Breaking the Silence Around Miscarriage
There needs to be more conversation about miscarriage. “It’s so important for people to know and be informed about it,” says Dr. Kristin Bendikson. “Because women don’t talk about it, there are so many misconceptions about why they happen and what you should do afterward.”
A fertility specialist at USC Fertility, and assistant professor of obstetrics and gynecology at the Keck School of Medicine of USC, Bendikson is an expert in all aspects of infertility treatment—including in vitro fertilization, egg freezing, and recurrent pregnancy loss, as well as LGBTQ family building. She says that while society has become “much more open when it comes to talking about female reproductive health,” miscarriage still gets lost in the conversation, even though it’s incredibly common. “It’s typical for people to share stories about IVF,” she says, “but people still don’t talk about if they’ve miscarried.”
Below, Bendikson explains how to begin to unpack this conversation and create more opportunities for open dialogue. While it can’t obviate the pain and grief caused by miscarriage, it can hopefully provide a greater understanding of ways to navigate through it physically and emotionally.
A Q&A with Kristin Bendikson, M.D.
In the simplest of terms, a miscarriage is the loss of a pregnancy before twenty weeks. This term does encompass both losses in the first trimester and part of the second trimester. However, when people use the term miscarriage, they are typically referring to the loss of a pregnancy in the first trimester. This is because losses in the first few months of pregnancy are just more common. In fact, the overwhelming majority of miscarriages occur before thirteen weeks.
A pregnancy can stop growing at any point. Sometimes the pregnancy stops growing after only a few days and a woman may not realize she is pregnant and just assume that her period has come a few days late. These very early losses can also present with bleeding in the first few weeks after the first positive pregnancy test. These types of losses are given the medical term “biochemical pregnancies.” What this means is that the pregnancy loss occurs so soon that it is too early to see anything on ultrasound. So, the only way to know a woman is pregnant is to test her blood or by a urine pregnancy test, which look for biochemical markers. A biochemical pregnancy is a very early miscarriage.
Miscarriages that occur a little later in the first trimester can present in several ways. A woman can experience bleeding or cramping, or a sudden loss in the symptoms of pregnancy. Other times a woman is feeling fine, and only finds out that the pregnancy has stopped growing when she goes in for an ultrasound. What is important to remember about miscarriage is that it is a process, so the symptoms a woman has, or how the miscarriage presents, is somewhat dependent on where it is in the process.
There are medical terms for the different ways a miscarriage can present that are useful to be aware of. When your body is showing signs that you might miscarry, like bleeding or cramping, but on ultrasound everything looks like it is growing okay, that is what’s called a “threatened miscarriage.” Not all women go on to miscarry when they have bleeding in the first trimester. In fact, we know that vaginal bleeding occurs in about 20 to 30 percent of pregnancies. If the bleeding is light and only lasts for a few days, the risk of miscarriage is not increased. Even with heavier bleeding that has a higher risk of ending in miscarriage, there is rarely anything a physician can do to prevent the miscarriage from happening.
When the process of miscarriage has started but isn’t complete, then it is termed an “incomplete” or “inevitable miscarriage.” Many times, the miscarriage will complete on its own without intervention. However, there are times when the bleeding will continue in a prolonged or intense fashion. In these cases, it’s best to immediately consult a healthcare professional to figure out if surgical intervention is necessary.
When there are no symptoms but an ultrasound shows that the pregnancy has stopped growing, that is what’s called a “missed miscarriage.” At this point you will need to make a decision with your doctor if you want to try to complete the miscarriage on your own or consider medical or surgical intervention.
Miscarriages are incredibly common, unfortunately. Many women are very surprised to hear that. I think that’s because women generally don’t tell their friends or family when they have had one. Therefore, going through a miscarriage can be an incredibly isolating experience. The associated grief is immense, with up to one third of women feeling that their grief over the loss of an early pregnancy is similar to the grief of losing a child later in life. Having a miscarriage is often associated with feelings of guilt and shame, as women often blame themselves, as if they did something to cause the loss. In reality, a woman’s actions—whether she had sex with her partner, stressed too much at work, or lifted something heavy at home—are rarely the cause for a miscarriage.
My patients are often very surprised to hear that close to one in four women who are pregnant will have a miscarriage. We believe that 15 to 25 percent of recognized pregnancies will end in a miscarriage, and when you include all those biochemical pregnancies that women don’t necessarily recognize, the numbers are even higher.
