While most pregnancies result in the birth of a healthy baby, every parent knows that some don’t.

Understanding miscarriage

The most common time for something to go wrong with a pregnancy is in the first days and weeks after conception. Many different conditions can lead to miscarriage at this time.

It’s thought many early miscarriages go undetected. If your period arrives as normal you may never even suspect you were pregnant.
About one in six confirmed pregnancies (when a pregnancy test has proved positive) miscarries, usually before 12 weeks. Most women who have one miscarriage go on to have a normal, healthy pregnancy next time.

If you miscarry at home, you’ll need to see your doctor and may also have to go to hospital. In some situations, you may need an operation called a dilatation and curettage (D&C) to be sure your uterus is clear.

Reasons for miscarriage

Miscarriage isn’t fully understood. Some miscarriages just happen with no explanation other than nature ‘taking a hand’ and expelling an embryo that’s less than perfect.

Other possibilities include:

• Blighted ovum – when a fertilised egg doesn’t develop as it should.
• Illness in the mother – for example, high fever due to a viral illness in early pregnancy.
• Problems with the cervix – the cervix starts to open and the uterus contracts, pushing the baby out too soon, often before 20 weeks.
• Ectopic pregnancy – the embryo develops in one of the fallopian tubes.
• Hydatidiform mole – this rare problem isn’t a real pregnancy, as there’s no fertilised egg. Instead, the body responds with pregnancy hormones to the development of a collection of fluid-filled sacs growing from tissue that would have become the placenta if the pregnancy had been successful. An operation may be needed to remove the mole, but hormonal treatment is also available.

Later miscarriage and stillbirth

Miscarriage is defined as the spontaneous loss of a foetus before 24 weeks. Stillbirth is when a baby dies in the uterus after this date.
Reasons for late miscarriages and stillbirths include:

• Poor nourishment by the placenta, which means the baby lacks oxygen and doesn’t survive.
• An abnormality in the baby’s development.

Sometimes babies die suddenly inside the womb without any apparent reason. In such cases, the mother often realises the baby has stopped moving – although you shouldn’t assume this is the only reason for lack of movement if it happens to you. Babies vary in their activity levels, and may even sleep for long periods.

If you think your baby has stopped moving, call the hospital. If there’s any concern, it may be suggested that you come to the antenatal clinic so they can listen to the baby’s heart.

You and your baby

Miscarriage is always a sad event, and both you and your partner will need understanding, sympathy and support. You may want to talk over the possible reasons for the miscarriage with a doctor and ask about becoming pregnant again.

In most cases, there’s no reason why you shouldn’t go on and become pregnant again fairly soon. However, you may want to wait for your next period so you can tell when you’ll be able to conceive.

With a late miscarriage, you might find it helpful to see and hold your baby, if that is possible. If your baby has grown enough and your loss has happened in hospital, you may be helped to dress them. A midwife or doctor may also take a photograph for you to keep. Many parents are glad to have had this opportunity to express their love and sadness.

You may be asked permission for a post-mortem examination. It may help to find out why your baby died. A post-mortem is done carefully and won’t affect how your baby looks.

Could I have prevented my miscarriage?

Miscarriage is almost always something that’s outside your control. Your doctor may be able to reassure you about this. Don’t blame yourself for something you couldn’t prevent.

Research into miscarriage

These are some of the latest theories why some women miscarry:

• Some women may have a ‘rogue gene’ that makes them more likely to miscarry repeatedly.
• Some painkillers used in early pregnancy appear to be linked with a higher risk of miscarriage.
• A malfunction in the mother’s immune system may lead it to identify the foetus as a foreign invader and destroy it.
• Women with recurrent miscarriage may have antiphospholipid syndrome. In this disorder, antibodies are produced against cell membrane phospholipids, increasing the risk of thrombosis and miscarriage.

The shock of an unintended pregnancy can leave you feeling scared and lost, even if you’re in a steady relationship. This is a time when you need all the support you can get.

There are lots of organisations that can provide expert, confidential and impartial advice and counselling if you find yourself facing an unplanned pregnancy. They can help you to consider the options and will support you once you’ve decided what is right for you.

They offer advice about everything, from where and how to seek help if you choose to continue with the pregnancy, to details of adoption agencies and abortion clinics.

Adoption

If you decide you’re not in the position to raise your own child but don’t want to terminate the pregnancy, you may want to consider adoption.

Before making a decision, it’s important you’re aware of all the facts. You’ll be advised to discuss things with your family, a counsellor and a social worker or adoption agency. You need to be aware of your rights and responsibilities and think carefully about what will happen during your pregnancy and afterwards.

