
• Smoking cigarettes.
• Using oral contraceptives (“the Pill”).
• Having a weakened immune system.

Tests are used to screen for different types of cancer.

Some screening tests are used because they have been shown to be helpful both in finding cancers early and in decreasing the chance of dying from these cancers. Other tests are used because they have been shown to find cancer in some people; however, it has not been proven in clinical trials that use of these tests will decrease the risk of dying from cancer.

Scientists study screening tests to find those with the fewest risks and most benefits. Cancer screening trials also are meant to show whether early detection (finding cancer before it causes symptoms) decreases a person’s chance of dying from the disease. For some types of cancer, the chance of recovery is better if the disease is found and treated at an early stage.

Clinical trials that study cancer screening methods are taking place in many parts of the country. Information about ongoing clinical trials is available from the NCI Web site.

Studies show that screening for cervical cancer helps decrease the number of deaths from the disease.

Regular screening of women between the ages of 25 and 60 years with the Pap test decreases their chance of dying from cervical cancer. In women younger than 25 years, screening with the Pap test may show changes in the cells of the cervix that are not cancer but lead to further testing and possibly treatment. Screening with the Pap test is not helpful in women older than 60 years who have had recent negative Pap tests.

A Pap test is commonly used to screen for cervical cancer.

A Pap test is a procedure to collect cells from the surface of the cervix and vagina. A piece of cotton, a brush, or a small wooden stick is used to gently scrape cells from the cervix and vagina. The cells are viewed under a microscope to find out if they are abnormal. This procedure is also called a Pap smear. A new method of collecting and viewing cells has been developed, in which the cells are placed into a liquid before being placed on a slide. It is not known if the new method will work better than the standard method to reduce the number of deaths from cervical cancer.

Screening tests have risks.

Decisions about screening tests can be difficult. Not all screening tests are helpful and most have risks. Before having any screening test, you may want to discuss the test with your doctor. It is important to know the risks of the test and whether it has been proven to reduce the risk of dying from cancer.

The risks of cervical cancer screening include the following:

False-negative test results can occur.

Screening test results may appear to be normal even though cervical cancer is present. A woman who receives a false-negative test result (one that shows there is no cancer when there really is) may delay seeking medical care even if she has symptoms.

False-positive test results can occur.

Screening test results may appear to be abnormal even though no cancer is present. Also, some abnormal cells in the cervix never become cancer. A false-positive test result (one that shows there is cancer when there really isn’t) can cause anxiety and is usually followed by more tests and procedures (such as colposcopy, cryotherapy, or LEEP), which also have risks. The long-term effects of these procedures on fertility and pregnancy are not known.

Women aged 20 to 24 are most likely to have abnormal Pap test results that lead to further testing and treatment.

Your doctor can advise you about your risk for cervical cancer and your need for screening tests.

Studies show that the number of cases of cervical cancer and deaths from cervical cancer are greatly reduced by screening with Pap tests. Many doctors recommend a Pap test be done every year. New studies have shown that after a woman has a Pap test and the results show no sign of abnormal cells, the Pap test can be repeated every 2 to 3 years.

The Pap test is not a helpful screening test for cervical cancer in the following groups of women:

• Women who are younger than 25 years.
• Women who have had a total hysterectomy (surgery to remove the uterus and cervix) for a condition that is not cancer.
• Women who are aged 60 years or older and have a Pap test result that shows no abnormal cells. These women are very unlikely to have abnormal Pap test results in the future.

The decision about how often to have a Pap test is best made by you and your doctor.

©2012 Women's Health First. All Rights Reserved.

Sleep Health Overview

Goal
Increase public knowledge of how adequate sleep and treatment of sleep disorders improve health, productivity, wellness, quality of life, and safety on roads and in the workplace.

Overview
Poor sleep health is a common problem with 25 percent of U.S. adults reporting insufficient sleep or rest at least 15 out of every 30 days.1 The public health burden of chronic sleep loss and sleep disorders, coupled with low awareness of poor sleep health among the general population, health care professionals, and policymakers, necessitates a well-coordinated strategy to improve sleep-related health.

