OBSTETRICS / GYNECOLOGY
Vaginal bleeding and discharge are a normal part of the menstrual cycle before menopause. Symptoms may result from mild infections that are easy to treat. But, if they are not treated properly, they can lead to more serious conditions, including kidney damage. Vaginal symptoms may also be a sign of more serious problems, such as cancers of the reproductive tract.
Common gynecologic problems include:
• Bleeding between periods
• Frequent and urgent need to urinate, or a burning sensation during urination
• Abnormal vaginal bleeding
• Bleeding after menopause
• Pain or pressure in your pelvis that differs from menstrual cramps
• Itching, burning, swelling, redness, or soreness in the vaginal area
• Sores or lumps in the genital area
• Vaginal discharge with an unpleasant or unusual odor, or of an unusual color
• Increased vaginal discharge
Abnormal bleeding can occur at any age. However, at certain times in a woman’s life it is common for periods to be somewhat irregular. Periods may not occur regularly when a girl first starts having them (around age 9–14 years). During perimenopause (beginning in the mid–40s), the number of days between periods may change. It also is normal to skip periods or for bleeding to get lighter or heavier during perimenopause.
Some of the causes of abnormal bleeding include the following:
• Problems with ovulation
• Fibroids and polyps
• A condition in which the endometrium grows into the wall of the uterus
• Bleeding disorders
• Problems linked to some birth control methods, such as an intrauterine device (IUD) or birth control pills
• Ectopic pregnancy
• Certain types of cancer, such as cancer of the uterus
• Ultrasound exam—Sound waves are used to make a picture of the pelvic organs.
• Hysteroscopy—A thin, lighted scope is inserted through the vagina and the opening of the cervix. It allows your ob-gyn or other health care professional to see the inside of the uterus.
• Endometrial biopsy—A sample of the endometrium is removed and looked at under a microscope.
• Sonohysterography—Fluid is placed in the uterus through a thin tube while ultrasound images are made of the inside of the uterus.
• Magnetic resonance imaging (MRI)—An MRI exam uses a strong magnetic field and sound waves to create images of the internal organs.
• Computed tomography (CT)—This X-ray procedure shows internal organs and structures in cross section.
Medications often are tried first to treat irregular or heavy menstrual bleeding. The medications that may be used include the following:
• Hormonal birth control methods—Birth control pills, the skin patch, and the vaginal ring contain hormones. These hormones can lighten menstrual flow. They also help make periods more regular.
• Gonadotropin-releasing hormone (GnRH) agonists—These drugs can stop the menstrual cycle and reduce the size of fibroids.
• Tranexamic acid—This medication treats heavy menstrual bleeding.
• Nonsteroidal anti-inflammatory drugs—These drugs, which include ibuprofen, may help control heavy bleeding and relieve menstrual cramps.
• Antibiotics— In case of an infection, antibiotics may be subscribed.
Most urinary tract infections (UTIs) start in the lower urinary tract. Bacteria from the bowel live on the skin near the anus or in the vagina. These bacteria can spread and enter the urinary tract through the urethra. If they move up the urethra, they may cause a bladder infection (called cystitis). Bacteria that have infected the bladder may travel to the upper urinary tract, the ureters and the kidneys. pyelonephritis is an infection of the kidneys. An upper urinary tract infection may cause a more severe illness than a lower urinary tract infection.
Women’s anatomy makes them prone to getting UTIs after having sex. The opening of the urethra is in front of the vagina. During sex, bacteria near the vagina can get into the urethra from contact with the penis, fingers, or devices.
Urinary tract infections also tend to occur in women when they begin having sex or have it more often. Using spermicides or a diaphragm also can cause more frequent UTIs. Infections also can occur when the bladder does not empty completely.
This condition may be caused by:
• blockage (a stone) in the ureters, kidneys, or bladder that prevents the flow of urine through the urinary tract
• a narrowed tube (or a kink) in the urinary tract
• problems with the pelvic muscles or nerves
Menopause also increases the risk of getting a UTI. During menopause, the level of estrogen decreases. This decrease can cause changes in the tissues around the urethra that can lead to a UTI. UTIs can occur during pregnancy.
