Okay, it’s Pop Quiz time: What syndrome affects at least 5 million American women, yet is believed to be vastly under-diagnosed, despite its rather startling symptoms: excessive facial hair, acne, high male hormone levels, irregular periods, infertility, significant weight gain and a strong tendency to become diabetic?

If you answered “polycystic ovarian syndrome” (or PCOS), you’re among the cognoscenti – and possibly well ahead of your doctors, who often spot pieces of the syndrome but fail to put it all together, much less treat it the new way – with drugs, including some usually used for diabetes, that can often reverse or at least control some of the most disturbing symptoms 

For years, many gynecologists told young women with irregular periods not to worry, or to simply take birth control pills. And that was partly right – the pills do help regularize cycles.

But acne, beards and abdominal hair?  Could doctors really have dismissed that as just a cosmetic thing? (Ah, yup.)  Dramatic weight gain? Could they have tossed that off as just another female character flaw? (You got it.) Out-of-whack insulin levels? Well, that may be a little more understandable – after all,  who would think to refer a woman with missed periods to a diabetes specialist?

In truth, PCOS has been recognized, by some doctors, for decades; in fact, it used to be called “diabetes of the bearded woman.” But it’s only recently that endocrinologists have really pieced together the links between the seemingly-obvious gynecological symptoms such as infertility and ovaries full of tiny cysts (un-released egg follicles), and the more complex and widespread hormonal disruption.

Today, PCOS is viewed as a serious hormonal imbalance triggered in part by faulty genes for sex hormones and other genes involved in a serious condition called insulin resistance, which often leads to diabetes.

Indeed, women with PCOS have seven times the normal risk of diabetes, as well as a higher risk of gestational diabetes (which starts while a woman is pregnant and can later become standard adult onset diabetes). Preliminary research also suggests that women with PCOS have a 50 percent increased risk of heart disease and stroke as well.

Essentially, PCOS is a “vicious cycle,” though it’s unclear which biochemical glitches come first, says Dr. Stanley Korenmann, an endocrinologist at the UCLA School of Medicine. Once the PCOS cycle gets started, the hallmark is insulin resistance, which can also be triggered or exacerbated by obesity and inactivity.

In insulin resistance, the pancreas goes into overdrive to make more and more insulin – a frantic attempt to get enough sugar into cells, notes Dr. Edward Horton, director of clinical research at the Joslin Diabetes Center in Boston. 

Even if a person is just insulin resistant and never develops outright diabetes,  the insulin resistance itself is linked to “a whole metabolic cluster” of problems, notes Horton. This cluster, dubbed Syndrome, is characterized by some of the well-known risk factors for heart disease: elevated triglycerides (fatty acids), low HDL (“good” cholesterol), high blood pressure, changes in blood clotting patterns and a build-up of fatty plaques in arteries.

And that’s just the beginning. In the ovary, excess insulin messes up the normal process by which an aromatase enzyme converts male hormones such as testosterone into estrogen. The result for many women with PCOS is unusually high levels of testosterone in the blood. The excess testosterone, in turn. causes women to sprout hair in a male pattern (on the face, chest and abdomen), and to get severe acne (which is driven by breakdown products of testosterone.)

And it gets worse. In this high-insulin, testosterone-excess state, the chemical signaling system between the hypothalamus in the brain and the pituitary gland, which lies just below the brain, goes awry, with the result that the pituitary never signals the ovary to release an egg. This means that ovulation fails, and when that happens, a woman becomes infertile.

In fact, PCOS is a leading cause of infertility.  But there’s another problem, too. Without ovulation, the uterine lining does not shed every month, which raises the risk of endometrial hyperplasia, a precursor of uterine cancer.

Excess testosterone can also lead to insulin resistance, which leads to even greater excess testosterone production by the ovaries and the cycle continues on its miserable way.

Given such complexity, perhaps it’s not surprising that many women, among them Kristin Rencher, a 37-year former investment banker from Portland, Ore., go from doctor to doctor and suffer through agonizing teenaged years (dating is tricky enough even if you’re not fat, bearded and pockmarked!), until they eventually, try and fail to get pregnant and wind up seeing a reproductive endocrinologist who finally diagnoses PCOS.

“Looking back, someone should have known something was wrong when I was 14,” says Rencher, who now heads the Portland-based Polycystic Ovarian Syndrome Association.

Rencher got her first period at 13, then had none for years. At 14, she developed severe acne. By 19, she began to get excessive hair on her face and abdomen, even between her breasts. She exercised and dieted, but still gained 25 pounds. She did get pregnant, with the help of a fertility drug, but it was only when she began trying to have a second child that she combed the web, diagnosed herself with PCOS and went to a reproductive endocrinologist, who confirmed her diagnosis.

Kim Maynard, 41, a Cohasset woman who works as an operations coordinator for a tour company, has an equally horrifying story: Irregular periods, 100 pounds of excess weight, multiple miscarriages (though she has had three children), excessive hair (even on her feet), and now, worst of all, a strong suspicion that her 16-year old  daughter, Amanda, is also developing PCOS.

The good news is that, thanks to the emerging view that insulin resistance is a core part of the PCOS problem, better treatments are becoming available, though so far, the drugs must be used “off label” because, although legally on the market, none have been approved specifically for PCOS by the US Food and Drug Administration.

The most important is the class of drugs called insulin sensitizers, says Dr. Andrea Dunaif, a leading PCOS researcher and chief of endocrinology at Northwestern University Medical School in Chicago. This class includes Glucophage (metformin), Avandia (rosiglitazone) and Actos (pioglitazone).

Several studies, including a pivotal one published several years ago in the New England Journal of Medicine, show that Glucophage can help correct the insulin resistance problem, “lower male hormone levels and, in a substantial percent of women, restore ovulation,” says Dunaif.  Glucophage may also boost the effectiveness of ovulation-stimulating drugs such as Clomid. (And a new, extended release version of Glucophage may have fewer side effects than the traditional one.)

Dr. Sandra Carson, a reproductive endocrinologist at the Baylor College of Medicine in Houston, agrees. “If you break the cycle by breaking insulin resistance, patients may ovulate. It’s been quite successful.”

That raises the question, though, of whether newly-pregnant women with PCOS should stay on Glucophage during pregnancy, says Dr. Veronica Ravnikar, director of reproductive endocrinology at the University of Massachusetts Medical Center in Worcester. There’s some evidence that doing so may decrease the risk of miscarriage, but many reproductive endocrinologists, including Ravnikar,  think it’s safer to stop the drug during pregnancy.

And while many women, including Kristin Rencher of Oregon, get dramatic weight loss on Glucophage, many others don’t, so insulin sensitizing drugs should not be considered miracle cures for obesity.

