Abnormal or Heavy Menstrual Bleeding

The menstrual cycle is counted from the first day of one period to the first day of the next. An average cycle is 28 days but anywhere from 23 to 35 days is normal. Periods usually last 3-5 days but anywhere from 2-7 days is normal. The amount of blood varies, usually starting out light, then heavy, then light again. Abnormal menstrual cycles can be caused by a variety of situations including hormonal imbalances, ovarian cysts, infections, fibroids, polyps, and cancers. Evaluation may include history and physical, laboratory blood work, imaging and biopsies. Treatments include, but are not limited to, medications, uterine ablations, dilation and curettage and sometimes hysterectomy.

Abnormal Pap Smears

Pap smears are done in order to identify abnormal changes on the cervix in an early stage. These changes can be mild to severe, depending on the spread of the abnormal cells. The abnormal cells are called dysplasia. Dysplasia occurs in females age 15 and over, and most often in those age 25 to 35. Usually no signs or symptoms are present. Your risk of developing dysplasia increases with smoking, multiple sexual partners and infection with HPV. Abnormal Pap smears can be evaluated with a colposcopy and depending on the findings, might require treatment and/or close follow-up.

Adolescent Care

Puberty in females occurs between the ages of 8 and 14, and may last for 2 or 3 years. Adolescence is the period of transition from childhood to adulthood and is generally considered to last from the beginning of puberty to age 18 or 20. During this time a girl experiences breast development, the growth of pubic and axillary hair and the onset of menses. The average age of onset of menses is 12.5 years. Menses typically start within a year of breast development and they may remain irregular for 1-2 years. A gynecologic evaluation is indicated if the adolescent has problems with delayed onset of menses, continued irregular menses, pain with menses, ovarian cysts or needs contraceptive counseling. Adolescents should also consider getting the HPV vaccine.

Breast Concerns

It is important to learn how to do self breast exam, the best time is after your menses if you are still menstruating since they tend to be less tender and full at that time. Some findings that might signify a problem that should be evaluated by a health professional include, but are not limited to, hard knots, change in the size or shape of your breast, unusual swelling, warmth, redness, dimpling or puckering of the skin, sore or rash on the nipple, pulling in of the nipple, nipple discharge that starts suddenly, pain in one spot that does not vary with your menstrual cycles. It is important to know what your baseline exam is, so that you know when your breast exam changes. Change is important, especially when it occurs in only one breast. Remember that most breast lumps are not cancer, but anything of concern should be evaluated. In addition to self breast exam, you should continue to get clinical breast exams by your healthcare professional and mammograms as recommended.

Cancer Screening

Screening involves checking for cancer in a person who does not have any symptoms of the disease. The goal of screening is to catch cancer in its earliest stages. Gynecologic screening includes examinations and tests for breast, cervical, colorectal and skin cancers. If there are specific concerns, symptoms, or family history, then other evaluations can be done for vaginal, uterine, ovarian and fallopian tube cancers. Please check with your health care provider regarding the best screening for you, based on your age, medical history and family history.

Contraceptive Counseling and Management

Choosing a method of birth control is a highly personal decision based on individual preferences, medical history, lifestyle, and other factors. Each method carries with it a number of risks and benefits of which the user should be aware. Each method of birth control has a failure rate, an inability to prevent pregnancy over a one-year period. Each method has possible side effects. Some methods require lifestyle modifications. Some cannot be used by individuals with certain medical conditions. The main types of birth control include barrier methods (condoms,diaphragms,sponge and cervical cap), hormonal methods (birth control pills, patches, rings, injectables, implantable rod), Intrauterine Contraceptives (Mirena and Paragard CopperT), natural family planning, and surgical sterilization (tubal ligation, vasectomy and Essure). Your healthcare professional will discuss your options based on your needs, medical history and concerns.

Endometriosis

Endometriosis occurs when tissue from the lining of the uterus becomes implanted in the outer surface of the uterus, the fallopian tubes or the ovaries. Endometriosis is often painful, and scar tissue can form in your pelvic area. Endometriosis can affect females between puberty and menopause but is most common between ages 20 and 30. Symptoms include painful periods, pain with sexual intercourse, premenstrual spotting, back pain, and infertility. Without treatment it can become severe, but with accurate diagnosis it can be treated and managed.

Fibroids

Fibroids are an abnormal growth of cells in the muscular wall of the uterus. Uterine fibroids are common and almost always not cancerous. They range in size from very tiny to the size of a cantaloupe or larger. Fibroids can cause abnormal bleeding and pain. There are a variety of treatments of fibroids including medications, ablative procedures and surgeries.

