Common Gynecologic Problems

Gynecologic Problems and female reproductive system

Gynecologic problems are those related to the female reproductive system. Some common problems are caused by such conditions as infections, injuries, or hormonal changes. These common problems include pelvic pain; inflammation of the uterus, fallopian tubes, vagina, or vulva: and non-cancerous uterine growths, such as fibroids. Other common problems are related to menstruation - for example, premenstrual syndrome and pain during menstrual periods (dysmenorrhea). Although some problems may be mild and correct themselves, others, such as infections may be serious and require medical attention.

Pelvic Pain

The pelvis, which contains the uterus, fallopian tubes, ovaries, vagina, bladder, and rectum, is the lowest part of the trunk, below the abdomen and between the hip bones. Women often pain in this area. Such pain varies in type and intensity, and the cause can be hard to identify.

Pelvic pain is frequently, but not always, caused by problems related to the reproductive system. Other causes of pelvic pain are related to the intestines or urinary tract. Psychologic factors can make pain seem worse or even cause a sensation of pain where no physical problem exists.

Diagnosis

When a woman suddenly develops very severe pain in the lower abdomen or pelvic area, a doctor must quickly decide whether the situation is an emergency requiring immediate surgery. Examples of emergencies are appendicitis, perforation of the intestine, a twisted ovarian cyst, an ectopic pregnancy, and a ruptured fallopian tube.

The doctor can often determine the cause of the pain from its description, including what it feels like (for example, sharp or dull), under what circumstances and how suddenly it began, how long it has lasted, and where it's located. Additional symptoms, such as a fever, nausea, or vomiting, may help the doctor make the diagnosis. Information about the timing of the pain in relation to eating, sleeping, sexual intercourse, movement, urination, and defecation may also help.

A physical examination is performed. A pelvic (internal) examination, always part of an evaluation of pelvic pain, helps the doctor determine which organs are affected and whether an infection is present. Laboratory tests, such as a complete blood cell count, a urinalysis, or a pregnancy test, may indicate internal bleeding, an infection, or an ectopic pregnancy. An ultrasound examination, a computed tomography (CT) scan, or magnetic resonance imaging (MRI) of the internal organs may be needed. Sometimes the doctor performs surgery or laparoscopy (a procedure in which a fiber-optic tube is used to examine the abdominal and pelvic cavities) to determine the cause of the pain.

Vaginitis and Vulvitis

Vaginitis is an inflammation of the lining of the vagina. 0ulvitis is an inflammation of the vulva (the external female genital organs). Vulvovaginitis is an inflammation of the vulva and the vagina.

In these conditions, the tissues are inflamed, sometimes resulting in a vaginal discharge. Causes include infections, irritating substances or objects, tumors or other abnormal tissue, radiation therapy, drugs, and hormonal changes. Poor personal hygiene can contribute to the growth of bacteria and fungi as well as cause irritation. Stool may enter through an abnormal passage (fistula) from the intestine to the vagina, resulting in vaginitis.

During a woman's reproductive years, hormonal changes can result in a normal discharge that's watery, mucous, or milky white, varying in amount and type with the different phases of the menstrual cycle. After menopause, the vaginal lining and vulvar tissues thin, and the normal discharge may decrease because of the lack of estrogen. Consequently, the vagina and vulva are more easily infected and injured.

Newborns may have a vaginal discharge caused by estrogen absorbed from the mother before birth. It usually disappears within 2 weeks.

Symptoms

The most common symptom of vaginitis is an abnormal vaginal discharge. A discharge is considered abnormal if it occurs in large amounts, has an offensive odor, or is accompanied by vaginal itching, soreness, or pain. Often, an abnormal discharge is thicker than a normal discharge and varies in color. For example, it may be the consistency of cottage cheese, or it may be yellow, greenish, or blood-tinged.

A bacterial infection of the vagina tends to pro-duce a white, gray, or yellowish cloudy discharge with a foul or fishy odor. The odor may become stronger after sexual intercourse or washing with soap, both of which reduce vaginal acidity, thus encouraging bacterial growth. The vulva may feel irritated or itch mildly.