Soon, a new drug, not yet on the market, may be marketed specifically for PCOS. Made by INSMED, INS-1 is still in clinical trials and but is believed to be a promising insulin sensitizer. Other insulin sensitizing drugs are also in the works.

To cope with the hirsutism – excess hair growth – of PCOS, many women take Vaniqa, a topical cream that speeds up cell turnover and slows down growth of hair. Alternatively, drugs such as Aldactone (spironolactone), which block the action of male hormones, may also help, though such drugs can be toxic to a fetus.

A new birth control pill called Yasmin also has spironolactone-like effects, which means in theory it could help with excessive hair growth. Other birth control pills can also help control both excessive hair growth and acne, though many women with PCOS simply use bleaching, waxing, electrolysis or laser treatments to control excess body hair.

For those who don’t want to take birth control pills but are concerned about the risk of uterine cancer because of the lack of menstrual periods, one solution is to take a progesterone drug such as Prometrium every few months to induce a period.

The bottom line for any woman who thinks she, or her daughter, may have PCOS is to “keep searching for a doctor who will listen,” says Kim Maynard of Cohasset. “Look on the Internet. Get the support you need. There are a lot of books out there now – buy them and read them.”

Judy Foreman’s column appears every other week in Health & Science. Her past columns are available on Boston.com and www.myhealthsense.com. Her email address is foreman@globe.com.

Sidebar:

For more information, call the Polycystic Ovarian Syndrome Association (877-775-PCOS, or 7267) or visit the group’s website,www.pcosupport.org

You might also want to read books on PCOS, including “Living with P.C.O.S.,” by Angela Boss and Evelina Weidman Sterling.

You’re 39 weeks pregnant, not quite full-term. You’re still working, of course – after all, you’re a modern mom – and you’ve got everything under control. Except the obvious.

If you knew exactly when the baby was coming, you could tell your boss when to start the maternity leave clock ticking. You could tell your mother when to take time off from her job to come take care of your older child. You could tell your husband to go on that business trip. Your obstetrician wouldn’t exactly mind knowing the precise ETA of your new baby, either – after all, she’s got kids of her own and would much rather deliver babies between 9 and 5 on weekdays than pull all-nighters on weekends.

Besides, you’ve gained 35 pounds. It’s been a long, uncomfortable summer.  And you are definitely TOP, or “tired of pregnancy.”

So, why not do the modern, high tech thing and get your doctor to induce labor so that you, not Mother Nature, can decide when the baby will come?

Actually, there are lots of compelling reasons why not, and we’ll get to them in a minute. But more and more busy mothers-to-be, used to being in control of most things in their lives, are flat-out demanding that childbirth be as easy to schedule into their Palm Pilots as a corporate meeting. And many obstetricians are only too happy to oblige.

Between 1989 and 1999, the number of labor inductions – in which doctors hurry childbirth along with drugs to dilate the cervix and stimulate uterine contractions –  has soared to 775,245, according  to the National Center for Health Statistics. That’s a whopping 19.6 percent of live births, up from 8.2 percent in 1989.

In many cases, the induction of labor is done for legitimate medical reasons such as toxemia (high blood pressure and other symptoms), gestational diabetes or a birth that’s a week or two overdue (which means the placenta, the organ that supplies the fetus with oxygen and nutrients, may start to break down).

But increasingly, induction of labor is done for “elective”  reasons, that is, pure convenience. And while some obstetricians hail this move -as elective inductions rise, weekend deliveries decrease – many obstetricians and nurse-midwives worry that the trend may lead to more Caesarean sections if induction fails, more respiratory problems in babies born with not-quite-mature lungs, and more chance of uterine ruptures triggered by drugs such as prostaglandins and Pitocin.

The national health statistics center does not keep track of how many labor inductions are done for medical reasons, how many for convenience and how many for a combination of the two, such as a woman with a track record of short labors who lives far from the hospital.

But Dr. Lewis Rosenberg, an obstetrician-gynecologist at New Island Hospital in Bethpage, N.Y., believes elective inductions now constitute 40 percent of all inductions. 

The trend toward scheduling childbirth, he adds, is also propelled by managed care and the need for doctors who work as solo practitioners or in small groups to maximize their own efficiency. “If you’re going to be seeing a large number of patients in one day, the worst thing is to have a patient in labor – you have to reschedule a lot of people.”

Indeed, a recent online survey by Americanbaby.com, a parenting website, found that 36 percent of 827 respondents said they would  “consider” scheduling induced labor and another third said that while they wouldn’t do it themselves, they didn’t object to other women doing so.

And that probably underestimates the actual number of requests for elective inductions.

“Almost everyone who walks through the door to my office wants a scheduled childbirth,” says Dr. Laura E. Riley, 41, a maternal-fetal medicine specialist at Massachusetts General Hospital who counsels against it, from both professional and personal experience.

Five years ago, shortly before Christmas, Riley begged her obstetrician to induce labor. She was 39 weeks pregnant. “I didn’t want to deliver at Christmas,” she says. “I wanted the baby beforehand so I could be home with my two-year old.”

So the week before Christmas, Riley’s doctor admitted her to the hospital,  “started the Pitocin and cranked it up to the highest number,” recalls Riley. “I went from having cramps to the most unbelievable labor out of nowhere because there was no ramp-up time. It was awful.”

On top of that, the painkilling drugs – given by injection epidurally (into the space around the spinal cord) didn’t work.  “It was a fast labor, only two hours,” says Riley. “But it was so intense I thought I would go out of my mind. Fortunately, I was fine and the baby was fine. But in retrospect it was silly.”

Just how silly, however, is a matter of contentious debate.

The American College of Nurse-Midwives takes a dim view of elective inductions. The American College of Obstetricians and Gynecologists does, too, although that group says labor may be induced for “psychosocial” reasons. But the group  warns that obstetricians should be very sure if they induce labor in a woman who is not quite full-term that the fetal lungs are mature or that other tests show the fetus is developed enough to be born. Generally, this means the woman should be at least 39 weeks pregnant and that her cervix be “ripened,” that is, already be soft, flat and at least partially open.

The chief argument against elective induction of labor is that nature does such a brilliant job of orchestrating the delicate dance of chemical signals that cause the cervix to ripen and the uterus to begin contractions that it’s tough for mere mortals to do nearly as well.

One theory is that when the fetal brain is mature, notes Joyce Roberts, a nurse-midwife at Ohio State University, it sends signals to the fetal adrenal glands to secrete cortisol, a stress hormone. That in turn may trigger a shift in the placental metabolism of  the two key hormones of pregnancy, estrogen and progesterone, so that estrogen begins to dominate. That, in turn, may make the uterus more capable of contracting.