Why Is Sleep Health Important?
Sleep, like nutrition and physical activity, is a critical determinant of health and well-being.2 Sleep is a basic requirement for infant, child, and adolescent health and development. Sleep loss and untreated sleep disorders influence basic patterns of behavior that negatively affect family health and interpersonal relationships. Fatigue and sleepiness can reduce productivity and increase the chance for mishaps such as medical errors and motor vehicle or industrial accidents.3, 4

Adequate sleep is necessary to:

-Fight off infection
-Support the metabolism of sugar to prevent diabetes
-Perform well in school
-Work effectively and safely
-Sleep timing and duration affect a number of endocrine, metabolic, and neurological  functions that are critical to the maintenance of individual health. If left untreated, sleep disorders and chronic short sleep are associated with an increased risk of:

-Heart disease
-High blood pressure
-Obesity
-Diabetes
-All-cause mortality

Sleep health is a particular concern for individuals with chronic disabilities and disorders such as arthritis, kidney disease, pain, human immunodeficiency virus (HIV), epilepsy, Parkinson’s disease, and depression. Among older adults, the cognitive and medical consequences of untreated sleep disorders decrease health-related quality of life, contribute to functional limitations and loss of independence, and are associated with an increased risk of death from any cause.

Understanding Sleep Health
The odds of being a short sleeper (defined as someone who sleeps less than 6 hours a night) in the United States have increased significantly over the past 30 years.8 Competition between sleep schedules, employment, and lifestyle is a recent trend. Intermittent sleep disturbances due to lifestyle choices are associated with temporary fatigue, disorientation, and decreased alertness.

Sleep-disordered breathing (SDB), which includes sleep apnea, is another serious threat to health. SDB is characterized by intermittent airway obstruction or pauses in breathing. People with untreated SDB have 2 to 4 times the risk of heart attack and stroke.9, 10 Obesity is a significant risk factor for SDB, and weight loss is associated with a decrease in SDB severity

SDB in Children:
African American children are at least twice as likely to develop SDB than children of European descent.12 The risk of SDB during childhood is associated with low socioeconomic status independent of obesity and other risk factors.13 Left untreated, SDB in children is associated with difficulties in school, metabolic disorders, and future heart disease risk.

SDB in Older Adults:
SDB may affect 20 to 40 percent of older adults and, if left untreated, is associated with a 2- to 3-fold increased risk of stroke and mortality.15, 16
Sleep health education and promotion strategies are needed to address disparities in sleep health across age, race, education, and socioeconomic groups. Health education and promotion programs can increase awareness of common sleep disorders, such as insomnia, restless leg syndrome, and SDB. Sleep health education programs in workplaces can promote better work schedule patterns and motivate managers and workers to adopt strategies that reduce risks to health and safety. Without sleep health education, individuals often prioritize other activities over sleep and accept constant sleepiness and sleep disruption as inevitable.

Emerging Issues in Sleep Health
Progress in the following areas will yield more information on sleep health over the coming decade:

-Further evolution of biomedical sleep research.
-Quantification of health risks associated with untreated SDB across the lifespan.
-Findings from the first U.S.-based phase III SDB treatment trials in children and adults.

Objectives:
-Increase the proportion of persons with symptoms of obstructive sleep apnea who seek medical evaluation Increase the proportion of persons with symptoms of obstructive sleep apnea who seek medical evaluation
Baseline: 25.5 percent of persons with symptoms of obstructive sleep apnea sought medical evaluation in 2005–08 (age adjusted to the year 2000 standard population)

-Reduce the rate of vehicular crashes per 100 million miles traveled that are due to drowsy driving Reduce the rate of vehicular crashes per 100 million miles traveled that are due to drowsy driving
Baseline: 2.7 vehicular crashes per 100 million miles traveled were due to drowsy driving in 2008.
-Increase the proportion of students in grades 9 through 12 who get sufficient sleep Increase the proportion of students in grades 9 through 12 who get sufficient sleep
Baseline: 30.9 percent of students in grades 9 through 12 got sufficient sleep (defined as 8 or more hours of sleep on an average school night) in 2009
-Increase the proportion of adults who get sufficient sleep Increase the proportion of adults who get sufficient sleep.

Source:  U.S. Department of Health and Human Services

©2012 Women's Health First. All Rights Reserved.

Pelvic Inflammatory Disease (PID)
Pelvic inflammatory disease (PID) is a general term that refers to infection and inflammation of the upper genital tract in women. It can affect the infection and inflammation (womb), fallopian tubes (tubes that carry eggs from the ovaries to the uterus), ovaries, and other organs related to reproduction. The scarring that results on these organs can lead to infertility, tubal (ectopic) pregnancy, chronic pelvic pain, abscesses (sores containing pus), and other serious problems. PID is the most common preventable cause of infertility in the United States.