There’s a large demand for adoptive children, especially babies, through a variety of charities or local social services. Potential parents are scrutinised and great care is taken in placing these babies with the right family. If you decide to go ahead with adoption, the adopted parents will then have legal responsibility for the baby.

After you’ve had your baby adopted, you’re likely to feel very emotional. It’s normal to feel a mixture of guilt, loss and grief, even if you’ve thought long and hard before making your decision and are certain you’ve made the right choice. It’s important that you don’t ignore these feelings. Several adoption organisations offer counselling and support.

What are the causes?

After a year of trying to get pregnant, around one in seven couples won’t have conceived.

In about 30 per cent of cases, the woman has a problem with ovulation, or releasing eggs. In another 20 per cent, there are other problems in the woman, such as endometriosis, previous pelvic infection or fibroids. These problems can block the passage of the egg or sperm through the fallopian tubes or prevent the fertilised egg implanting in the lining of the womb.

In about 20 per cent of cases, the problem is found to lie with the man. Most often this is a very low sperm count.

In the remaining 30 per cent, no cause can be identified.

Miscarriage is common, even among fertile women. A considerable number of women who think they’re infertile do manage to conceive but miscarry before they know they’re pregnant.

What will your doctor do?

Your doctor will want to know about your development as a teenager and your periods. They’ll ask when they started, how regular they are, whether you’ve ever been pregnant before or whether you’ve ever had a pelvic infection or sexually transmitted infection.

It’s also important to mention any other illnesses you’ve had and any medication you may be taking.

Your doctor will examine you, including an internal examination, and send you for blood tests to check your blood count and hormone levels.

Your doctor may ask your partner about his development too, check his medical history for problems such as mumps, examine him and give him instructions to collect a semen sample for testing.

They may then refer you to a specialist clinic for further tests and advice. This is usually done once you’ve been trying to get pregnant for at least 18 months, but may be sooner if you’re in your mid-30s or older.

What can specialists do?

Once referred to a fertility specialist (a reproductive medicine specialist), the cause of your infertility will be investigated.

The treatment will depend on the cause. It can range from hormone treatments and the use of donor sperm, to assisted conception techniques such as in vitro fertilisation (IVF) or intracytoplasmic sperm injection (ICSI).

IVF and ICSI

IVF involves removing eggs from the woman’s ovaries and mixing them with either her partner’s or a donor’s sperm in a laboratory. If the eggs are fertilised successfully, they may then be placed back in the womb.

This is a demanding treatment for the couple and only about one in three women will become pregnant. Some of these pregnancies will be lost in the early stages. Many cycles may be required.

ICSI is sometimes recommended to couples who’ve had no success with IVF. It involves injecting a single sperm into the egg. If a healthy embryo develops, it’s then placed back in the womb as in IVF.

PMS is the name given to the physical and psychological symptoms that appear regularly before a period, but improve when bleeding begins. It’s widely accepted as a recognised medical condition that affects one in three women.

What are the symptoms?

There are more than 150 symptoms associated with PMS and a woman’s individual symptoms can vary from month to month.
The most common symptoms include:

• Depression and agitation
• Breast tenderness
• Fluid retention and bloating
• Irritability and mood swings
• Headaches
• Skin and hair changes

Some women’s lives are badly disrupted by these symptoms, which can appear up to two weeks before a period.

What causes it?

No one knows the exact cause of PMS, although it’s thought to be linked to the fluctuations in hormone levels that occur throughout the menstrual cycle.

Women with low levels of the chemical serotonin have been found to be particularly sensitive to levels of the hormone progesterone, which is thought may lead to symptoms of PMS.

Who’s affected?

Women of all ages suffer from PMS, but it can be more of a problem at these times:

• After childbirth
• During your 30s and 40s
• During times of stress

PMS is often worse at either end of a woman’s reproductive life, around puberty and before the menopause.

What’s the treatment?

If you think you’re suffering from PMS, it may be helpful to keep a diary of symptoms so you can identify patterns and possible triggers.
Keeping to a diet that’s low in salt, fat and caffeine but high in fibre, and eating small, regular meals, can be beneficial. Make sure you put aside time for regular exercise and relaxation.

Vitamins B6 and E, gamma-linolenic acid (GLA), calcium and magnesium have all been recommended for PMS. Many women find them helpful, but studies have mixed results. Flower oils such as evening primrose and starflower (which contain GLA) have also been advocated by some sufferers.

Your doctor can give advice if these simple measures don’t work. They may recommend hormone treatments – either the contraceptive pill or progestogen may be helpful.

Selective serotonin reuptake inhibitors (SSRIs), a type of antidepressant drug often used to treat depression and anxiety, may also be prescribed.