Meanwhile, scientists believe, the fetal lungs secrete signals signaling that they are mature, along with enzymes that trigger the release of prostaglandins, which in turn tell the cervix to ripen and the uterus to contract. Oxytocin, made in the mother’s body, triggers further uterine contracts. (It is the natural hormone of labor on which Pitocin is modeled.)

“To push those mechanisms is foolish,” she says. “There’s an optimal timing” in nature’s method  “and most of the time, it works out amazingly well.” When labor is induced “for no good reason, the fetus may not be optimally mature and the mother’s uterus may not be capable of good labor contractions.”

But some obstetricians argue that, when done carefully in the right patients, elective induction of labor can be safe.

“Personally, I think if the patient is well worked up in terms of the baby’s maturity” and if  the cervix is ripe, ” I don’t think there’s anything wrong with it,” says Dr. Alan De Cherney, chairman of obstetrics and gynecology at the UCLA School of Medicine. “But you have to do it in the right people.”

A good candidate, he adds, is a woman who has had one previous vaginal delivery, whose cervix is ripe and who is likely to go into labor spontaneously in a few days anyway.

Dr. Lewis Rosenberg, of New Island Hospital, agrees. “You have to make sure there is adequate dating” of the pregnancy to be sure the woman is at least 39 weeks pregnant. By 39 weeks, the fetal lungs contain enough of a crucial substance called surfactant that they are reasonably mature, which means there’s less than 1 percent chance of respiratory problems. (For babies born at 36 weeks, the risk of respiratory distress syndrome is 5 percent, and it goes up steeply with shorter and shorter pregnancies.)

Some obstetricians start an elective induction by rupturing the membranes of the amniotic sac (what lay people call “breaking the waters”) with a small, blunt  “amniotic hook.” Often, this starts spontaneous contractions. If it doesn’t, then Pitocin can be given, but once the waters are broken, the delivery should happen (by C-section, if necessary) within 24 hours because the risk of both maternal and fetal infection rises.

It is possible to artificially trigger an unripe cervix to ripen with drugs, chiefly, prostglandin gels. But a woman whose cervix was unripe to begin with has a higher risk of C-section than one who is induced with an already ripe cervix.

“If the cervix is ripe, the risk for C-section is probably low,” concedes Riley of MGH. “However, many people want elective induction with an unripe cervix or want drugs to ripen it. My personal opinion is that any form of intervention that is unnecessary is probably not in anybody’s best interest.”

But that doesn’t stop Riley’s patients from begging for induced labor anyway, even trying to bribe her with chocolates. “A tremendous number of people want an induction because they want to control everything. Most are control freaks…..I can completely relate because I am one of them. But I  don’t do very many elective inductions. I refuse because of the risks.”

SIDEBAR

The American College of Obstetricians and Gynecologists recommends that labor be induced only if the doctor is sure that the fetal lungs are mature or that at least one of the following criteria of fetal maturity have been met:

• The fetal heartbeat has been documented for 20 weeks by a stethoscope or 30 weeks by a more sophisticated “Doppler” test of gestational age.

• It has been 36 weeks (or more) since reliable lab tests showed the presence on a blood or urine test to detect a hormone called HCG, or human chorionic gonadotropin, a sign of pregnancy.

• The fetus can be assumed to be at least 39 weeks old as judged by an ultrasound measurement of the length of the fetus from crown to rump, obtained at 6 to 12 weeks of pregnancy.

• An ultrasound taken at 13 to 20 weeks confirms a gestational age of 39 weeks determined by the doctor’s clinical impression and a physical exam.

It is also important, the doctors’ group says, that medical personnel carefully monitor uterine contractions stimulated by Pitocin because they can cause fetal distress and uterine rupture. And a recent paper in the New England Journal of Medicine suggests that inducing labor after a woman has had a previous C-section may lead to a higher incidence of uterine rupture.

So, there it sits on the desktop, this ridiculous, ever-growing collection of moisturizers, seemingly endless bottles and stand-up tubes that rise like little mountain peaks amid the stacks of floppy disks and piles of papers.

There’s the tall squirt bottle of Keri lotion, billed as “moisture-rich therapy,” which might be true, judging by the way it makes fingers slide off the keyboard. There’s the oh-so-cutesy Nivea spray, whose nozzle could drive a woman crazy the way it spins around, spraying the room instead of dry skin.

And, for sheer kinkiness, there’s “Udderly Smooth,” a moisturizer originally designed for cows, whose directions begin, “Wash udder and teat parts thoroughly . . .”

American women spend billions a year on moisturizers in hopes of looking younger, healthier and more smooth-skinned.

Are they wasting their money?

Not completely, dermatologists say, at least in the narrow sense that it’s a good health practice to keep skin moist. Skin is a crucial barrier against infection that is more easily invaded once it becomes dry or cracked. Of more concern to most people, well-hydrated skin does look and feel better to the touch.

But moisturizers can indeed be a waste of money in the sense that something that costs $30 or more an ounce may not keep skin any moister than a big glob of Vaseline, though the high-priced spread may go on more easily and smell nicer. In fact, a January report in the Wellness Letter at the University of California-Berkeley, as well as an extensive Consumer Reports investigation last year, reached just that conclusion.

Why don’t moisturizers, like wines, generally get better the more they cost? Because most moisturizers, despite their baffling array of ingredients, work basically the same way: They trap water that’s already inside the skin, as opposed to adding moisture from the outside.

“Moisturizers help seal things off and allow less moisture to escape,” said Dr. Tom Rohrer, a dermatologist at the Boston University School of Medicine.

To accomplish this, moisturizers are made up of “some combination of oil and water,” said Dr. Richard Glogau, a dermatologist at the University of California at San Francisco. “You can go from pure oil at one end to pure water at the other.” The more oil it contains, the better the moisturizer is at trapping trap water beneath it. The more water it has, the lighter and easier it is to rub in and disappear.

“Once you get away from the basic combination of those two agents,” Glogau said, “everything else is aimed at making a moisturizer feel better to the skin at touch or making it smooth on better. . . . But that doesn’t really affect the way a moisturizer prevents evaporation of water.”

If it’s so simple, why, then, do moisturizer manufacturers bombard us with technical-sounding words like liposomes, humectants and the like? The answer, of course, is marketing, or as the US Food and Drug Administration, which regulates the cosmetics industry, puts it, “cosmetic puffery.”

“The average consumer has no idea what these things mean,” said one FDA spokesman who asked not to be named. “People throw out these terms because they seem mystical or magical.” And the FDA lets such pseudo-scientific hype slide, he said, unless it can prove in court that the cosmetic labels are downright “false or misleading.”