A candidal (yeast) infection produces moderate to severe itching and burning of the vulva and vagina. The skin appears red and may feel raw. A thick, cheesy discharge from the vagina tends to cling to the vaginal walls. Symptoms may worsen during the week before a menstrual period.

This infection tends to recur in women who have diabetes that isn't well controlled and in those who are taking antibiotics.

An infection by Trichomonas vaginalis, a protozoan, produces a white. gravish-green, or yellowish discharge that may be frothy.

The discharge often appears shortly after a menstrual period and may have an unpleasant odor. Itching is severe.

A watery discharge, especially if it contains blood, can be caused by cancer of the vagina, cervix, or uterine lining (endometrium).

Polyps on the cervix may produce vaginal bleeding after sexual intercourse. If the vulva has been itchy or uncomfortable for sometime, causes may include a human papillomavirus infection or carcinoma in situ, a very early cancer that hasn't invaded other areas and can usually be removed easily by a surgeon.

A painful sore on the vulva may be caused by a herpes infection or an abscess. A sore that isn't painful may be caused by cancer or syphilis. Pubic lice can cause itching in the area of the vulva (pediculosis pubis).

Diagnosis

The characteristics of the discharge may suggest its cause to a doctor, but additional information is needed to make the diagnosis-such as when in the menstrual cycle the discharge occurs, whether the discharge is sporadic or continuous, how it has responded to previous therapy, and whether the woman has vulvar itching, burning, or pain or a vaginal sore. The doctor may ask about birth control, pain after sexual intercourse, previous vaginal infections, sexually transmitted diseases, and the use of laundry detergents that may cause irritation. Questions may include whether the sex partner has symptoms or whether anyone else in the household has itching in the groin.

While examining the vagina, the doctor uses a cotton-tipped swab to take a sample of the discharge, which is examined under a microscope, grown in a laboratory (cultured), or both to identify the infective organism. The cervix is inspected, and a tissue sample is removed for a Papanicolaou (Pap) test, which can detect cervical cancer. The doctor also performs a two-handed examination, inserting the index and middle fingers of one gloved hand into the vagina and gently pressing on the outside of the lower abdomen with the other hand to feel the reproductive organs between the hands.

When a woman has a long-standing inflammation of the vulva (chronic vulvitis) that doesn't respond to treatment, the doctor usually removes a tissue sample for examination under a microscope (biopsy) to look for cancer cells.

Treatment

For a normal discharge, occasional douching with water may reduce the amount. However, a discharge caused by vaginitis requires specific treatment according to its cause. If the cause is an infection, treatment consists of an antibiotic, antifungal, or antiviral drug, depending on the infective organism.

Until the infection has been cured, a premeasured vinegar and water douche can be used briefly to control symptoms.

However, douching frequently and using medicated douches are discouraged because they increase the risk of pelvic inflammatory disease.

If the labia (folds of skin around the vaginal and urethral openings) are stuck together because of previous infections, applying a vaginal estrogen cream for 7 to 10 days usually opens them.

In addition to an antibiotic, treatment of a bacterial infection may include propionic acid jelly to make the vaginal secretions more acidic - which discourages bacterial growth. For sexually transmitted infections, both sex partners are treated at the same time to prevent reinfection.

Thinning of the vaginal lining after menopause (atrophic vaginitis) is treated with estrogen re-placement therapy. Estrogen can be given by mouth or through a skin patch or applied as a cream directly to the vulva and vagina.

The drugs used to treat vulvitis depend on its cause and are the same as those used to treat vaginitis. Additional measures include wearing loose, absorbent clothing that allows air to circulate, such as cotton or cotton-lined underpants, and keeping the vulva clean. Glycerin soap should be used because many other soaps can irritate the area.

Occasionally, placing ice packs against the vulva, sitting in a cool sitz bath, or applying cool compresses may reduce soreness and itching. Corticosteroid creams or ointments, such as those containing hydrocortisone, and antihista-mines taken by mouth may also reduce itching that's not caused by an infection.

Acyclovir applied as a cream or taken by mouth may reduce symptoms and shorten the course of a herpes infection. Analgesics taken by mouth may help reduce pain.