Signs of UTIs
One sign is a strong urge to urinate that cannot be delayed (urgency). As urine flows, a sharp pain or burning, called dysuria, is felt in the urethra. The urge to urinate then returns minutes later (frequency). Soreness may be felt in the lower abdomen, in the back, or in the sides.
Other signs may show up in the urine. It may have a strong odor, look cloudy, and sometimes be tinged with blood.
Symptoms linked with a UTI, such as painful urination, can be caused by other problems (such as an infection of the vagina or vulva). Tests may be needed to confirm the diagnosis.
Antibiotics are used to treat UTIs. The type, dose, and length of the antibiotic treatment depend on the type of bacteria causing the infection and on medical history. Treatment is usually quick and effective. Most symptoms go away in 1–2 days.
Vaginitis is an inflammation of the vagina. As many as one third of women will have symptoms of vaginitis sometime during their lives. Vaginitis affects women of all ages but is most common during the reproductive years.
A change in the balance of the yeast and bacteria that normally live in the vagina can result in vaginitis. This causes the lining of the vagina to become inflamed. Factors that can change the normal balance of the vagina include the following:
• Use of antibiotics
• Changes in hormone levels due to pregnancy, breastfeeding, or menopause
• Sexual intercourse
Yeast infection or Candidiasis
Candidiasis is one of the most common types of vaginal infection. The infection is caused by a fungus called Candida. It is found in small numbers in the normal vagina. However, when the balance of bacteria and yeast in the vagina is altered, the yeast may overgrow and cause symptoms.
The most common symptoms of a yeast infection are itching and burning of the area outside the vagina called the vulva. The vulva may be red and swollen. The vaginal discharge usually is white, lumpy, and has no odor.
Use of some types of antibiotics increase the risk of a yeast infection. The antibiotics kill normal vaginal bacteria, which keep yeast in check. The yeast can then overgrow. A woman is more likely to get yeast infections if she is pregnant or has diabetes.
Yeast infections can be treated either by placing medication into the vagina or by taking a pill.
Bacterial vaginosis is caused by overgrowth of the bacteria that occur naturally in the vagina. The main symptom is increased discharge with a strong fishy odor. The discharge usually is thin and dark or dull gray, but may have a greenish color. Itching is not common, but may be present if there is a lot of discharge.
Several different antibiotics can be used to treat bacterial vaginosis. They can be taken by mouth or inserted into the vagina as a cream or gel.
Trichomoniasis is a condition caused by the microscopic parasite Trichomonas vaginalis. It is spread through sex. Women who have trichomoniasis are at an increased risk of infection with other sexually transmitted infections (STIs).
Signs of trichomoniasis may include a yellow-gray or green vaginal discharge. The discharge may have a fishy odor. There may be burning, irritation, redness, and swelling of the vulva. Sometimes there is pain during urination.
Trichomoniasis usually is treated with a single dose of an antibiotic by mouth. Sexual partners must be treated to prevent the infection from recurring.
Chlamydia is caused by a type of bacteria, which can be passed from person to person during vaginal sex, oral sex, or anal sex. Infections can occur in the mouth, reproductive organs, urethra, and rectum. In women, the most common place for infection is the cervix (the opening of the uterus).
The following factors increase the risk of getting chlamydia:
• More than one sexual partner
• A partner who has or has had more than one sexual partner
• Sex with someone who has an STI
• Having a history of STIs
• Not using condoms consistently when not in a mutually monogamous relationship
Chlamydia usually does not cause symptoms. When symptoms do occur, they may show up between a few days and several weeks after infection. They may be very mild and can be mistaken for a urinary tract or vaginal infection. The most common symptoms in women include the following:
• A yellow discharge from the vagina or urethra
• Painful or frequent urination
• Vaginal bleeding between periods
• Rectal bleeding, discharge, or pain
Chlamydia is treated with antibiotic pills. Chlamydia can be passed to sex partners even during treatment. Sexual contact should be avoided until the end of treatment. The patient should be retested for chlamydia 3 months after treatment.
If left untreated, chlamydia can cause pelvic inflammatory disease (PID). PID can lead to long-term health problems and affect your ability to get pregnant.
Gonorrhea (Gonococcal Vaginitis)
Gonorrhea and chlamydia often occur together. Gonorrhea also is caused by bacteria that can be passed to a partner during vaginal, anal, or oral sex. The risk factors for gonorrhea are the same as the risk factors for chlamydia.