Dr. Melanie Grossman, a dermatologist in private practice in New York City, puts it more bluntly: “The FDA doesn’t regulate this stuff. So companies can claim whatever they want.”

How, then, does a winter-wizened or sun-scorched consumer begin to unravel the mysteries of moisturizers? One good place to start, perhaps surprisingly, is the industry itself, specifically, Martin Rieger, an organic chemist who consults for the Cosmetic, Toiletry and Fragrance Association, a trade group based in Washington.

Asked how moisturizers work, Rieger pulls no punches:  “Moisturizers are stupid materials. They have no brains. They pick up water from wherever they can find it, steal that water and hold onto it. They will not let this water go and give it back to skin cells, no matter how attractive that concept may appear. They don’t really penetrate the skin. I take a very dim view of some of the claims made for moisturizers.”

Take humectants, substances such as glycerine that attract water and hold it against the skin. “I have very little faith in humectants,” Rieger said, though dermatologists, Rohrer of BU among them, say humectants can make the skin somewhat more moist in some people.

Occlusives, on the other hand, substances like petroleum jelly and oils, are quite effective. “They are heavy, greasy and work precisely because they sit on top of the skin and preclude evaporation of water,” Rieger said. The downside is that, because they coat the skin so well, occlusives can leave a residue that many people don’t like, said Dr. Diane Berson, a dermatologist at New York University School of Medicine. They can also clog pores and lead to acne.

In addition to humectants and occlusives, moisturizers often contain emollients and other ingredients designed to make the skin feel slick and soft, though they have nothing to do with moisturizing per se. Some manufacturers add silicone, for instance, to make a moisturizer more slippery; others add dispersing agents like soaps to make the oil in a moisturizer break down into smaller particles.

Some manufacturers also add liposomes, delivery vehicles whose job it is to bring a substance into the skin. The trouble is, if liposomes are too big to penetrate the skin – and many are – whatever product they are carrying won’t get in, either.

Many moisturizers also contain collagen. In its natural form, this fibrous, connective tissue is important for maintaining firm, healthy-looking skin. But collagen that’s taken from cows and then slathered on human skin does not penetrate because the molecules are too big. The same goes for elastin.

“It would be wonderful if we could replace old, damaged collagen and elastin with a cream. But, unfortunately, at this point, it is physically impossible,” Rohrer said.

Sadly, the news on wrinkle reducers and anti-aging creams is no cheerier. Moisturizers that claim to get rid of wrinkles or reduce the appearance of age really don’t – all they do is plump up the skin momentarily, despite manufacturers claims of clinical trials to the contrary, Rohrer said.

What does help with wrinkles is Retin-A, or Renova, dermatologists say, but that is a genuine drug that is regulated as such by the FDA and is only available by prescription.

On the plus side, there are ingredients in moisturizers that may be genuinely effective. Vitamins E and C, for instance, are antioxidants that combat the oxygen free radicals that can damage skin. They may also penetrate the skin and combat free radicals from the inside.

Alpha hydroxy agents such as glycolic acid work, too, dermatologists say, penetrating the skin and making it look more moist and healthy by helping it slough off dead cells on the surface. That’s particularly important for older people since their skin has less ability to slough off dead cells on its own.

As for that cheap old trick, drinking water to make your skin look better? Go ahead, dermatologists say. But water probably only makes your skin look better if you were dehydrated to begin with, and most people aren’t.

The bottom line, Rohrer said, is that “most moisturizers don’t penetrate your skin. They only penetrate your pocketbook.”

That doesn’t mean you shouldn’t use them, said Grossman. But don’t break the bank to do it. Buy something that you will really use, she said, nothing too thick and goopy. And nothing that will wind up in the garbage. Or behind the piles of papers on your desk.

The time has come to do the obvious about the whole abortion mess: Provide emergency “morning-after” contraception over the counter. Right now. In every state. In every pharmacy. For every woman who needs it. And at a reasonable price.

One way you can tell the time has come is that the American Medical Association, not exactly known for its out-on-a-limb stances, endorsed the idea in December. In Great Britain, Finland and France, emergency contraception already can be obtained without a prescription.

Another way to tell is that even the National Right to Life Committee, which opposes abortion and strenuously opposed RU-486 (the abortion pill), has not opposed emergency contraception – the group takes no position on prevention of fertilization. Like standard birth-control pills, emergency contraception, or EC, pills – commonly called “morning after” pills, even though they work for up to 72 hours – are hormones that act, at least in part, by blocking ovulation, which occurs before fertilization.

So far, only one state – Washington – has gone out of its way to make emergency contraception pills easily accessible to women, 24 hours a day, seven days a week, by allowing them to get them from pharmacists without a doctor’s prescription. Alaska, Oregon and other states (though not Massachusetts) soon may follow suit.

But the real breakthrough would come if the US Food and Drug Administration allows the emergency contraceptives to be sold over the counter like aspirin. The FDA states that it is waiting for either of the two companies that make EC pills – the Women’s Capital Corp., which makes Plan B, and Gynetics Inc., which makes PREVEN – to submit applications to switch their products from prescription to over-the-counter status.

The need for safe, effective and accessible emergency contraception is unarguable. In the United States alone, about 3 million unwanted pregnancies occur a year, half of which are due to broken condoms or other contraceptive failures, according to The Alan Guttmacher Institute in New York, a private, nonprofit group. Half of unwanted pregnancies end in abortion.

In fact, one in every two American women between 15 and 44 has had an unintended pregnancy, though only 1 percent has ever used emergency contraceptive pills, noted James Trussell, a professor of economics and public affairs at Princeton University and a leading scholar on contraception issues.

Indeed, survey data show that only one in 10 American women know that emergency contraceptive pills are available, despite the fact that in 1997 the FDA ruled that some regular birth-control pills – taken in a special pattern that varies by pill type – can be safe and effective methods of emergency contraception if taken within 72 hours of unprotected sex. Or that, since then, the agency has approved two other pills – PREVEN (a combined estrogen and progestin pill) and Plan B (a progestin-only pill) – spe cifically for emergency contraception.

This lack of awareness is a shame because there is now no question that emergency contraception is very safe and highly effective, as a 1998 World Health Organization study of nearly 2,000 women in 21 countries, and other studies, have shown.

Overall, emergency contraception reduces the risk of pregnancy by at least 75 percent, and it works best if taken as soon after unprotected sex as possible.

For instance, if 100 women have unprotected sex once during the second or third week of their monthly cycle – when the chance of pregnancy is highest – eight, on average, will become pregnant. With emergency contraception such as PREVEN or standard birth-control pills that combine progestin and estrogen, only two women would become pregnant. With pills such as Plan B that contain only progestin, only one would, Trussell said.