If chronic vulvitis is caused by poor personal hygiene, instruction in proper hygiene is the first step. A bacterial infection in the area is treated with antibiotics. Skin conditions such as psoriasis may be treated with corticosteroid creams.

Sub-stances that may be causing persistent irritation, such as creams, powders, and some brands of condoms, should not be used.

Pelvic Inflammatory Disease

Pelvic inflammatory disease (salpingitis) is an inflammation of the fallopian tubes, usually caused by an infection.

The fallopian tubes extend like arms from the top of the uterus toward each ovary.

Inflammation of the fallopian tubes occurs mainly in sexually active women. Women using intrauterine devices (IUDs) are especially at risk.

An inflammation is usually caused by a bacterial infection, which often enters through the vagina and moves into the uterus and the fallopian tubes.

These infections rarely occur before the first menstrual period (menarche), after menopause, or during pregnancy. They are most commonly acquired during sexual intercourse. Less commonly, bacteria move into the tubes during a vaginal delivery, a miscarriage, or an abortion.

Less common causes of inflammation include actinomycosis (a bacterial infection). schistosomiasis (a parasitic infection), and tuberculosis. Medical procedures, such as the injection of dye during certain x-ray examinations. may introduce an infection.

Although symptoms may be worse on one side, both tubes are usually infected. The infection can spread into the abdominal cavity, causing peritonitis. The ovaries generally resist infection, unless the infection is severe.

Symptoms

Symptoms usually begin shortly after a menstrual period. Pain in the lower abdomen be-comes increasingly severe and may be accompanied by nausea or vomiting. Particularly at first, many women have only a low fever, mild to moderate abdominal pain. irregular bleeding, and a scant vaginal discharge. making the diagnosis difficult for a doctor.

Later a high fever and a puslike discharge from the vagina are typical, although a chlamydial infection may produce no discharge.

Usually, the infection blocks the fallopian tubes. A blocked tube may become swollen with trapped fluid. Chronic pain, irregular menstrual bleeding, and infertility may result.

The infection can spread to surrounding structures, resulting in scarring and abnormal fibrous attachments (adhesions) between organs in the abdomen, causing chronic pain.

Abscesses (collections of pus) may develop in the tubes, ovaries, or pelvis. If antibiotics don't cure the abscesses, surgical drainage may be necessary. If an abscess ruptures-spilling pus into the pelvic cavity-symptoms progress rapidly from severe pain in the lower abdomen to nausea, vomiting, and very low blood pressure (shock).

This type of infection may spread to the blood-stream-a condition called sepsis-and can be fatal. A perforated abscess requires emergency surgery.

Diagnosis and Treatment

The symptoms suggest the diagnosis to a doctor. A woman feels considerable pain when the doctor presses on the cervix or surrounding areas during a pelvic examination or palpates the abdomen.

The white blood cell count is usually high. Specimens are generally taken from the cervix, some-times also from the rectum and throat, and then cultured and examined under a microscope to identify the infective organism. The doctor may perform a culdocentesis, a procedure in which a needle is inserted into the pelvic cavity through the vaginal wall. to obtain a sample of pus. The doctor can also look inside the abdominal cavity with a fiber-optic tube (laparoscope).

Antibiotics are usually given as soon as specimens have been taken to be cultured. Commonly, a woman is treated at home, but if the infection doesn't improve within 48 hours, she is usually hospitalized. In the hospital, two or more antibiotics are given intravenously to eliminate the infection as quickly and completely as possible. The longer and more severe the inflammation, the higher the risk of infertility and other complications.

Fibroids

A fibroid is a rtoncancerous growth composed of muscle and fibrous tissue that occurs in the wall of the uterus.

Fibroids occur in at least 20 percent of all women over age 35 and are more common among black women than among white women. The size of fibroids ranges from microscopic to as large as a cantaloupe. The cause is unknown, but fibroids seem to be affected by estrogen levels, often growing larger during pregnancy and shrinking after menopause.