Gonorrhea often causes no symptoms or only very mild symptoms. Women with gonorrhea may think they have a minor urinary tract or vaginal infection. Symptoms include the following:
• A yellow vaginal discharge
• Painful or frequent urination
• Vaginal bleeding between periods
• Rectal bleeding, discharge, or pain
Gonorrhea is treated with two kinds of antibiotics. The recommended treatment is an injection of one of the antibiotics followed by a single pill of the other antibiotic. This treatment also is effective against chlamydia. Sex partners also need to be tested for gonorrhea and treated.
If left untreated, gonorrhea can lead to the same long-term health complications as chlamydia, including PID, as well as disseminated gonococcal infection.
Syphilis is a sexually transmitted infection that can cause serious health problems if it is not treated. Syphilis is divided into stages (primary, secondary, latent, and tertiary). There are different signs and symptoms associated with each stage. Syphilis is spread by direct contact during vaginal, anal, or oral sex.
A person with primary syphilis generally has a sore or sores at the original site of infection. These sores usually occur on or around the genitals, around the anus or in the rectum, or in or around the mouth. These sores are usually (but not always) firm, round, and painless. Symptoms of secondary syphilis include skin rash, swollen lymph nodes, and fever. The signs and symptoms of primary and secondary syphilis can be mild, and they might not be noticed. During the latent stage, there are no signs or symptoms. Tertiary syphilis is associated with severe medical problems. A doctor can usually diagnose tertiary syphilis with the help of multiple tests. It can affect the heart, brain, and other organs of the body.
Symptoms of syphilis differ by stage:
• Primary stage—Syphilis first appears as a painless chancre. This sore goes away without treatment in 3–6 weeks.
• Secondary stage—If syphilis is not treated, the next stage begins as the chancre is healing or several weeks after the chancre has disappeared, when a rash may appear. The rash usually appears on the soles of the feet and palms of the hands. Flat warts may be seen on the vulva. There may be flu-like symptoms.
• Latent infection—In some people, the rash and other symptoms may go away in a few weeks or months, but that does not mean the infection is gone. It still is present in the body.
Unlike testing for chlamydia and gonorrhea, routine screening for syphilis is not recommended for women who are not pregnant. All pregnant women should be screened at their first prenatal visit and retested later in pregnancy and at delivery if they are at high risk. Two blood tests usually are needed to diagnose syphilis.
Syphilis is treated with antibiotics. If it is diagnosed and treated early, long-term problems can be prevented. The length of treatment depends on the duration of infection. Sexual contact should be avoided during treatment. Sex partners should be treated for syphilis.
Viruses are a common cause of vaginitis. One form caused by the herpes simplex virus (HSV) is often just called “herpes” infection. These infections are spread by sexual contact. The primary symptom of herpes vaginitis is pain associated with lesions or “sores”. These sores usually are visible on the vulva or the vagina but occasionally are inside the vagina and can only be seen during a gynecologic exam. Outbreaks of HSV often are associated with stress or emotional distress.
Another source of viral vaginal infection is the human papillomavirus (HPV). HPV, sometime referred to as genital warts, also can be transmitted by sexual intercourse. This virus can cause painful warts to grow in the vagina, rectum, vulva, or groin. These warts usually are white to gray in color, but they may be pink or purple. However, visible warts are not always present, and the virus may only be detected when a Pap test is abnormal. Many of the infections that cause vaginitis can be spread between men and women during sexual intercourse. Use of a barrier contraceptive, such as a condom, can help reduce your risk (but does not offer 100% protection against) contracting these and more serious infections, such as the human immunodeficiency virus (HIV), which can lead to AIDS.
Not uncommonly, a woman can have itching, burning, and even a vaginal discharge without having an infection. The most common cause is an allergic reaction or irritation from vaginal sprays, douches or spermicidal products. However, the skin around the vagina also can be sensitive to perfumed soaps, lotions, sexual lubricants, detergents, and fabric softeners. In addition, the long-term use of over-the-counter topical products to help block odor and itch can cause vaginitis.
Vulvitis is not a disease, but refers to the inflammation of the soft folds of skin on the outside of the female genitalia, the vulva. The irritation can be caused by infection, allergic reaction, or injury. The skin of the vulva is especially susceptible to irritation due to its moistness and warmth.