While half of women who take the combined hormones experience nausea and20 percent of them vomit, these side effects are reduced considerably in women who take progestin-only pills such as Plan B, the WHO study shows. Some women who use the combined hormone approach also take an over-the-counter drug called meclizine (Dramamine II) to control nausea.

Furthermore, emergency contraception does not appear to be dangerous either to a woman or to her fetus, if she turns out to be pregnant. “There is no known contraindication,” said Dr. Phillip Stubblefield, chairman of the department of obstetrics and gynecology at Boston Medical Center. Emergency contraception pills are not advised for women who are sure they are pregnant, but that’s not because they are dangerous; it’s because they would not work. “They will not provoke an abortion,” Stubblefield said.

Even if a woman who took the pills turned out to be pregnant, the pills would have no effect on the fetus because they would have been taken long before fetal organs start forming. Moreover, studies of women who inadvertently took standard birth-control pills without knowing they were pregnant showed no increased risk of birth defects.

Still, scientists acknowledge that they are not quite sure of all the biological pathways through which emergency contraception works. The method clearly can block ovulation, Trussell noted, and that is probably its chief mode of operation. Emergency contraception may also block implantation of a fertilized egg, although data on this point are mixed, and it may block fertilization.

However it works, emergency contraception has been a clear boon to women in Washington state who participated in the 1998-1999 pilot project run by PATH, the Program for Appropriate Technology in Health, a nonprofit, health advocacy group.

In the pilot project, which has now become a standard program throughout the state, women who had had unprotected sex within the previous 72 hours were able to go to a pharmacy, have a 15-minute consultation with a pharmacist, and walk away with EC pills. They never had to see a doctor, thanks to a collaborative agreement between the state’s doctors and pharmacists that allows the pharmacists to write and fill emergency contraception prescriptions.

During 16 months of the pilot program, nearly 12,000 prescriptions for emergency contraception were filled, said Jane Hutchings, senior program office at PATH. That translates to an estimated 720 pregnancies prevented. And since roughly half of unwanted pregnancies end in abortion, by inference, it means 360 abortions were prevented, too.

As one woman wrote: “The easy-access program saved me from a stupid mistake.” Wrote another: “I’m so grateful that this drug is available. I don’t think I could emotionally handle an abortion and am not ready for kids.” A third put it this way: “Abortion, and unwanted pregnancy, is very painful and this saves a lot of tears, money, fear and time.”

Moreover, in the Washington program, 42 percent of the women went to pharmacies after normal business hours. That’s important, said Sharon Camp, founder and chief executive officer of the Women’s Capital Corp., which makes Plan B, “because the `morning after’ is very often Sunday morning, when clinics and doctors offices are closed.

Judy Norsigian, a women’s health advocate at the Boston Womens Health Book Collective in Somerville, applauds the pharmacy-based program. Women who fear they may become pregnant don’t really need contact with a doctor, she said. But talking with pharmacists is important because “pharmacists are noted for giving better information than physicians on many drugs.”

But, ultimately, it’s over-the-counter availability that will make emergency contraception most effective. Many women’s health advocates, including the National Women’s Health Network, an advocacy group based in Washington, D.C., strongly endorse the idea, although they note that women who have a history of migraine headaches or blood clots should probably take pills that do not contain estrogen. Women’s health advocates also urge that EC pills be sold at a reasonable price – perhaps $20 – since over-the-counter drugs are not usually reimbursed by insurance.

Granted, there may be some opposition. In Italy last fall, a church-state battle erupted when emergency contraception pills went on sale. The Vatican condemned the pills as a form of abortion and urged pharmacists not to sell them.

Even in the United States, some doctors may resist being left out of the(income-producing) loop if women can simply go to a drug store and get the emergency contraception they need. But, because emergency contraception pills do not interrupt an established pregnancy, they are unlikely to provoke the kind of furor that accompanied approval of RU-486, the abortion pill.

In other words, there is no reason not to make them widely – and cheaply –         available.

Judy Foreman is a Lecturer on Medicine at Harvard Medical School. Her column appears every other week. Past columns are available on www.myhealthsense.com.

SIDEBAR: Existing Alternatives

Even without emergency contraception pills becoming available over the counter, there are several things women can do to prevent pregnancy if they act quickly.

First, you can be prepared in advance. Ask your doctor for a prescription for Plan B, PREVEN or regular birth-control pills to be used as emergency contraception. Fill the prescription and keep it where you can find it at home or in your purse. Emergency contraception works best in the first 12 hours after sex, but it is effective up to 72 hours later.

If you think you would like to use an intrauterine device, or IUD, for regular contraception anyway and you need emergency contraception as well, go to a doctor and ask for a copper IUD. This will prevent pregnancy if inserted up to five to seven days after unprotected sex.

Remember that emergency contraception is designed only to prevent pregnancy; it isn’t a treatment for sexually transmitted diseases. If you think you have been exposed to HIV or another sexually transmitted disease, call a doctor immediately.

Until seven years ago, when she was 40, Nancy Nangeroni lived as a man, which was not all that surprising, given that she was born, as she puts it, with standard male plumbing.

Unlike many transgendered people, who feel they are male but trapped in a female body or female stuck with male anatomy, Nangeroni felt she was male. But she hated it.

 “From the time I was very young, I resented the restrictions that were placed on me because I was not a woman,” said Nangeroni, her skirt and long hair blowing in the breeze one warm, fall afternoon in Cambridge. Now, she said, she takes female hormones, lives with a woman (though she doesn’t “presume” to call herself a lesbian), and feels somewhere in between male and female.

But Nangeroni, a leading figure in the transgender movement and the host of the GenderTalk radio show, has not had sex-change surgery. Instead, she said, “I reserve the right to change my gender tomorrow. That’s part of the freedom that transgenderism advocates for.”

For most of us, answering the question, “What sex are you?” is simple. We feel sure we’re male or female, and we’ve got the anatomy to prove it. 

Indeed, throughout the animal kingdom, most creatures fall neatly into one of two categories: Males, who make sperm and usually carry one X and one Y chromosome, and females, who make eggs and usually carry two X chromosomes.

But it’s the exceptions that make biology interesting – and make life difficult for people who don’t fit so clearly into one category or another. Gender, researchers increasingly realize, encompasses a host of possibilities including men who feel like women and vice versa, and people who are a little bit of both.

Transgendered individuals, who say they comprise about 1 to 2 percent of the population, usually face a conflict between their gender identity (the “Who am I?” question) and sex as defined by their anatomy. In short, many of them feel like they got the wrong sexual plumbing, perhaps because of some misfire in the complex process by which the fetal brain becomes masculinized or feminized. The idea that men and women have different brains is far from roven, although scientists do know that sex hormones do play a role in brain development.