There are many known causes of miscarriages. The vast majority of miscarriages are caused by chromosomal abnormalities in the embryo. However, there are other causes that need to be ruled out. If you have had even one miscarriage it is worth speaking with your healthcare provider who would be managing your pregnancy. You can review any potential causes and rule them out or treat them when indicated.
The uterus itself is less often the cause of a miscarriage. Women often think that it is the uterus that is rejecting the embryo, when most of the time there is an abnormality in the embryo that prevents it from implanting or progressing normally. Unlike the ovary, the uterus doesn’t significantly change with age. However, women can either be born with an abnormally shaped uterus or they can develop non-cancerous lesions inside the uterus—polyps or fibroids. These abnormalities can be screened for with a pelvic ultrasound, but more informative radiologic tests may be necessary to completely rule them out.
Certain hormonal disorders like thyroid disease, an elevated prolactin, polycystic ovarian syndrome (PCOS), or uncontrolled diabetes can increase the chance of a pregnancy loss. There is also a blood clotting disorder that increases the chance of miscarriage, as well as some heritable genetic abnormalities.
The more miscarriages a woman has, the more likely it is that one of these other factors may be the cause. That’s because we think that chromosomal abnormalities account for around 60 percent of first miscarriages.
Women can potentially influence their chance of miscarriage by keeping themselves healthy. Women who are underweight, overweight, or who use cigarettes or other drugs all have a higher chance of miscarriage. Alcohol, excessive caffeine consumption, and environmental exposures to toxins like BPA and phthalates, have all been associated with an increased chance of miscarriages.
It is important to mention marijuana, as it is becoming legal in more states: The data on marijuana is less clear as there aren’t many studies on marijuana and reproduction. But there are some studies that have shown marijuana to have a detrimental impact on both male and female fertility. Though we don’t have any strong evidence that it increases the chance of miscarriage, it is wise to avoid marijuana when trying to conceive.
Age plays a huge role in how often miscarriages occur. The chance of miscarriage doubles from the age of thirty-five to forty, and by forty-five it’s thought that 50 percent of pregnancies will end in miscarriage.
Most miscarriages are caused by genetic abnormalities where the embryo has an abnormal number of chromosomes, either too many or too little. The chromosome count is more likely off in older women because the mechanical parts inside the egg that are responsible for sorting the chromosomes are aging, just like any other part of our body does as we get older. A woman is born with all the eggs she is going to have already inside her ovaries, and so those mechanical parts that are critical for the normal development of the egg and embryo are just more likely to malfunction as a woman ages.
These chromosomal abnormalities often prevent the embryo from implanting, and therefore inhibit a woman from getting pregnant. However, these abnormalities are also the leading cause of miscarriages and cause certain types of genetic diseases like Down Syndrome. This increase in abnormalities with age is why it can take longer for older women to get pregnant, and it makes older women more likely to suffer from infertility or miscarriages.
When a woman has a miscarriage, the pregnancy tissue can be tested to figure out if a chromosomal abnormality was the cause. The new genetic testing is much improved compared to what we had even a few years ago and provides us with more precise information. And it is a lot less expensive. These results can sometimes affect treatment options for the patient when she next attempts conception, especially if a woman has had a second or third loss. Although most women who have a miscarriage will go on to have a healthy pregnancy the next time they get pregnant, I always recommend considering getting the genetic testing, especially with a second loss. You never know for which patients having that information will be helpful in the future, as we can’t predict which women will go on to have multiple losses. Some providers only recommend genetic testing once a woman has three losses. However, most women want to know why they miscarried and the information from this test can provide some level of closure even if it doesn’t change future options or treatments.
You have a couple of options when it comes to the treatment of miscarriage—and what is recommended may depend on how far along in the process the miscarriage is, as well as how far along you were in the pregnancy. If you have already started bleeding and the miscarriage process is pretty far along, it often makes sense to let it complete on its own. The stage of the miscarriage can sometimes be determined with an ultrasound or if you have already passed tissue. If you haven’t had any symptoms, you may be able to wait and let the pregnancy pass on its own when its ready to come out. The downsides of this approach are that you don’t know when it will happen and sometimes it doesn’t pass or finish completely and you will need additional treatment. Because of these unknowns, some women opt for taking medication that can help the miscarriage process along. If taking the medications, the miscarriage will often pass in the next few days, alleviating the anxiety of waiting.