• The use of colored or perfumed toilet paper
• An allergic reaction to bubble bath or soap used to clean the genital area
• Use of vaginal sprays or douches
• Irritation by a chlorinated swimming pool or hot tub water
• Allergic reaction to spermicide
• Allergic reaction to sanitary napkins
• Wearing synthetic underwear or nylon pantyhose without a breathable cotton crotch
• Wearing a wet bathing suit for extended periods of time
• Bike or horseback riding
• Fungal or bacterial infections including scabies or pubic lice
• Skin conditions such as eczema or dermatitis
• Extreme and constant itching
• A burning sensation in the vulvar area
• Vaginal discharge
• Small cracks on the skin of the vulva
• Redness and swelling on the vulva and labia (lips of the vagina)
• Blisters on the vulva
• Scaly, thick, whitish patches on the vulva
The first treatment is to immediately stop the use of any products that may be causing the irritation and to wear loose-fitting, breathable white cotton undergarments. Over-the-counter (OTC) anti-itch products should be avoided, as they can make the condition worse, or last longer. An over-the-counter cortisone ointment may be applied on the affected area several times a day. This can help reduce the irritation and itching.
Sitz baths and the use of a topical estrogen cream may also be prescribed to deal with the itching and other symptoms of vulvitis. If these treatments do not reduce the irritation, further tests may be prescribed to rule out more serious underlying conditions such as vulvar cancer.
Premenstrual syndrome (PMS) is a medical condition that affects some women of childbearing age. More than one in three women suffer from PMS. One in 20 suffer so severely that their lives are seriously affected. PMS is related to a variety of physical and psychological symptoms that occur just before the menstrual period.
The exact cause of PMS is unknown, but it seems to be related to the fluctuating levels of hormones (including estrogen and progesterone) that occur in preparation for menstruation.
There are many symptoms of PMS, and the number and severity of symptoms vary from woman to woman. In addition, the severity of the symptoms can vary from month to month. Common symptoms of PMS include:
• Breast tenderness
• Weight gain
• Trouble concentrating
• Skin problems/acne
• Mood swings and/or depression
There is no single test to diagnose PMS.
To diagnose PMS, a health care provider must confirm a pattern of symptoms.
A woman’s symptoms must
• be present in the 5 days before her period for at least three menstrual cycles in a row
• end within 4 days after her period starts
• interfere with some of her normal activities
Keeping a record of the symptoms can help the health care provider diagnose PMS.
Treatment for PMS is based on relieving symptoms. Treatment begins with a thorough assessment of the symptoms, as well as the impact on the patient’s daily life.
Education — While symptoms may vary from month to month, the symptoms diary can provide information of how the periods affect patient’s physical health and moods. Learning how to cope with the problems may help relieve the stress and irritability that women feel before their period.
Nutrition — A healthy diet is important to overall physical and mental wellness. Making changes in patient’s diet—including reducing the amount of caffeine, salt and sugar and staying well-hydrated with water and light juices—may help relieve symptoms of PMS. A number of vitamin supplements are often taken to try to help PMS symptoms, including vitamin B6, vitamin E, calcium, and magnesium. However, none of these supplements have been shown in well-designed studies to be better than placebo (sugar pills or dummy pills, which can help 30 percent of the time without an active ingredient). Excess vitamin E or vitamin B6 is usually discouraged due to studies showing concerns about side effects, especially with vitamin B6. This vitamin can cause permanent nerve damage in women with daily doses in excess of 50 mg per day.
Exercise — Like a healthy diet, regular exercise can improve overall health. It also can help relieve and help the patient cope with the symptoms associated with PMS, especially dysmenorrhea (painful cramping and bloating).
Medications — Drugs that prevent ovulation, such as hormonal contraceptives, may lessen physical symptoms. However, not all may relieve the mood symptoms of PMS. It may be necessary to try more than one of these medications before finding one that works.
Antidepressants can be helpful in treating PMS in some women. These drugs can help lessen mood symptoms. They can be used 2 weeks before the onset of symptoms or throughout the menstrual cycle.
Nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, can help reduce pain. Talk with your health care provider before taking NSAIDs. Long-term use of NSAIDs may cause stomach bleeding or ulcers.