Some seek a sex-change operation to end the conflict, but others live with it, appearing to the world as ordinary heterosexuals.

For Nancy Nangeroni, gender expression certainly involves an element of choice, but it’s not just a political decision. “It’s a very personal decision,” said Nangeroni, who holds a degree in electrical engineering  from the Massachusetts Institute of Technology.

As a young person, Nangeroni spent years dressing as a woman, “something I did as a compulsion.” Then, in her late 20s, she said, “I had a terrible motorcycle accident. And the accident was a direct result of the terrible depression and self-hatred that I had because I was cross-dressing in secrecy and great shame. With that accident, I recognized that it was really important for me to do something about the gender issues. I had to make some kind of change.”

Eventually, she decided to live openly as a woman. But it wasn’t easy, and she never felt that “after living for 38, 39 years as a man that I could just flip a switch and all of a sudden be a woman.”

For other transgendered people, the issues are physical as well. Some people are born intersexed, that is, with features of both male and female anatomy, an agonizing situation in which parents and doctors sometimes try to figure out which tendency is dominant and surgically make the child’s body conform to that.

In some African populations, there are also true hermaphrodites, people with two X chromosomes (the typical female genetic pattern), but who look male because they have penises and  testicular tissue (though they have ovarian tissue as well.).

There are even cultures, such as in the Dominican Republic, where people recognize three sexes: male, female and people who are born looking female (they have no penis or visible testes) but at puberty produce so much testosterone, a male hormone, that the clitoris turns into a penis.

To many lay people, the idea that something as seemingly basic as sexual and gender identity can be so complicated is often disturbing. And scientists are far from being able to explain why there can be such variation. But they do have some clues.

In a basic sense, sexual fate is set at the moment of fertilization by the incoming sperm. The sperm carries either a Y chromosome, which determines maleness,  an X chromosome, said David Page, a geneticist at  the Whitehead Institute in Cambridge. (The egg always contains one X chromosome, resulting in XY chromosomes for boys and XX for girls.)

The fascinating thing, though, is that “for the first six or seven weeks of development after the egg is fertilized by the sperm, XX and XY embryos look exactly alike. There are no differences,” Page said. A 6-week embryo has the full potential to become either a male or a female.

At this stage, the embryo has both male and female internal structures. One of these – the Mullerian ducts – has the potential to become fallopian tubes and a uterus; the other – Wolffian ducts – has the potential to become the sperm-making machinery and tubes to carry sperm.

Early embryos also contain primitive gonads that are capable of turning into either ovaries,  which make eggs, or testes, which make sperm. “But, at about seven weeks, the embryo sort of takes stock of whether it got that Y chromosome seven weeks back at the moment of fertilization,” Page said. On the Y chromosome lies a key gene called SRY, which stimulates the primitive gonads to become testes. If the SRY gene is not present, the gonads become ovaries.

Once testes form, they begin pumping out the male hormone, testosterone, which causes the Wolffian ducts to become the sperm production and transport system. The testes also pump out a chemical called MIS that causes the Mullerian ducts to shrivel up, so they cannot form fallopian tubes and the uterus.

As fetal development continues, male and female hormones then imprint the brain, nudging it toward masculinization or feminization. “One of the things we believe is that it is more common for men to become female in transgender change than for females to become men,” said Dr. Marshall Forstein, medical director of Fenway Community Health in Boston. “If something goes wrong in [the fetal development] process, or something is variable in that process, some of the brains of those men don’t become masculinized at the appropriate development time: Their brains are female, even though their bodies are male.

“So far, however, the idea that incomplete brain imprinting causes transgenderism is merely a hypothesis, and it makes some transgendered people like Nancy Nangeroni and Joan Roughgarden, a Stanford University biologist who now lives as a woman but was born male, cringe because it suggests that there might be something wrong with them. They also strongly dispute that men are more likely to be transgendered than women.

“Medical people are the worst,” Roughgarden said. `They don’t know any biology or zoology. They just superimpose their preconceptions on the data. They try to construct a norm and pathologize all states that differ from the norm.”Instead of speaking of one gender or another, people should think in terms of a “gender rainbow,” she said. Transgendered people “view rigid categories as tools of oppression.”

Nancy Nangeroni agreed: “There’s not just black and white. There’s every color of the spectrum. Likewise, there aren’t just two genders.”The real mission of the transgender movement, she said, is to challenge the way we think of gender and the gender restrictions that we put on individuals.Ultimately, she said, “gender expression is a form of speech. It’s not spoken, but it’s a form of speech that should be constitutionally protected.”

Judy Foreman’s column appears every other week in Health-Science. Her past columns are available on Boston.com and myhealthsense.com. Her e-mail address is foreman@globe.com. 

SIDEBAR: Identity, Orientation Issues Cause Confusion

Many people confuse the terms sex, gender identity and sexual orientation.Sex usually refers to physical characteristics, such as a penis or vagina; sometimes it also refers to the chromosomes – XY for males, XX for females.”Gender identity is how people describe themselves. `I’m a man’ or`I’m a woman,’ ” said Dr. Marshall Forstein, medical director of Fenway Community Health. “So, the term gender is filled with all sorts of social customs.”Sexual orientation is about whom one is attracted to. And “gender identity is a totally separate issue from sexual orientation,” said Laura Berman, a sex therapist in the department of urology at the UCLA Medical Center.In other words, Berman said, a person can have a mixture of traits: “You can be male but feel female and be attracted to either men or women. You can be female and feel male and be attracted to either men or women. You can be male and feel male, but be attracted to men. And you can be female, feel female and be attracted to women.”

Cross-dressing, that is, dressing as the opposite sex, can also cut across categories. For some straight men, dressing as a woman may be erotic. For some transgendered people, it may be the first step in living fully as the opposite sex.

Doris Laird, a humanities professor at Florida A&M, believes RU-486, the controversial abortion pill that won government approval late last month, will be a lifesaver.

She should know. The 69-year-old Laird has been taking the drug for seven years, not to induce abortion but to control a slow-growing, benign brain tumor called meningioma that once threatened her vision and her life.

Though the medical community is divided on the effectiveness of RU-486 on meningioma, you can’t tell that to Laird. Since she’s been on it, “my brain tumor has not grown at all,” she said.

Lost in all the heated rhetoric and debate over RU-486, which the Food and Drug Administration OK’d after years of political wrangling, is the likelihood that the drug could be much more than just an abortion inducer.

Researchers around the country are already gearing up to study other potential uses of the drug in projects that had been impossible while RU-486 was not legally available in this country and research supplies were limited.