Symptoms

Even when large, fibroids may produce no symptoms. Symptoms depend on the number of fibroids, their size, and their location in the uterus, as well as their status-whether they are growing or degenerating. Symptoms may include heavy or prolonged menstrual bleeding or, less often, bleeding between menstrual periods; pain, pressure, or heaviness in the pelvic area during or between menstrual periods; a need to urinate more frequently; swelling of the abdomen; and rarely, infertility caused by blockage of the fallopian tubes or distortion of the uterine cavity. Menstrual bleeding may be heavy because fibroids increase the surface area of the uterine lining and the amount of tissue shed during menstruation. The heavy bleeding can cause anemia. A fibroid that has previously produced no symptoms occasionally causes problems during pregnancy, such as a miscarriage, early labor, or postpartum hemorrhage (excessive blood loss after delivery).

Diagnosis and Treatment

A doctor can usually make the diagnosis during a pelvic examination. The diagnosis may be con-firmed by ultrasound scanning. An endometria: biopsy (removing a tissue sample of the uterine lining for microscopic examination), hysteros-copy (examination of the uterus with a fiber-optic tube), and a Pap test may be performed to make sure the symptoms aren't being caused by other disorders, such as cancer of the uterus.

Most fibroids don't need treatment, but a woman who has them is reexamined every 6 to 12 months. Surgery to remove a fibroid (myomectomy) may be necessary if the fibroid increases n size or produces unacceptable symptoms. A woman may be given hormones for several months before surgery to shrink the fibroid.

Generally, surgery is avoided during pregnancy be-cause it can cause a miscarriage and severe blood loss. Removal of the entire uterus (hysterectomy) may be necessary if menstrual bleeding is very severe, symptoms such as pressure or severe pain develop, a fibroid is growing rapidly, or a large fibroid becomes twisted or infected.

Menstrual Disorders

Common menstrual disorders include premenstrual syndrome (PMS) and pain during menstruation (dysmenorrhea). Complex hormonal inter-actions control the start of menstruation during puberty, the rhythms and duration of cycles during the reproductive years, and the end of menstruation at menopause. Hormonal control of menstruation begins in the hypothalamus (the part of the brain that coordinates and controls hormonal activity) and the pituitary gland, located at the base of the brain, and is ultimately determined by the ovaries. Hormones produced by other glands, such as the adrenal glands, can also affect menstruation.

Premenstrual Syndrome

Premenstrual syndrome (PMS, premenstrual dysphoric disorder, late luteal phase dysphoric disorder) is a condition in which a variety of symptoms, including nervousness, irritability, emotional upset, depression, headaches, tissue swelling and breast tenderness, may occurduring the 7 to 14days before a menstrual period begins.

Premenstrual syndrome may be related to the fluctuations in estrogen and progesterone levels that occur during the menstrual cycle. Estrogen causes fluid retention, which probably explains the weight gain, tissue swelling, breast tender-ness, and bloating. Other hormonal and metabolic changes may also be involved.

Symptoms

The type and intensity of symptoms vary, from woman to woman and from month to month in the same woman. The broad range of physical and psychologic symptoms can temporarily upset a woman's life. Women who have epilepsy may have more seizures than usual. Women who have a connective tissue disease, such as systemic lupus erythematosus or rheumatoid arthritis, may have flare-ups at this time.

Usually, symptoms occur a week or two before the menstrual period, last from a few hours to about 14 days, and stop when the next period begins. Women close to menopause may have symptoms that persist through and after the menstrual period. The symptoms of premenstrual syndrome are often followed each month by a painful period.

Treatment

Taking combination oral contraceptives, which contain estrogen and progestin, helps reduce the fluctuations in estrogen and progesterone levels.

Fluid retention and bloating are often relieved by reducing the intake of salt and taking a mild diuretic, such as spironolactone, just before symptoms are expected to begin.

Other dietary changes-such as decreasing the amount of sugar, caffeine, and alcohol consumed; eating more carbohydrates; and having more frequent meals-may help. Dietary supplements containing calcium and magnesium may be beneficial.

Taking vitamin B supplements, especially B6 (pyridoxine), may reduce some symptoms, although the benefits of vitamin B6 have recently been questioned, and a dose that's too high may be harmful (nerve damage has occurred with as little as 200 milligrams a day). Nonsteroidal anti-inflammatory drugs (NSAIDs) may help relieve head-aches, pain from uterine cramps, and joint aches.