Hysterectomy and PMS

Sometimes doctors advise removing the ovaries during a hysterectomy because this can be effective for PMS. Such advice, however, is controversial.

Removing the ovaries is a big step. It causes the menopause in women who haven’t yet reached it and increases the risk of osteoporosis unless women take hormone replacement therapy (HRT) for some years, which carries its own risks.

Women who keep their ovaries during a hysterectomy may not escape their PMS as the ovaries continue the hormonal cycle until the menopause, even though they can’t have periods.

How much sleep do we need?

Most adults need between seven and eight hours’ sleep each night, although we’re all different. Some people find they can manage on just three hours. The amount we need reduces as we age. Older women often find their night’s sleep is broken, especially if they’ve taken a nap during the day.

Self-help

There are many remedies for sleep problems, some more effective than others. The most important thing is to have a good bedtime routine, as this helps to prepare the mind for sleep.

Other things you might like to try include:

• Going to sleep and waking up at the same time every day, whether you’re tired or not.
• Making sure the environment is right for sleep – your bedroom should be the right temperature and not too noisy (don’t have a TV in your bedroom)
• Getting some moderate exercise each day, such as swimming or walking
• Avoiding stimulants such as caffeine before going to bed – try a milky drink instead
• Avoiding too much alcohol – this induces unnatural sleep, so although you may fall asleep easily, you’ll almost certainly wake up during the night
• Not eating or drinking a lot late at night
• Trying relaxation techniques before going to bed, such as yoga, hypnosis or simply listening to music

If you can’t sleep, don’t lie there worrying about it. Get up again and do something relaxing such as reading or having a bath.

If your sleep problem persists, see your doctor. He or she may be able to refer you to a local sleep disorder clinic, which will investigate your problem in depth, although there may be a long waiting list.

Symptoms of clinical depression (depression that’s disrupting a person’s ability to live a normal life) include:

• Feelings of hopelessness, guilt, failure
• Low self-esteem
• Sometimes extreme anxiety
• Sleep problems, particularly waking early in the morning and being unable to get back to sleep
• Loss of appetite and weight
• Loss of sex drive
• Slowing of thought and movement (some have described it like living in treacle)
• Recurrent thoughts of death and suicide

If you’re at all worried about your mood, but particularly if these symptoms sound familiar, you should seek help. Talk to your doctor or, if you’d rather, find someone you feel comfortable with such as a good friend, relative or member of the clergy, and tell them how you feel.

Causes and treatments

There’s a lot that can be done for depression, including drug treatments and talking therapies. Stigma often stops people seeking help, but it’s important that you see a doctor because depression can be a symptom of a treatable condition, such as thyroid disease or chronic fatigue syndrome.

Depression can also be mixed up with other psychological problems, such as anxiety, phobias and stress.

You may need expert help to sort these out – don’t be afraid to ’shop around’ for a counsellor or therapist who meets your needs and with whom you feel comfortable.

Try to stay positive. As many thousands of people who’ve been through depression can tell you, there is light at the end of the tunnel.
For a more in-depth look at depression, see the Mental health site.

Seasonal affective disorder (SAD)

Many people feel a bit ‘down’ during the winter, but some people suffer more severe bouts of depression at this time, accompanied by low energy levels, sleep and appetite problems and reduced concentration. These can develop to the point where the person has difficulty functioning at home or work. This is known as seasonal affective disorder (affective is a psychiatric term for mood), or SAD. During the spring and summer, sufferers feel well and ‘normal’.

Common symptoms include:

• Extreme fatigue and lack of energy
• Increased need for sleep
• Carbohydrate craving and increased appetite
• Weight gain

How common is it?

Researchers believe SAD results from a lack of sunshine owing to winter’s shorter days – it definitely seems to be more common in northern countries. In the southern US state of Florida, for example, less than one per cent of the population has SAD, compared with as many as ten per cent of people in Canada.

What’s the treatment?

People with milder symptoms of the ‘winter blues’ may be helped by simply spending more time outdoors and taking regular exercise during the winter months.

Research has found that many people with SAD improve when exposed to bright, artificial light. Spending just 30 minutes under a lightbox results in a significant improvement in 60 to 80 per cent of patients. The side-effects of such light therapy, or phototherapy, are mild, but it should be avoided by people with certain medical conditions or those taking some medications.

Other treatments, including antidepressants and counselling, may also be helpful.

Patterns of hair loss

One of the commonest forms of hair loss in women (and men) is a condition called telogen effluvium, in which there is a diffuse (or widely spread out) shedding of hairs around the scalp and elsewhere on the body.