Research was stalled for years because there has been virtually no supply of the drug, said Eleanor Smeal, president of the Feminist Majority Foundation, a Virginia-based national women’s-rights group that helped provide Laird and the roughly 40 other Americans who have been using the drug for nonabortion purposes on a compassionate-use basis.

But now that the drug is approved, “researchers are beating on my door to test it for other uses,” said Dr. Richard Hausknecht, medical director at Danco Laboratories in New York City, the drug’s distributor. “We’re anxious to see this research go forward,” he added, noting Danco has plenty of the drug on hand to share with researchers.

Researchers are excited about RU-486 as a multipurpose drug because of its effectiveness at blocking the hormone progesterone. Because a woman’s uterus cannot maintain pregnancy without progesterone, blocking its production effectively ends gestation.

But progesterone also can drive a number of tumors – both benign tumors like meningioma and malignant ones such as breast, uterine and ovarian cancer. Thus, blocking progesterone in patients with these conditions should, in theory, slow tumor growth.

Progesterone also drives a number of non-cancerous conditions such as uterine fibroids, which affect more than 20 percent of women over 30 and contribute substantially to America’s 600,000 hysterectomies every year, and endometriosis, an abnormal growth of uterine tissue outside the uterus, which affects 5 to 15 percent of reproductive-age women.

Moreover, by lowering levels of the stress hormone, cortisol, RU-486 may also help people with Cushing’s disease, a disorder of the pituitary.

Even outside of research trials, some patients may soon be able to get access to RU-486, also known as mifepristone and Mifeprex, for nonabortion uses. Once the drug is on the market, which is expected within a month, any qualified doctor who sets up an account with Danco can legally provide

Mifeprex to patients both for abortion and “off-label,” or nonapproved, uses as well. The first off-label uses are likely to be other pregnancy-related conditions. In France, Hausknecht noted, the drug is already approved to soften the cervix before a surgical second trimester abortion and to induce labor in women whose fetuses have died in utero.

Mifeprex also may help women who have early ectopic pregnancy, in which the fertilized egg implants in a Fallopian tube rather than the uterus. Hausknecht, who is also an associate professor of obstetrics and gynecology at Mount Sinai School of Medicine in New York, hopes to start a multicenter trial of Mifeprex for this use soon. In Europe, he said, researchers have already shown that when RU486 is combined with another

drug, methotrexate, it boosts the success rate for early ectopic abortion from 75 to 90 percent.

Uterine fibroids, which, like the uterus itself, are sensitive to progesterone, also respond to Mifeprex, though they may start growing again when the drug is stopped. A small study by California researchers published in 1993 in the Journal of Clinical Endocrinology and Metabolism showed that RU-486, taken daily for three months at far smaller doses than those used for abortion, shrank fibroids significantly.

Another small California study, published in 1998 in the American Journal of Obstetrics and Gynecology, showed that RU-486, in tiny doses, reduced the pain of endometriosis, although it did not seem to slow the abnormal growth per se. More data are needed, said Dr. Johanna Perlmutter, an obstetrician-gynecologist at Beth Israel Deaconess Medical Center in Boston, but Mifeprex should be useful for endometriosis.

For cancer treatment, perhaps the most tantalizing findings were those published earlier this year in the Journal Gynecologic Oncology by researchers from the Robert Wood Johnson Medical School in New Jersey.

They studied 34 women whose ovarian tumors had not responded to standard chemotherapy drugs and found that Mifeprex seemed to slow the cancer in about a quarter of the women, resulting either in at least a temporary shrinkage of the tumor or a decrease in a tumor marker called CA-125 as shown by blood tests.

In uterine cancer, preliminary data suggest that RU-486 can stop tumor growth in the test tube. In breast cancer, early studies suggest that the drug may hold the disease in check in some women, according to a 1994 review of the data by Dutch researchers.

And what of those, like Doris Laird, who struggle with meningioma? Laird’s tumor seems not to have grown, though whether that’s due to RU-486 or the naturally-slow growth of this kind of tumor is unclear. Other people with meningioma, among them, Sheila, a 53-year old writer and editor who lives in a Boston suburb and did not want her last name used, have not been so lucky. Sheila took RU-486 as part of a study and believes “it bought me at least18 months or better of time.” She stopped taking the drug when brain scans showed her tumor was growing slowly. Unfortunately, the biggest study to date on RU-486 and meningioma seems to be yielding disappointing results.

Several years ago, a pilot study led by Dr. Steven Grunberg, a medical oncologist at the Vermont Cancer Center in Burlington, showed that the drug seemed to benefit about a half-dozen of the 28 people tested.

“You do not get dramatic shrinkage of the tumors but vision improved in two people who had been losing their sight,” he said. “It only takes a slight change in the right direction to see that they were delighted.”

At Beth Israel in Boston, Dr. Daniel Karp, director of cancer clinical research, also saw two of his meningioma patients stay stable for many months after stopping the drug.

But a number of researchers around the country, including Karp and Grunberg, have now pooled their data on 192 meningioma patients and the emerging picture is less rosy. In fact, patients taking RU-486 did not fare any better than those on placebo, Karp said.

“For the average patient, it did not look promising,” said Dr. Peter Ravdin, a medical oncologist at the Southwest Oncology Group in San Antonio, Texas, who is analyzing the study. “But we’re still looking to see if there is a subset of people who would benefit.”

Such hopes and disappointments, of course, are the essence of medical research. But even if RU-486 does not fulfill all of researchers’ hopes, that it can now be studied for many conditions other than abortion is welcome news.

Smeal, of the Feminist Majority, vows to continue fighting for the drug, this time for nonabortion uses: “Our next major campaign is to press the NIH [National Institutes of Health]for funding for these trials.”

Jennifer Peterson was 35 and barely one week pregnant when she noticed a lump the size of half a banana in her breast. A few weeks later, tests  showed she had invasive breast cancer.

The irony was mind-numbing: A potential new life beginning inside her,   her own life threatened. For months, Jennifer, a resident of Manchester, N.H., who runs a small Boston law firm with her husband, had been trying to get pregnant. Now, the choices were stark: If they waited to treat the cancer until Jennifer gave birth, her survival could be greatly diminished. If they terminated the pregnancy, they might never conceive again, because chemotherapy can put a woman into premature menopause.

And then there was the third terrifying option, the one they chose: To go ahead with both treatment and the pregnancy.

“There were bad times – three surgeries and three months of chemo. I was bald, fat and one-breasted,” she said. But, through it all, Jennifer said, husband Karl Sucheki “loved me and was just as excited as I was.” Their “chemo kid,” Michael, was born full term and healthy two years ago.