Women at greater risk for PID include those at risk for sexually transmitted diseases (STDs) and those with a prior episode of PID. Sexually active women under age 25 are at risk as well because the cervix (opening to the uterus) of teens and young women has greater susceptibility to STDs. This may be because the cervix of teenage girls and young women is not fully matured, increasing their risk for STDs linked to PID.

Other potential risk factors include douching. Douching can change the vaginal flora and can force bacteria from the vagina into the upper reproductive organs. In some women, using an intrauterine device (IUD) to prevent pregnancy can also cause PID. Rarely, PID results from gynecological procedures or surgeries.

In the United States, it is estimated that more than 750.000 women suffer from an episode of acute PID each year, according to the Centers for Disease Control and Prevention (CDC). Up to 10-15% of women may become infertile as a result of PID.

Symptoms

Cause

Although many different microbes (germs) can cause PID, many cases of PID are associated with gonorrhea and chlamydia, two very common sexually transmitted infections caused by bacteria.

Prevention

The surest way to avoid getting or transmitting sexually transmitted diseases (STDs) is to abstain from sex or to be in a long-term, mutually monogamous relationship with a partner who has been tested and isn’t infected. Condoms, when used consistently and correctly, can reduce your risk of getting chlamydia and gonorrhea.

In addition, you can protect yourself from PID by getting treated quickly if you do get an STD.

The most common preventable cause of PID is an untreated STD, mainly chlamydia or gonorrhea. The Centers for Disease Control and Prevention recommends yearly chlamydia testing of all sexually active women age 25 or younger and  older women with risk factors for chlamydia (those who have a new sex partner or many sex partners). If you have had chlamydia, you also should be re-tested several months after completing treatment so you can be re-treated, if necessary.

Treatment

According to Centers for Disease Control and Prevention (CDC), healthcare providers should start treating sexually active young women and other women at risk for STIs if they have motion tenderness of the uterus, ovaries, fallopian tubes, or cervix. Without adequate treatment, 20 to 40 percent of women with chlamydia and 10 to 40 percent of women with gonorrhea may develop PID.

Many different bacteria may cause an episode of PID. Therefore, your healthcare provider will prescribe antibiotics (generally two at once, by injection or by mouth) that are effective against a wide range of bacteria, including those causing chlamydia and gonorrhea. You should begin treatment as soon as your healthcare provider diagnoses PID because you may prevent getting complications of the disease by taking antibiotics immediately.

Women who douche may have higher risk of developing PID. Douching can change the vaginal flora and can force bacteria from the vagina into the upper reproductive organs.

Even if your symptoms go away, you should finish taking all of the medicine. You also should return to your healthcare provider 2 to 3 days after beginning the medicine to be sure the antibiotics are working.

Your healthcare provider may recommend going into the hospital to treat your PID if you

• Are severely ill
• Are pregnant
• Do not respond to or cannot take oral medicine
• Need intravenous (in the vein) antibiotics
• Have an abscess (swelling) in your fallopian tube or ovary

If your symptoms continue or if an abscess does not go away, you may need surgery.

Complications of PID such as chronic pelvic pain and scarring are difficult to treat, but sometimes they improve with surgery.

Many sex partners may be infected with bacteria that cause PID and do not know it because they do not have symptoms. To protect yourself from being re-infected with bacteria that cause PID, you should discuss this with your healthcare provider.

For updated information on treatment for PID, read the CDC STD Treatment Guidelines.

Complications

Prompt and appropriate treatment can help prevent complications of PID. Without treatment, PID can cause permanent damage to the female reproductive organs. Infection-causing bacteria can silently invade the fallopian tubes, causing normal tissue to turn into scar tissue. This scar tissue blocks or interrupts the normal movement of eggs into the uterus.

If your fallopian tubes are totally blocked by scar tissue, sperm cannot fertilize an egg and you become infertile. Infertility also can occur if the fallopian tubes are partially blocked or even slightly damaged. About one in five women with PID becomes infertile.

In addition, a partially blocked or slightly damaged fallopian tube may cause a fertilized egg to remain in the fallopian tube. If this fertilized egg begins to grow in the tube as if it were in the uterus, it is called an ectopic or tubal pregnancy. An ectopic pregnancy can rupture the fallopian tube, causing severe pain, internal bleeding, and even death.

Scarring in the fallopian tubes and other pelvic organs can also cause chronic pelvic pain (pain lasting for months or even years). You are more likely to suffer infertility (20 percent of women), ectopic pregnancy (9 percent), or chronic pelvic pain (18 percent) if you have repeated episodes of PID.

Source: U.S. Department of Health & Human Services

©2012 Women's Health First. All Rights Reserved.