Genital Herpes

Genital herpes is a sexually transmitted disease caused by herpes simplex viruses type 1 (HSV 1) or type 2 (HSV 2). Nationwide,16% of individuals between the ages of 14-49 have genital HSV 2. Both types of herpes can be found in and released from the sores that the viruses cause, but can also be released between outbreaks from skin that does not appear to have a sore. Generally, a person can only get HSV 2 infection during sexual contact with someone who has a genital HSV 2 infection. HSV 1 can cause genital herpes but more commonly causes infections of the mouth and lips, so-called “fever blisters.” HSV 1 infections of the genitals can be caused by oral-genital or genital-genital contact with a person who has HSV 1 infection. Genital herpes can cause recurrent painful genital sores . Herpes can be diagnosed by visual inspection if the outbreak is typical, and by taking a sample from the sore and testing it in a laboratory. Blood tests can detect antibodies to HSV 1 and 2. There is no treatment to cure herpes, but medications can shorten and prevent outbreaks during the period of time the person takes the medication. The surest way to avoid transmission of any sexually transmitted disease, including HSV 1 and 2, is to abstain from sexual contact or to be in a long term monogamous relationship with a partner who has been tested and is known to be uninfected. Correct and consistent use of latex condoms can reduce the risk of genital herpes. Discuss your concerns with your healthcare provider.

Genital Warts

Genital warts are caused by a subtype of the same virus that causes other warts, the human papillomavirus (HPV). They are considered the most common sexually transmitted disease and can affect both sexes. The incubation period may be several months duration. You can have no signs or symptoms and still be contagious and transmit the infection. Warts can appear on moist surfaces at the entrance to the vagina and the rectum. They may be small, flat, flesh-colored bumps or cauliflower bumps. They can be without symptoms or can cause itching, burning, tenderness or pain. Genital warts in children may be a sign of sexual abuse. Warts are diagnosed by physical exam, and sometimes biopsy. Treatment is based on the size, number and location of the warts.

Hormone Replacement Therapy

Hormone replacement therapy (HRT), medications containing female hormones to replace the ones the body no longer makes after menopause, can be a treatment for women with menopausal symptoms. Women who choose HRT typically take estrogen and progesterone. It can ease symptoms of menopause such as hot flashes and night sweats. Long term benefits may include osteoporosis prevention, decrease in colorectal cancer and cardiovascular disease in newly menopausal patients. Risks could include an increased risk of breast cancer, strokes, blood clots and cardiovascular disease. There are many conflicting studies that discuss the risks and benefits of HRT. There are different types of HRT with different effects and side effects. Each patient is an individual and must make decisions about HRT along with their health professional based on their needs and medical history.

Kegel Exercises

The purpose is to recognize, control and develop the muscles of the pelvic floor. These are the ones used to interrupt urination in mid-stream. The following exercises strengthen these muscles so you can control or relax them completely:

• To identify which muscles are involved, alternately start and stop urinating when using the toilet.
• Practice tightening and releasing these muscles while sitting, standing, walking, driving, watching TV, etc.
• Tighten the muscles a small amount at a time, “like an elevator going up to the 10th floor.” Then release very slowly, “one floor at a time.”
• Tighten the muscles from front to back, including the anus, as in the previous exercise.
• Practice exercises every morning, afternoon and evening. Start with 5 times each, and gradually work up to 20 or 30 each time.

Menopausal Concerns

Menopause is the permanent cessation of menstruation. It occurs typically between the ages of 45 and 55, with the average being 51 years. It is normally diagnosed in females after 1 year of absent menstrual periods. Frequent signs and symptoms include hot flushes, night sweats, vaginal dryness, bladder irritability, mood fluctuations, and many others. Menopause is a natural process, not an illness, but some women have a more difficult transition than others. These individuals may need assistance is addressing these concerns so that quality of life can be maintained. Many treatments and solutions are available based on symptoms and medical history.

Osteoporosis Diagnosis and Treatment

Osteoporosis is a progressive disease where the loss of normal bone density, bone mass and bone strength leads to increased thinning and risk of fracture. It most often affects women after menopause. There are typically no symptoms until a fracture occurs in bone, most commonly the spine and hip. The risk increases with poor nutrition, low calcium and vitamin D intake, small frame body type, family history of osteoporosis, smoking, heavy alcohol use, steroid use, and thyroid dysfunction. The maintenance of adequate calcium and vitamin D intake is crucial. Diagnosis is typically made with a bone density test called a DEXA scan. Treatment includes medications, supplements, weight bearing exercise and behavior modification.