This is usually a reaction to intense stress on the body’s physical or hormonal systems, or as a reaction to medication.

The condition, which can occur at any age, generally begins fairly suddenly and gets better on its own within about six months, although for a few people it can become a chronic problem.

Because telogen effluvium develops a while after its trigger, and causes generalised thinning of hair density rather than a bald patch, women with the condition can easily be diagnosed as overanxious or neurotic.

Fortunately, it often gets better with time. Telogen effluvium is a phenomenon related to the growth cycles of hair.

Hair growth cycles alternate between a growth phase (called anagen, it lasts about three years) and a resting phase (telogen, which lasts about three months). During telogen, the hair remains in the follicle until it is pushed out by the growth of a new hair in the anagen phase.
At any one time, up to about 15 per cent of hairs are in telogen. But a sudden stress on the body can trigger large numbers of hairs to enter the telogen phase at the same time. Then, about three months later, this large number of hairs will be shed. As the new hairs start to grow out, so the density of hair may thicken again.

Many adults have had an episode of telogen effluvium at some point in their lives, reflecting episodes of illness or stress.

Another common type of hair loss in women is androgenetic alopecia, which is related to hormone levels in the body. There’s a large genetic predisposition, which may be inherited from the father or mother.

Androgenetic alopecia affects roughly 50 per cent of men (this is the main cause of the usual pattern of balding seen as men age) and perhaps as many women over the age of 40.

Research shows that up to 13 per cent of women have some degree of this sort of hair loss before the menopause, and afterwards it becomes far more common – one piece of research suggests that over the age of 65 as many as 75 per cent of women are affected.
The cause of hair loss in this condition is a chemical called dihydrotestosterone, or DHT, which is made from androgens (male hormones that all men and women produce) by the action of an enzyme called 5-alpha reductase.

People with a lot of this enzyme make more DHT, which in excess can cause the hair follicles to make thinner and thinner hair, until eventually they pack up completely.

Women’s pattern of hair loss is different to the typical receding hairline and crown loss in men. Instead, androgenetic alopecia causes a general thinning of women’s hair, with loss predominantly over the top and sides of the head.

Another important cause of hair loss in women is a condition called alopecia areata, an autoimmune disease that affects more than two per cent of the population. In this, the hair follicles are attacked by white blood cells. The follicles then become very small and hair production slows down dramatically, so there may be no visible hair growth for months and years.

After some time, hair may regrow as before, come back in patchy areas, or not regrow at all. The good news is that in every case the hair follicles remain alive and can be switched on again; the bad news is that we don’t yet know how to do this.

Myths about hair loss in women

• It means you’re not a proper women with two X chromosomes
• It’s caused by washing your hair too often
• It’s caused by too much brushing or combing
• Hair dyes and perms can cause permanent loss
• It may result from wearing hats and wigs
• Shaving your hair will make it regrow thicker
• Standing on your head will help it grow back
• It’s a sign of an overactive brain
• There’s a miracle cure out there waiting for you

Beware miracle cures

Scan the internet and you’ll see all sorts of miracle cures for baldness on offer, from strange herbal lotions to mechanical devices. Perhaps the most useful first step you can take is to avoid the myths.

After this there are several options. You can find some way to accept the change and live with it (let’s face it, this is a tall order – most men struggle to come to terms with their baldness and for them at least society equates it with maturity and power).

You can try cosmetic treatments such as wigs or hair thickeners, or you can try medical therapies. The last option is hair-replacement surgery.

Medical treatments

The drug minoxidil was first developed for treating high blood pressure, which was found to have the side effect of thickening hair growth in some people. It’s now available as a lotion to apply directly to the scalp.

No one really knows how it works, however, and it’s not effective for everyone. Studies show that only about 20 per cent of women between 18 and 45 have moderate regrowth using the drug, while another 40 per cent experience minimal regrowth.

It works best on younger people with early hair loss. A big disadvantage is that you have to carry on using minoxidil indefinitely or the new hair will fall out.

Another drug, finasteride, which was developed for treating prostate cancer, has also been found to be effective but is only available for men.

Surgery

Surgical techniques for restoring hair have improved greatly in the past couple of decades, but this is still an option that requires careful consideration.
There are two main options:

• Hair transplantation – tiny punch-holes of skin containing a few follicles of hair are taken from elsewhere in the body (such as the back of the head, if this is still well covered) and implanted into the thinning areas. Some surgeons use a needle to sew in just one or two hairs. However, as women are more likely to have diffuse loss of hair all over the scalp, this technique may not be possible. There has been little success with implanting artificial fibres.

• Scalp reduction – devices are inserted under the skin to stretch areas of scalp that still have hair, then the redundant bald areas are removed. Alternatively, flaps of hairy scalp can be moved around the head.