Diuretics may help reduce fluid buildup. Using NSAIDs and diuretics at the same time may cause kidney problems.
Premenstrual dysphoric disorder
Premenstrual dysphoric disorder (PMDD) is a severe form of PMS. The symptoms of PMDD are similar to those of PMS, but are severe enough to interfere with work, social activities, and relationships.
Clinical evaluation should include a comprehensive review of the patient’s symptoms and medical history, a physical exam, a gynecologic exam, and basic laboratory tests as needed.
Psychiatric evaluation should focus on symptoms of depression, seasonal variation of depression (looking for worsening in the winter), alcohol and drug use, early victimization and trauma, family history of affective disorder (a group of disorders characterized by a disturbance of mood), alcoholism, and current stresses.
Many women gain relief from the symptoms of PMDD with education and lifestyle changes including exercise, vitamins, and a caffeine-free diet. Medications, including anti-depressants like selective serotonin reuptake inhibitors (SSRIs), may be used to treat the emotional symptoms of PMDD. Hormonal contraceptives may help, though it is important to be patient until a right fit for the woman’s body chemistry can be found. The optimal hormonal option/method can vary between each person. The FDA has approved the birth control pill Yaz® for the treatment of PMDD. However, other oral contraceptives may also help a woman with PMDD. In addition, individual and group counseling, and stress management can be beneficial in helping a woman cope with PMDD.
Most women have menstrual periods that last four to seven days. A woman’s period usually occurs every 28 days, but normal menstrual cycles can range from 21 days to 35 days.
Examples of menstrual problems include:
• Periods that occur less than 21 days or more than 35 days apart
• Missing three or more periods in a row
• Menstrual flow that is much heavier or lighter than usual
• Periods that last longer than seven days
• Periods that are accompanied by pain, cramping, nausea, or vomiting
• Bleeding or spotting that happens between periods, after menopause, or following sex
Amenorrhea is a condition in which a woman’s periods have stopped completely. The absence of a period for 90 days or more is considered abnormal unless a woman is pregnant, breastfeeding, or going through menopause (which generally occurs for women between ages 45 and 55). Young women who haven’t started menstruating by age 15 or 16 or within three years after their breasts begin to develop are also considered to have amenorrhea.
Oligomenorrhea refers to periods that occur infrequently.
Dysmenorrhea refers to painful periods and severe menstrual cramps. Some discomfort during the cycle is normal for most women.
Abnormal uterine bleeding may apply to a variety of menstrual irregularities, including: a heavier menstrual flow; a period that lasts longer than seven days; or bleeding or spotting between periods, after sex, or after menopause.
Stress and lifestyle factors. Gaining or losing a significant amount of weight, dieting, changes in exercise routines, travel, illness, or other disruptions in a woman’s daily routine can have an impact on her menstrual cycle.
Birth control pills. Most birth control pills contain a combination of the hormones estrogen and progestin (some contain progestin alone). Some women have irregular or missed periods for up to six months after discontinuing birth control pills. Women who take birth control pills that contain progestin only may have bleeding between periods.
Uterine polyps or fibroids. Uterine polyps are small benign (noncancerous) growths in the lining of the uterus. Uterine fibroids are tumors that attach to the wall of the uterus. There may be one or several fibroids that range from as small as an apple seed to the size of a grapefruit. These tumors are usually benign, but they may cause heavy bleeding and pain during periods. If the fibroids are large, they might put pressure on the bladder or rectum, causing discomfort.
Endometriosis. The endometrial tissue that lines the uterus breaks down every month and is discharged with the menstrual flow. Endometriosis occurs when the endometrial tissue starts to grow outside the uterus. Often, the endometrial tissue attaches itself to the ovaries or fallopian tubes; it sometimes grows on the intestines or other organs in the lower digestive tract and in the area between your rectum and uterus. Endometriosis may cause abnormal bleeding, cramps or pain before and during periods, and painful intercourse.
Pelvic inflammatory disease. Pelvic inflammatory disease (PID) is a bacterial infection that affects the female reproductive system. Bacteria may enter the vagina via sexual contact and then spread to the uterus and upper genital tract. Bacteria might also enter the reproductive tract via gynecologic procedures or through childbirth, miscarriage, or abortion. Symptoms of PID include a heavy vaginal discharge with an unpleasant odor, irregular periods, pain in the pelvic and lower abdominal areas, fever, nausea, vomiting, or diarrhea.
