Period 27 Miscarriages and heat
It’s the first week of classes, but not for me! I’m on teaching leave this year to focus both on some administrative work for the university and to write my book. Last semester was one of the best semesters of teaching I’ve ever had, yet I’m really looking forward to this year. I’ll miss the students – I swear they get smarter and better every year. I am glad of having it off my plate, though, to make room for other things. The prep, the grading, the emails, and the emotional labor, especially in the kinds of classes I like to teach, can grind me down. I’m eager to put that energy into my writing.
I’ll share one thing I’ve been reading and thinking about this week: miscarriage misdiagnosis. If you’ve ever seen miscarriage portrayed in movie, television, or novel form, it’s probably been a dramatic moment of bleeding, like Grey’s and Bailey’s miscarriages over the years on Grey’s Anatomy. Maybe there’s a single, quick scan to confirm. But identifying and diagnosing miscarriage is incredibly difficult for several reasons: gestational age estimates are almost always off, there is decent interobserver variability in how scans are read, especially for tiny little embryos, and sometimes those embryos/fetuses “hide” from the scan but is in fact in there (to be clear, this last one is pretty rare). But we also now know that growth rates are much more variable in early pregnancy than was previously thought, so what a single scan might suggest is a miscarriage may in fact just be a slow growing embryo, or a young one that was misdated.
If you have ever been in this situation of suspected or actual miscarriage, you might have been given really vague language about “possible” or “threatened” miscarriage, maybe even had to schedule a follow up scan a week or two later. If that was the case for you, you were receiving good care. We all want direct and clear answers – am I miscarrying or not? But the only way to truly know as much as half the time is to wait and see. Here, clear communication is crucial and is something you deserve: a person potentially miscarrying deserves to have the situation explained.
Based off my reading of the fights that happened about ten years ago between radiologists and obstetricians about miscarriage diagnosis guidelines, I offer a few questions to take with you for a visit like this:
Is the embryo smaller than expected? Is the gestational sac empty? Are the hCG numbers off? What exactly about the measurements are concerning?
What will be measured in follow up and how will a progressing versus ending pregnancy be diagnosed at that visit?
If it turns out I’m miscarrying, can I have the embryonic/fetal materials assessed to see if it was genetic, an infection, or other cause? (This might be hard to convince your physician of unless it’s a second or third miscarriage, but it is 100% worth it to ask!)
If it turns out I’m miscarrying, what are my options for management?
Some things you will want to have with you is the date of your last menstrual period, and if you were measuring your own ovulation day (ovulation kit/LH strip) or implantation day (hCG/home pregnancy test) bring the days those occurred too. Depending on when your ovulation/implantation day actually was versus what they assume it was based on last menstrual period can be off by two weeks!
Please note none of this is medical advice nor medical care. These are the questions I would ask and the things I’d push on in order to better understand what is happening and how much of a gray area I’m really in. Is the physician just doing due diligence but is 95% convinced it’s a miscarriage? Or are they truly unsure? Does providing my ovulation and/or implantation day, or telling them about my typically irregular cycle length, change their read of gestational age?
I’m not going to talk about pregnancy loss that much on this here newsletter (cough cough until it’s time to start talking about Book Two), but this week as I was reading the literature I felt very passionately that people should understand that at least half the time miscarriage diagnosis, when done well, takes time. And while it means sitting in uncertainty for some period of time, you deserve at that visit to be able to ask every conceivable question you have so you understand as much as you can.
Links
Oh look New Jersey is making period products free to all sixth to twelfth graders! I need people to understand that not making these freely available everywhere is like saying only some people deserve toilet paper when they use the bathroom. We all need bathroom accommodations, it’s just only those of us who menstruate who need to talk about them all the time. So, thanks New Jersey and especially the activists who made this happen! Illinois, you’re next!