The farther you are along the pregnancy, the harder it is to pass it on its own or with medications because the symptoms—bleeding and pain—can be much worse.
The other option to complete the miscarriage is to have a procedure called a D&C, which stands for dilation and curettage, that removes the pregnancy tissue. This can be a good option for miscarriages occurring later in the first trimester. However, some women opt to have a D&C because the thought of passing a miscarriage at home is too emotionally or physically difficult. The D&C is also what is recommended if the pregnancy is not passing on its own or if the bleeding and pain are becoming an issue medically.
Though it is appropriate to see your general female health provider after one miscarriage, you should consider a specialized evaluation if you have had two or more consecutive miscarriages. (The medical term for this is recurrent pregnancy loss.) This process can be started with a general obstetrician/gynecologist who has some experience, however you should consider seeing a fertility specialist. Many women don’t realize that fertility specialists are also experts in helping women who have had recurrent pregnancy loss. While some generalist and even high-risk obstetricians have had some training in this area, our knowledge of what causes miscarriages and what the recommended treatments are is ever changing. So a fertility specialist tends to be best equipped with the most current information and has the best ability to provide all levels of treatment.
After a miscarriage, your body will return back to its normal menstrual cycle as soon as the pregnancy hormone is out of your system. How long this takes depends on how far along the pregnancy was and how the miscarriage occurred. If you get pregnant immediately, there is no evidence to show that you are more likely to miscarry again. It is reasonable to wait a full cycle to allow the system to totally reset. However, waiting for three months or longer—which was conventional wisdom for a long time—can be problematic for older women who also have the issue of declining fertility. The best time to try to start getting pregnant is when you are emotionally and physically ready.
The good news is that after suffering a miscarriage, there is an 85 percent chance that the next time you are pregnant, you will go on to have a baby. Even after two miscarriages, which only occurs in 5 percent of women, the chance of having a baby is 75 percent.
After a thorough investigation, 50 percent of couples with multiple losses will still not have an answer as to what caused their miscarriages. When there isn’t an answer, it is important to have a thorough discussion with a fertility specialist as couples will need to decide if they want to try again on their own or pursue other options, like treatment with IVF where embryos can be screened to rule out chromosomal abnormalities. There are many unproven and questionable treatments that have been proposed to treat miscarriages. It is important that you seek care with a qualified expert who can guide you through this difficult time, providing support, compassion, and sound medical advice.
First and foremost, one of the most important things you can do is allow yourself to grieve. Don’t minimize the pain you are going through. Reach out to those around you for support. There are around one million women who miscarry every year, so you are not alone.
It’s also important to understand that the partners are going through a loss as well. They too have grief to deal with, so it is important that they have support through the process.
Above all, it’s essential to realize that everyone grieves in their own way. There is no right way to grieve and no right way to recover from a miscarriage. Give yourself whatever time you need to recover emotionally and physically.
Dr. Kristin Bendikson is a fertility specialist and assistant clinical professor at USC Fertility, a part of the Keck School of Medicine of USC. She is the founder and director of the Fertility Diagnostic Testing Program at USC Fertility and USC Center for Pregnancy Loss. Bendikson received her bachelor’s degree in psychobiology from UCLA and medical degree from New York University. She completed her obstetrics and gynecology training at Harvard, working at both Brigham and Women’s Hospital and Massachusetts General Hospital, and did her fellowship training at the Weill Cornell Center for Reproductive Medicine. She is board certified in both obstetrics and gynecology, as well reproductive endocrinology and infertility. As an active member of the American Society for Reproductive Medicine (ASRM), she previously sat on the ASRM Patient Education Committee and now serves as its chair. A current member of the ASRM Practice Committee, Bendikson is committed to educating the next generation of fertility specialists and serves as the associate fellowship program director for the USC fellowship for reproductive endocrinology and infertility. In addition, she lectures to both USC medical students and USC undergraduates every year. She is an expert in ovulation induction, in vitro fertilization, egg freezing, and LGBTQ family building, as well as the management of disorders including recurrent pregnancy loss, endometriosis, and polycystic ovarian syndrome.
The views expressed in this article intend to highlight alternative studies and induce conversation. They are the views of the author and do not necessarily represent the views of goop, and are for informational purposes only, even if and to the extent that this article features the advice of physicians and medical practitioners. This article is not, nor is it intended to be, a substitute for professional medical advice, diagnosis, or treatment, and should never be relied upon for specific medical advice.