Polycystic ovary syndrome. In polycystic ovary syndrome (PCOS), the ovaries make large amounts of androgens, which are male hormones. Small fluid-filled sacs (cysts) may form in the ovaries. These can be seen often on ultrasound. The hormonal changes can prevent eggs from maturing, and so ovulation may not take place consistently. Sometimes a woman with polycystic ovary syndrome will have irregular periods or stop menstruating completely.
Premature ovarian insufficiency. This condition occurs in women under age 40 whose ovaries do not function normally. The menstrual cycle stops, similar to menopause. This can occur in patients who are being treated for cancer with chemotherapy and radiation, or if you have a family history of premature ovarian insufficiency or certain chromosomal abnormalities.
A physical examination, including a pelvic exam and sometimes a Pap test should be performed. The doctor might also order certain tests, including the following:
• Blood tests to rule out anemia or other medical disorders
• Vaginal cultures, to look for infections
• A pelvic ultrasound exam to check for uterine fibroids, polyps, or an ovarian cyst
• An endometrial biopsy, in which a sample of tissue is removed from the lining of the uterus, to diagnose endometriosis, hormonal imbalance, or cancerous cells. Endometriosis or other conditions may also be diagnosed using a procedure called a laparoscopy, in which the doctor makes a tiny incision in the abdomen and then inserts a thin tube with a light attached to view the uterus and ovaries
The treatment of abnormal menstruation depends on the underlying cause:
Regulation of the menstrual cycle: Hormones such as estrogen or progestin might be prescribed to help control heavy bleeding.
Pain control: Mild to moderate pain or cramps might be lessened by taking an over-the-counter pain reliever, such as ibuprofen or acetaminophen. Aspirin is not recommended because it might cause heavier bleeding. Taking a warm bath or shower or using a heating pad might help to relieve cramps.
Uterine fibroids: These can be treated medically and/or surgically. Initially, most fibroids that are causing mild symptoms can be treated with over-the-counter pain relievers. If you experience heavy bleeding, an iron supplement might be helpful in preventing or treating anemia. Low-dose birth control pills or progestin injections (Depo-Provera®) may help to control heavy bleeding caused by fibroids. Gonadotropin-releasing hormone agonists may be used to shrink the size of the fibroids and control heavy bleeding. These drugs reduce the body’s production of estrogen and stop menstruation for a while. If fibroids do not respond to medication, there are a variety of surgical options that can remove them or lessen their size and symptoms. The type of procedure will depend on the size, type, and location of the fibroids. A myomectomy is the simple removal of a fibroid. In severe cases where the fibroids are large or cause heavy bleeding or pain, a hysterectomy might be necessary. During a hysterectomy, the fibroids are removed along with the uterus.
Endometriosis: Although there is no cure for endometriosis, over-the-counter or prescription pain relievers may help to lessen the discomfort. Hormone treatments such as birth control pills may help prevent overgrowth of uterine tissue and reduce the amount of blood loss during periods. In more severe cases, a gonadotropin-releasing hormone agonist or progestin may be used to temporarily stop menstrual periods. In severe cases, surgery may be necessary to remove excess endometrial tissue growing in the pelvis or abdomen. A hysterectomy might be required as a last resort if the uterus has been severely damaged.
There are other procedural options which can help heavy menstrual bleeding. A 5-year contraceptive intrauterine device (IUD), called Mirena®, has been approved to help lessen bleeding, and can be as effective as surgical procedures such as endometrial ablation. This is inserted in the doctor’s office with minimal discomfort, and also offers excellent contraception. Endometrial ablation is another option. It uses heat or electrocautery to destroy the lining of the uterus. It is usually only used when other therapies have been tried and failed. This is because scar from the procedure can make monitoring the uterus more difficult if bleeding persists in the future.
Women with polycystic ovary syndrome (PCOS) have a hormonal imbalance that interferes with normal reproductive processes. PCOS usually starts at puberty and is associated with irregular periods and other hormone-related symptoms.
The most concerning issues with PCOS are the increase of infertility, the risk of developing type 2 diabetes and cardiovascular disease, and the higher risk of developing endometrial (uterine) cancer at an early age.