Kaiser Permanente is reinstating their mask mandate amid rising cases of covid. I know so many people who got covid this summer, many of whom were getting it for the first time, not because they relaxed their practices, but because everyone else around them stopped caring. If I’m in a crowded room and the only one masking I am not really that safe. Please consider that as cases climb and as this variant looks to be the most evasive yet. Listen, I’ll be getting the next booster as soon as it’s out in order to reduce severity if I am exposed, but you need to understand covid vaccines don’t reduce transmission. To reduce transmission and care about people around you you need to mask. Even if you don’t care if you get it. I care if you give it to asthmatic me, my children, my two-time-cancer-surviving husband, or my friends.
Sneaking this in even though the deadline is TONIGHT: bid on these bookish auction items, the proceeds of which go to support wildfire victims in Maui.
Weird period fact: heat stress and menstrual cycles
Thanks to colleague Dr. Katie Lee for asking me about heat stress this morning in a meeting; without her there would have been no weird period fact today! But down the rabbit hole we go…
It’s been a hot week, and since fossil fuel and other climate disaster corporations are hell bent on making it hotter, expect more in the coming years! Of course the question is, to what extent does heat stress affect the menstrual cycle?
I suspected there would be a bit of a literature among domesticated animals, because capitalism. You will find some of the most sophisticated and thorough research on reproduction of cows because they are an expensive business! It turns out, people have also looked at heat stress on sheep. Very, very little work has been done on humans, but I was thrilled to see one paper from this year on the topic that I’ll get to in a moment.
The short answer is that heat is stressful, and we know that things that stress our bodies take energy, and if we are taking extra energy to regulate our temperature, and hydration, and adapt our physical activity in the context of hotter temperatures, then we may end up with less energy to allocate towards reproduction. Heat stress isn’t just an energetic issue though; it’s also an inflammatory one. All that additional exertion can lead to the secretion of inflammatory cytokines, like IL-6.
What does this do to elements of the menstrual cycle? Well in cows it looks like it messes with ovulatory function and reduces their rates of conception; in ewes a study has noted a reduction in progesterone in the hotter months. Given some of the basics of mammalian reproduction it wouldn’t surprise me if these effects were about the same in humans.
But I said there was a human study, right? Out this year even! The findings are supportive of what’s found among domestic animals, but the methods were very different. Study authors did more of a comparative study between two groups of people who lived in a hotter region of China and a cooler region of China. They examined differences between these groups, but we don’t know how adapted these populations are to their regions or anything (inclusion criteria were that they had to have lived in that region at least six months, but later in the discussion participants are described as “young migrant women”). They found that the high temperature group reported having more menstrual disorders, especially “heavy menstruation,” and were more likely to experience anxiety. They also collected saliva and performed some additional analyses. Study authors found that metabolites in the saliva of the high temperature group indicated that the body’s immune system was upregulated, and that cell membrane stability might be more compromised. Basically: the body was busy with a lot of other stuff when it was overheated, some of which is relevant to the menstrual cycle but a lot of it is just relevant with being preoccupied with staying alive and therefore less occupied with reproducing.
So: your cycle could be a little wonky when it’s hot out, and if you’re looking to get pregnant that could be compromised too. Maybe we should care about this planet before it’s too late!
Sources:
1. Wei, M. et al. Characteristics of menstrual cycle disorder and saliva metabolomics of young women in a high-temperature environment. Front Physiol 13, 994990 (2022).
2. Notley, S. R., Dervis, S., Poirier, M. P. & Kenny, G. P. Menstrual cycle phase does not modulate whole body heat loss during exercise in hot, dry conditions. J Appl Physiol (1985) 126, 286–293 (2019).
3. De Rensis, F., Saleri, R., Garcia-Ispierto, I., Scaramuzzi, R. & López-Gatius, F. Effects of Heat Stress on Follicular Physiology in Dairy Cows. Animals (Basel) 11, 3406 (2021).
4. Macías-Cruz, U. et al. Effects of summer heat stress on physiological variables, ovulation and progesterone secretion in Pelibuey ewes under natural outdoor conditions in an arid region. Anim Sci J 87, 354–360 (2016).