Nervousness and agitation may be helped by exercise and stress reduction (using meditation or relaxation exercises). Fluoxetine can reduce depression and other symptoms.

Buspirone or alprazolam, taken for a short period, may reduce irritability and nervousness and help reduce stress, but drug dependency is a risk of treatment with alprazolam.

A woman may be asked to re-cord her symptoms in a diary to help the doctor judge the effectiveness of treatment.

Dysmenorrhea

Dysmenorrhea is abdominal pain, stemming from uterine cramps, during a menstrual period.

This condition is called primary dysmenorrhea when no underlying cause is found and secondary dysmenorrhea when the cause is identified as a gynecologic disorder. Primary dysmenorrhea is common, possibly affecting more than 50 percent of women; it's severe in about 5 to 15 percent.

It usually starts during adolescence and can be severe enough to interfere with everyday activities, resulting in absence from school or work.

Primary dysmenorrhea may become less severe with age and after pregnancy. Secondary dysmenorrhea is less common, affecting about one fourth of the women who have dysmenorrhea.

The pain of primary dysmenorrhea is thought to result from contractions of the uterus that occur when the blood supply to its lining (endometrium) is reduced. The pain occurs only during menstrual cycles in which an egg is released.

The pain may worsen as endometrial tissue shed during a menstrual period passes through the cervix, particularly when the cervical canal is narrow, as it may be after treatment for cervical disorders.

Other factors that may worsen the pain include a uterus that tilts backward (retroverted uterus) instead of forward, lack of exercise, and psycho-logic or social stress.

One of the most common causes of secondary dysmenorrhea is endometriosis. Others are fibroids and adenomyosis (noncancerous invasion of the muscular wall of the uterus by the uterine lining).

Inflammation of the fallopian tubes and abnormal fibrous attachments (adhesions) between organs may cause abdominal pain that's either mild, vague, and continuous or more severe, localized, and short-lived. Either type of pain may be worse during a menstrual period.

Symptoms

Dysmenorrhea causes pain in the lower abdomen, which may extend to the lower back or legs. The pain may consist of cramps that come and go or a dull ache that's constant.

Generally, the pain starts shortly before or during the menstrual period, peaks after 24 hours, and subsides after 2 days. Often a woman has a headache, nausea, constipation or diarrhea, and an urge to urinate frequently. Occasionally, vomiting occurs.

The premenstrual syndrome symptoms of irritability, nervousness, depression, and abdominal bloating may persist during part or all of the menstrual period. Sometimes clots or pieces of bloody tissue from the lining of the uterus are expelled from the uterus, causing pain.

Treatment

The pain can usually be alleviated most effectively with nonsteroidal anti-inflammatory drugs, such as ibuprofen, naproxen, and mefenamic acid. Such drugs are most effective when begun up to 2 days before a menstrual period and continued through 1 or 2 days of the period.

Nausea and vomiting may be alleviated with an antinausea (antiemetic) drug, but these symptoms usually disappear without treatment as cramps sub-side. Getting enough rest and sleep and exercising regularly may also help reduce symptoms.

If pain continues to interfere with normal activity, ovulation can be suppressed with low-dose oral contraceptives containing estrogen and progestin or with long-acting medroxyprogesterone.

If these treatments are ineffective, additional tests may be needed, such as laparoscopy (a procedure in which a fiber-optic tube is used to examine the abdominal cavity).

The treatment of secondary dysmenorrhea depends on the cause. A narrow cervical canal can be widened surgically, often providing about 3 to 6 months of relief.

When treatment isn't successful and the pain is extreme, severing the nerves to the uterus occasionally helps; complications include injury to other pelvic organs, such as the ureters. Alternatively, hypnosis or acupuncture may be tried.n

Symptoms of Premenstrual Syndrome


Adopted from the writing of Professor James H. Lin of University of Cincinnati, USA.

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Comments

I have severe pain that travels through uterus going to other organs. It’s like bad labor pains and it comes only when my cycle. I can’t bear it no more. I don't know what it is and the doctors don't know.

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