Pain with Intercourse

Pain with intercourse, also called Dyspareunia, is defined as recurrent and persistent genital pain associated with sexual intercourse. Pain may be mild or severe and may vary with different intercourse positions. Potential causes include infection, scar tissue, endometriosis, an intact hymen, inadequate lubrication, low estrogen levels and psychological or emotional causes. Diagnosis is based on symptoms, your medical and sexual history, pelvic examination, laboratory tests and imaging. Appropriate treatment is then recommended based on the diagnosis.

Pelvic and Ovarian Masses

Pelvic masses may originate from gynecologic organs like the cervix, uterus and ovaries, or from other pelvic organs such as the intestines, bladder, bone and muscle. In reproductive age women common pelvic masses include physiologic ovarian cysts, dilated fallopian tubes, fibroids in the uterus, endometriosis or tumors. Tumors can be either benign or malignant. Pelvic masses in postmenopausal women are slightly more concerning, although the majority of these are benign. Symptoms of a pelvic mass include pelvic pain, pressure, bloating, pain with intercourse and irregular or postmenopausal bleeding. The evaluation involves a history and physical exam, laboratory blood work, and radiology imaging. Specialized blood work may be ordered as indicated, called tumor markers. Ultimately surgery could be necessary, either by laparoscopy or exploratory laparotomy. The surgery is tailored to the diagnosis.

Pelvic Pain

Pelvic pain is defined as pain occurring in the lower abdomen and pelvic region. If it is present for more than 6 months, it is considered chronic. The pain may be intermittent or recurrent, or it may be constant and severe. Symptoms vary for different women. There are many causes to include ovulation pain, menstrual pain, endometriosis, ovarian cysts, pelvic infections and scar tissue. Diagnosis begins with a medical history and physical examination, including a pelvic exam, laboratory tests and imaging. Surgery may be indicated. The treatment will depend on the diagnosis.

Pelvic Relaxation and Prolapse

The loss or weakening of support of the pelvic organs can cause prolapse through the pelvic floor which can cause symptoms. Pelvic relaxation can include the bladder, vagina, small bowel, rectum and uterus. Frequent signs and symptoms include pelvic pressure, back pain, painful sexual relations, bladder infections or difficulty urinating, constipation, and vaginal bleeding. Symptoms typically worsen with prolonged standing and straining. Diagnosis includes a pelvic examination. Treatment is based on the degree of prolapse and severity of the symptoms. Mild prolapse can respond to physical therapy and Kegel Exercises while some circumstances require surgery.

Polycystic Ovarian Syndrome (PCOS)

Polycystic ovarian syndrome affects 5-10% of all women of childbearing age regardless of race or nationality. It is described as a hormonal imbalance that is associated with ovulation problems. Symptoms include irregular menses, increased hair growth, trouble getting pregnant and acne. Possible long term complications include adult onset diabetes, high cholesterol and triglycerides, cardiovascular disease, uterine cancer and glucose problems during pregnancy. The evaluation for PCOS may include a physical exam, medical history, laboratory tests, and pelvic ultrasound. There are a variety of medical treatments for this condition based on the findings and goals of treatment.

Post Coital Bleeding

Intercourse should not be accompanied by any type of bleeding. Some causes include infections or inflammation of the cervix, estrogen deficiency, cervical or uterine polyps, or abnormal cells of the cervix or uterus. Diagnosis can be made with the help of cultures, pap smears, ultrasound and biopsies. Treatment is based on the diagnostic results and clinical history.

Postmenopausal Bleeding

Postmenopausal bleeding is defined as unexpected bleeding that begins 6-12 months or more after menopause. The bleeding may be light brown or heavy red. Bleeding episodes may vary in length. The type or quality of the bleeding is not relevant, only that it has taken place. Causes include cancer of the reproductive system, vaginal atrophy or thinning, trauma to the vagina, infections in the vagina or uterus, polyps in the cervix or uterus, blood cell disorders, liver disorders or medication problems. The bleeding is evaluated by imaging, usually ultrasound and hysteroscopy and uterine biopsy. Once the evaluation is done, the treatment is based on those results. A dilation and curettage is sometimes needed to evaluate the condition further. If cancer is found, a hysterectomy may be recommended.