Research is ongoing to uncover a cause for PCOS. There is evidence that shows a link between certain forms of PCOS and family history, suggesting a genetic basis for the condition.
• Irregular menstrual periods, or no menstrual periods at all
• Decreased frequency or complete lack of ovulation, resulting in problems with infertility
• Obesity, often specifically characterized by weight gain in the upper body and abdomen
• Oily skin and hair and persistent acne into adulthood
• Abnormal hair growth, in a masculine distribution (facial hair, heavy hair growth on arms, chest, and abdomen)
• Tendency to develop type 2 diabetes
Most cases can be diagnosed with a thorough evaluation of medical history and symptoms, as well as a physical exam. A blood test may be required to measure the levels of various hormones. In some cases, an ultrasound of the ovaries may help with diagnosis.
Although PCOS can be treated with medications, treatment is often highly dependent on patient’s symptoms and goals
If the patient wants to become pregnant, she may need the assistance of oral or injected fertility medications. If the patient does not want to become pregnant, she may consider birth control pills to prevent pregnancy and regulate periods. Periods can also be regulated using the hormone progesterone.
There is also a non-hormonal treatment option, which is a medication usually used for diabetes. This medication may help restore fertility and assist with weight loss.
Oral contraceptives (birth-control pills) are used to prevent pregnancy. Estrogen and progestin are two female sex hormones. Combinations of estrogen and progestin work by preventing ovulation (the release of eggs from the ovaries). They also change the lining of the uterus (womb) to prevent pregnancy from developing and change the mucus at the cervix (opening of the uterus) to prevent sperm (male reproductive cells) from entering. Oral contraceptives are a very effective method of birth control, but they do not prevent the spread of human immunodeficiency virus (HIV, the virus that causes acquired immunodeficiency syndrome [AIDS]) and other sexually transmitted diseases.
Some brands of oral contraceptives are also used to treat acne in certain patients. Oral contraceptives treat acne by decreasing the amounts of certain natural substances that can cause acne.
Some oral contraceptives (Beyaz, Yaz) are also used to relieve the symptoms of premenstrual dysphoric disorder (physical and emotional symptoms that occur before the menstrual period each month) in women who have chosen to use an oral contraceptive to prevent pregnancy.
• stomach cramps or bloating
• gingivitis (swelling of the gum tissue)
• increased or decreased appetite
• weight gain or weight loss
• brown or black skin patches
• hair growth in unusual places
• bleeding or spotting between menstrual periods
• changes in menstrual flow
• painful or missed periods
• breast tenderness, enlargement, or discharge
• swelling, redness, irritation, burning, or itching of the vagina
• white vaginal discharge
Oral contraceptives may increase the chance of liver tumors development. These tumors are not a form of cancer, but they can break and cause serious bleeding inside the body. Oral contraceptives may also increase the chance of breast cancer, or a heart attack, a stroke, or a serious blood clot.
Some studies show that women who take oral contraceptives that contain drosperinone (Beyaz, Gianvi, Loryna, Ocella, Safyral, Syeda, Yasmin, Yaz, and Zarah) may be more likely to develop deep vein thrombosis (a serious or life-threatening condition in which blood clots that form in the veins, usually in the legs and may move through the body to the lungs) than women who take oral contraceptives that do not contain drosperinone. However, other studies do not show this increased risk.
Infertility is a condition in which a person is not able to reproduce by natural means after 12 months (or longer) of unprotected sexual intercourse on a regular basis. Infertility may be treated with drugs, surgery, artificial insemination, or assisted reproductive technology.
The most common cause of female infertility is lack of or irregular ovulation. The most common causes of male infertility are problems in the testes that affect how sperm are made or how they function. Other factors in women include problems with the reproductive organs or hormones. Scarring or blockages of the fallopian tubes may contribute to infertility. This may be the result of past sexually transmitted infections (STIs) or endometriosis. Problems with the thyroid gland or pituitary gland also may contribute to infertility. In men, blockage of the tubes that carry sperm from the testes may be a cause of infertility.
For healthy couples in their 20s or early 30s, the chance that a woman will become pregnant is about 25–30% in any single menstrual cycle. This percentage decreases rapidly after age 37 years. By age 40 years, a woman’s chance of getting pregnant drops to less than 10% per menstrual cycle. A man’s fertility also declines with age, but not as predictably.