Not long ago, many prospective parents – and doctors, too – would have shuddered at the very idea of subjecting a pregnant woman and her fetus to powerful drugs or surgery. But growing evidence suggests that, in many cases, such interventions may not only be safe but essential to protect both mother and fetus.

Mercifully, the collision of pregnancy and serious illness is not an everyday occurrence. But some cancers, notably leukemia and some types lymphoma, often strike in the mid to late 20s, said Dr. Lawrence Shulman, an oncologist at the Dana-Farber Cancer Institute and Brigham and Women’s Hospital. Breast cancer is an even bigger threat, now occurring in one in 3,000 pregnancies, according to the National Cancer Institute. That figure is likely to rise as more women have babies later in life.

Other serious problems, including depression, asthma, epilepsy and infections also can occur during pregnancy and may need to be treated just as aggressively as if the woman were not pregnant, said Dr. Michael Greene, director of maternal-fetal medicine at MGH.

The biggest problem is drugs that cross the placenta, which nourishes the fetus. Once inside, some drugs can cause congenital malformations, especially during the first trimester of pregnancy, when the major organs are forming.

But, surprisingly, few prescription drugs are “absolute no-nos,” Greene said. Those are Accutane, an acne medication; thalidomide, now used to treat leprosy; ACE inhibitors to control blood pressure; Cytotec, which both causes birth defects and induces abortion; methotrexate, an anticancer drug that also induces abortion; and Coumadin, a blood thinner that can induce fetal hemorrhage.

Not quite as dangerous but still risky are some antiseizure medications and drugs used to control an overactive thyroid gland. Curiously, some over-the-counter drugs may also carry risks, especially aspirin and the NSAIDS (nonsteroidal anti-inflammatory drugs like ibuprofen).

With those caveats firmly in place, however, it’s often better for both mother and fetus to treat a serious disease than leave it untreated.

Take depression. For many years, doctors thought the sheer bliss of expecting a baby – not to mention the hormone surges of pregnancy – meant “that patients would do fine psychiatrically without medications even if they had been on them for many years,” said Dr. Lee Cohen, director of the perinatal and reproductive psychiatry research program at Mass. General.

It is now clear, Cohen said, that women who stop antidepressant medications during pregnancy fare poorly, generally relapsing in three to six months. That prospect terrified a Boston lawyer, now in her mid-30s, who had been taking Prozac for years and didn’t want to stop when she got pregnant. She “had to keep on working and stay highly functional,” she said, and knew her own “mental health would be important for the baby.”

Indeed, leaving depression untreated can be life-threatening for women who are suicidal and may be bad for the fetus as well because of the stress hormones that accompany depression. Pregnant women who are depressed are more likely to have obstetrical complications, including premature labor, low-birth-weight babies and to have babies who are cognitively impaired, Cohen noted.

Once the baby comes home, women who were depressed during pregnancy are five times more likely to suffer postpartum depression, which can interfere with parent-child bonding.

Moreover, some antidepressant medications appear to be quite safe for the fetus, particularly Prozac, a so-called SSRI (selective serotonin reuptake inhibitor) whose effects have now been tracked in 2,000 pregnant women.

In a major study published in 1997 in the New England Journal of

Medicine, Canadian researchers studied the children of 80 mothers who took Prozac or an older type of antidepressant drug such as Tofranil and Pamelor during pregnancy. As other studies had hinted, no matter when in the pregnancy a woman took the medications, there were no congenital malformations in the fetus, said psychiatrist Donna Stewart, who heads the women’s health department at the University of Toronto and was a co-author of the study.

In fact, the researchers followed the children for up to seven years and still could find no evidence that those exposed in utero to antidepressants were any different from unexposed children in global IQ, language or behavioral development A separate study in California in 1996 did show a slightly increased risk that babies with in-utero exposure to antidepressants would be placed temporarily in intensive care nurseries for observation, but more recent research by Cohen’s team at MGH refutes this.

For pregnant women with manic depression, severe anxiety or schizophrenia, it may also make sense to continue on medication. Lithium, a major treatment for manic depression, has caused concern because it can raise the risk of congenital heart disease. But the risk with lithium is smaller than once thought, Cohen said. He calls lithium “100 times safer than

Depakote,” an antiseizure drug that’s often used in manic-depression, but that can significantly raise the risk of spina bifida (incomplete closure of the spinal cord) in the fetus.

For pregnant women who are schizophrenic, older antipsychotic drugs such as Haldol and Stellazine do not increase the risk of birth defects, though there’s less data on newer antipsychotic drugs such as Zyprexa and Risperdal. Anxiety and especially panic attacks may also need treatment during pregnancy, either with antidepressants (that combat anxiety, too) or low dose benzodiazepines such as Klonopin if psychotherapy fails to help.

For pregnant women with cancer, the decision to treat the cancer is a delicate balancing act that is slightly easier at the extreme ends of pregnancy.

If a woman develops acute leukemia in the first few weeks of pregnancy, said Shulman of Dana-Farber, “you have little option to” wait because the woman could die quickly, which means terminating the pregnancy often makes sense. And if a woman is close to the end of pregnancy – say, 30 weeks (a normal pregnancy is 40 weeks) – doctors can often deliver the baby safely and then treat the mother’s cancer.

But for women who learn of their cancer mid-pregnancy, the choices get tougher. Fortunately, some chemotherapy drugs such as Cytoxan appear to

be safe for the fetus, at least in the last trimester, even though such drugs often act on rapidly dividing cells (and a fetus could be viewed as a collection of such cells).

Radiation is usually avoided during pregnancy because of possible damage to the fetus, but if the mother has a tumor that’s pressing on major blood vessels in the chest, it may be necessary. Jennifer Peterson, for example, delayed radiation treatment for her breast cancer until six days after her son, Michael, was born.

On the other hand, surgery – except on the uterus itself – is often safe for pregnant women. Even general anesthesia is not a big deal, said Greene of MGH. “The fetus gets sleepy, but it wakes up” when the operation is over.

No pregnant woman, of course, wants to have any of these interventions if she can help it.

Chemotherapy, in particular, is terrifying, Jennifer Peterson said. “You are putting a highly toxic substance into your body at this sacred time in life when your body is supposed to be a temple and all of a sudden you’re turning it into a toxic waste dump.”

But right after Michael, her “chemo kid,” was born, she and her husband began thinking of having another child. Their second gorgeous baby, Matthew, was born two months ago, and Jennifer has no signs of cancer.

“I think the human body is truly amazing,” she said. “And it’s never more awe-inspiring than during pregnancy and birth. My beautiful son, Michael, is testament to the fact that you and your in-utero baby can endure surgery and chemotherapy while pregnant and both end up healthy. And my wonderful newborn, Matthew, is proof that the circle of life does, indeed, continue to miraculously turn.”