Preconception Counseling

The health of both partners before conception is vital to the development of a healthy baby. As soon as you decide to have a child, you and your partner should assess your lifestyle to determine if any changes are necessary. Some things to consider would be nutrition and diet, smoking, alcohol use, drug abuse, exercise, family or genetic concerns, environmental exposures, medical conditions, age, and current medication use. Prior to conceiving, you should schedule a visit to the doctor for prepregnancy planning, counseling and physical exam. Remember to take a prenatal vitamin that contains adequate folic acid while you are trying to conceive.

Premenstrual Syndrome (PMS)

Premenstrual syndrome involves symptoms that begin up to 14 days prior to a menstrual period and usually stop when menstruation begins. About half of all women experience PMS at some time, some very frequently. The peak incidence occurs between ages 25 and 40. Frequent signs and symptoms include depressed mood, dizziness, fatigue, headaches, breast pain, bloating, digestive disturbances, and acne. The cause is unknown but may be due to fluctuations in circulating hormones. There are a wide variety of treatments to include medications, vitamins and lifestyle changes.

Sexual Dysfunction

Female sexual dysfunction may involve lack of sexual desire, an inability to experience sexual pleasure or an inability to achieve orgasm. Medical illnesses, medications, atrophy of genital tissues, drug or alcohol use, stress, and psychological issues are just some of the causes of sexual dysfunction. An evaluation includes a history and physical, laboratory blood tests and imaging as indicated. Counseling, medications and physical therapy are some treatment options based on the evaluation results.

Sexually Transmitted Diseases Diagnosis and Treatment

Sexually transmitted diseases affect more than 15 million men and women in the US each year. The more sexual partners you have, the higher your chance of being exposed to an STD. STDs include HIV, Chlamydia, genital herpes, trichomoniasis, pubic lice, genital warts, gonorrhea, syphilis, viral hepatitis, scabies, and human papillomavirus. Some STDs can cause pelvic infections, infertility, tubal pregnancies, cervical cancer, chronic pain and death. Symptoms may include vaginal discharge, painful intercourse, pelvic pain, blisters, rashes, swelling, and fever. Diagnosis may require cultures and/or blood work. Treatment is based on the results of the cultures and symptoms. Once a diagnosis is established, a sexual partner may need to be treated as well.

Urinary Incontinence

The two most common types of incontinence are stress and urge. Stress incontinence is the unintentional loss of urine with lifting, sneezing, singing, coughing, laughing or straining. It is caused by a change in the relationship of the uterus to the bladder resulting in the shortening of the urethra and loss of the normal muscular support for the bladder and pelvic floor. These changes occur during pregnancy and after childbirth, particularly repeated childbirth. Obesity is also a factor. Risk increases with repeated vaginal births, vaginal birth of large children, adults over 60, obesity and chronic lung disease with cough. Management includes physical therapy, Kegel exercises, weight loss, smoking cessation, and surgery. Urge incontinence is the inability to control the bladder once the urge to urinate occurs. It can occur with stress incontinence as well. It is typically caused by overactive muscles that cause the bladder to contract and empty. The treatment for urge incontinence is similar to stress incontinence with the exception that it usually responds to medications rather than surgery.

Vaginal Infections

Vaginitis is an inflammation of a woman’s vagina. As many as 30% of all women will experience vaginitis sometime in their lives. There are many possible causes and the treatment depends on the diagnosis. Common causes of vaginitis are yeast, bacterial vaginosis, trichomonas, and low estrogen levels. Symptoms include vaginal discharge, odor, itch, irritation and sometimes bleeding. Diagnosis is typically made by inspection, culture and by looking at the discharge under a microscope. Lifestyle changes may be necessary in order to prevent recurrences.

Vulvar Skin Disorders

The vulva, the outer part of the female genital area, can be the site of a variety of diseases. Many of these disease are relatively minor, causing only minor discomfort and inconvenience. Others, such as cancer, though rare, can have more serious consequences if not treated early. Any body part that is covered with skin can develop dermatologic diseases and cancer, the vulva is no exception. The vulva can get chronic irritations or contact allergies. It can develop a chronic inflammation called vestibulitis and a pain condition called vulvodynia. The skin can become thin and sensitive, causing itching and burning. These skin disorders typically require long term medication use. Unfortunately the vulva can also have precancerous conditions, invasive cancer, and melanomas. Some sexually transmitted diseases may present on the vulva, the most common being genital warts and herpes. Skin conditions commonly found in other locations can manifest on the vulva, such as psoriasis. This area is commonly inspected during a routine gynecologic exam. If an abnormality is found, or a patient is symptomatic, a biopsy or culture is often needed in order to make a diagnosis and form a treatment plan.