Tests for infertility
Tests for infertility include laboratory tests, imaging tests, and certain procedures. Imaging tests and procedures look at the reproductive organs and how they work. Laboratory tests often involve testing samples of blood or semen.
Laboratory tests may include a urine test, a progesterone test, thyroid function tests, a prolactin level test, and tests of ovarian reserve. Imaging tests and procedures may include an ultrasound exam, hysterosalpingography, sonohysterography, hysteroscopy, and laparoscopy.
A urine test determines when and if you ovulate by detecting an increase in the levels of luteinizing hormone (LH) in the urine. A surge in the level of LH triggers the release of an egg. If the test result is positive, it suggests that ovulation will occur in the next 24–48 hours.
Problems with the thyroid gland may cause infertility problems. If a thyroid problem is suspected, levels of hormones that control the thyroid gland are measured to see if it is working normally.
Prolactin level test measures the level of the hormone prolactin. A high prolactin level can disrupt ovulation.
Different imaging tests and procedures are used to look at the uterus, ovaries, and fallopian tubes to find problems.
Common imaging tests for female infertility include the following:
• Ultrasound exam—This test can predict when ovulation will occur by viewing changes in the follicles.
• Sonohysterography—This special ultrasound exam looks for scarring or other problems inside the uterus.
• Hysterosalpingography—This X-ray procedure shows the inside of the uterus and whether the fallopian tubes are blocked.
• Hysteroscopy—The procedure uses a camera with a thin light source that is inserted through the cervix and into the uterus. This can show problems inside the uterus and help guide minor surgery.
• Laparoscopy—This procedure uses a camera with a thin light source that is inserted through the abdomen. This can show the fallopian tubes, ovaries, and the outside of the uterus.
Treatment options will depend on the cause of infertility. Lifestyle changes, medication, surgery, or other approaches may be recommended. Some treatments may be combined to improve results. Infertility often can be successfully treated even if no cause is found.
Lifestyle – Staying at a healthy weight and eating a healthy diet can be helpful for both men and women with infertility. Smoking, use of illegal drugs, or drinking alcohol, should be stopped.
Surgery – In women, surgery may be able to repair blocked or damaged fallopian tubes.
A common problem that leads to male infertility is the enlargement of a vein in the scrotum. It sometimes can be treated with surgery.
Hormone problems – Abnormal levels of hormones can cause irregular ovulation or lack of ovulation. If a hormone problem is found, treatment often can be given to correct it. This treatment also may improve the chances of becoming pregnant.
Ovulation induction – Ovulation induction is the use of drugs to help ovaries release an egg. This treatment is used when ovulation is irregular or does not occur at all and other causes have been ruled out. Ovulation induction may be used with other infertility treatments.
Oral drugs used to induce ovulation include clomiphene citrate, aromatase inhibitors, and insulin-lowering drugs.
If clomiphene citrate or other drugs are not successful, drugs called gonadotropins may be tried to induce ovulation. Gonadotropins also are used when many eggs are needed for infertility treatments.
Gonadotropins are given in a series of shots early in the menstrual cycle. Blood tests and ultrasound exams are used to track the development of the follicles. When test results show that the follicles have reached a certain size, another drug may be given to signal a follicle to release its matured egg.
Twins occur in 5–8% of women treated with clomiphene citrate and aromatase inhibitors. Triplets or more are rare. The risk of multiple pregnancy is higher when gonadotropins are used. Up to 30% of pregnancies achieved using gonadotropins are multiple. If too many eggs are developing, your health care professional may postpone the cycle to reduce the possibility of a multiple pregnancy.
Ovulation induction, especially with gonadotropins, can lead to ovarian hyperstimulation syndrome. Women undergoing ovulation induction are monitored for this condition. Another risk of using gonadotropins is ectopic pregnancy. This is a pregnancy that begins to grow in a place other than the uterus, usually in one of the fallopian tubes. Ectopic pregnancy requires treatment with medication or surgery.
In intrauterine insemination (IUI), healthy sperm are placed in the uterus as close to the time of ovulation as possible. IUI can be used with ovulation induction. The woman’s partner or a donor may provide the sperm. Sperm that has been collected earlier and frozen also can be used.
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