Main points

• Many causes of female hair loss are temporary – check your general health and be patient
• Take a look at your family for an idea of your risk of female pattern baldness
• Don’t be taken in by claims for wonder products – there’s no cure for female pattern hair loss
• Many women cope well by using cosmetic products, hats and wigs, so persevere until you find your own style

What is it?

The menopause occurs when levels of the female hormones oestrogen and progesterone fall and your body stops producing eggs. Menstruation ceases permanently and you’re no longer able to conceive. It can be a time of great physical and emotional change that can overwhelm you if you don’t know what to expect.

When does it occur?

There’s no predicting when the menopause will occur. Generally, it’s between the ages of 45 and 55, but for a few women it can start as early as 35 – or as late as 60. This doesn’t mean you’re in any way abnormal, although an unusually early menopause (before the age of 36, sometimes as young as 18) may have implications that need to be addressed.

Without the previously high levels of oestrogen, your risk of heart disease and osteoporosis (brittle bones) increases. If the menopause comes early – or if there’s a high family risk of these diseases – you should see your doctor. If he or she thinks it appropriate, tests such as a bone-density scan or mammogram will be arranged.

Usually, there’ll be some sign that the menopause is approaching. Periods can gradually become further apart, they may be scantier and not last as long. Alternatively, some women experience heavier bleeding with shorter gaps between. Occasionally, menstruation just stops altogether with no warning.

For the majority of women, the menopause will last no more than a couple of years, although others experience symptoms for as long as five or six years.

Before you’re born

The sex of a baby is determined primarily by the two sex chromosomes. In normal male cells, there’s an X and a Y sex chromosome. In normal female cells there are two X chromosomes.

Initially, the embryonic tissue that later becomes testes in boys or ovaries in girls is undifferentiated. At around six to eight weeks of pregnancy, the presence of a Y chromosome causes this tissue to develop into testes. If there’s no Y chromosome, ovaries develop.
As well as the hormones released by the testes and ovaries, which determine whether we grow into boys or girls, hormones also influence brain development and behaviour.

Most of the brain is similar in males and females, but some regions such as the hypothalamus and amygdala, which control functions related to sexuality, differ between the sexes. In these tissues there are receptors or receiving units that allow the cells to respond to androgens, or male sex hormones.

Early hormone environment permanently influences behaviour. Girls exposed to high levels of androgens in the womb show more interest in toys such as cars and less interest in dolls, are more likely to prefer boys as playmates and engage in male-typical rough-and-tumble play.

Puberty and beyond

In nature, as for any living organism, the probable sole aim of the human body is to reach maturity and reproduce before it dies, in order for the species to continue. Girls are born with all the eggs they’ll ever have – in fact, the number of viable eggs falls steadily throughout life until the menopause. It takes, on average, 12 years for the female human to develop to puberty and become fertile.

It’s not clear why it takes this long, although there’s probably a critical weight – around 47kg (7.5st) – at which menstruation is triggered, dependent on the other hormone systems functioning properly, including growth hormone.

The changes puberty brings are vast, prompted by rapidly increasing levels of many hormones including oestrogen, progesterone and androgens.

During puberty, girls go through obvious outward changes, such as breast development, shape and hair pattern changes. The complex hormonal rhythm of the ovulatory cycle, involving brain, glands, ovaries and other organs, also begins.

Every month the body’s hormones coordinate the production of an egg with a thickened uterine lining and receptive cervical mucus. If the egg’s fertilised, the different series of hormonal changes that support pregnancy will follow, suppressing ovulation.

In our culture, girls of this age aren’t considered emotionally mature enough for motherhood, but their bodies are capable of having children and in most cases continue to be so until the onset of the menopause between 45 and 55.

After the birth of a child, falling levels of hormone signal the brain to start the ovulatory cycle again, although if the mother is breastfeeding this will be suppressed and periods may not start for several months.

Why does it all stop?

Why women go through the menopause when they do – at what is just over halfway through their lifespan – and the exact trigger are unknown. It may be that thousands of years ago, 50 was the normal female lifespan.

Oestrogen production by the ovaries falls as the menopause occurs. This triggers the brain to release other hormones, LH and FSH, in an attempt to make the ovaries work harder. The number and quality of eggs released decreases, the lack of oestrogen means the vagina begins to dry and thin, and fertility falls.

Symptoms such as hot flushes, sweats, muscle and bone pains, irritability and poor concentration are all linked to these hormonal changes.

The extent of these symptoms varies immensely, but the end result is the same for everyone – failure of the reproductive organs and the subsequent effects throughout the body.