The Islamic university of Gaza
Faculty of nursing
Midwifery department
Gynecology
Sep.2012
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Menstrual Cycles:
Basic Biology: the cycle begins
Did you know that when a baby girl is born, she has all the eggs her
body will ever use, and many more, perhaps as many as 450,000? They
are stored in her ovaries, each inside its own sac called a follicle. As she
matures into puberty, her body begins producing various hormones that
cause the eggs to mature. This is the beginning of her first cycle; it's a
cycle that will repeat throughout her life until the end of menopause.
Let's start with the hypothalamus. The hypothalamus is a gland in the
brain responsible for regulating the body's thirst, hunger, sleep
patterns, libido and endocrine functions. It releases the chemical
messenger Follicle Stimulating Hormone Releasing Factor (FSH-RF) to
tell the pituitary, another gland in the brain, to do its job. The pituitary
then secretes Follicle Stimulating Hormone (FSH) and a little Leutenizing
Hormone (LH) into the bloodstream which cause the follicles to begin to
mature.
The maturing follicles then release another hormone, estrogen. As the
follicles ripen over a period of about seven days, they secrete more and
more estrogen into the bloodstream. Estrogen causes the lining of the
uterus to thicken. It causes the cervical mucous to change. When the
estrogen level reaches a certain point it causes the hypothalamus to
release Leutenizing Hormone Releasing Factor (LH-RF) causing the
pituitary to release a large amount of Leutenizing Hormone (LH). This
surge of LH triggers the one most mature follicle to burst open and
release an egg. This is called ovulation. [Many birth control pills work by
blocking this LH surge, thus inhibiting the release of an egg.
Ovulation
As ovulation approaches, the blood supply to the ovary increases and
the ligaments contract, pulling the ovary closer to the Fallopian tube,
allowing the egg, once released, to find its way into the tube. Just before
ovulation, a woman's cervix secretes an abundance of clear "fertile
mucous" which is characteristically stretchy. Fertile mucous helps
facilitate the sperm's movement toward the egg. Some women use daily
mucous monitoring to determine when they are most likely to become
pregnant. Mid cycle, some women also experience cramping or other
sensations. Basal body temperature rises right after ovulation and stays
higher by about .4 degrees F until a few days before the next period.
Inside the Fallopian tube, the egg is carried along by tiny, hair like
projections, called "cilia" toward the uterus. Fertilization occurs if sperm
are present. [A tubal pregnancy, called ectopic pregnancy, is the rare
situation when e a fertilized egg implants or gets lodged outside the
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uterus. It is a dangerous life-threatening situation if the fertilized egg
starts developing and growing into an embryo inside the fallopian tube
or elsewhere. The tube will rupture causing internal bleeding and
surgery is require
A woman can use a speculum to monitor her own ovulation and use this
information to avoid or encourage a pregnancy. This is the allnatural fertility awareness method (FAM) of family planning.
Uterine Changes
Between midcycle and menstruation, the follicle from which the egg
burst becomes the corpus luteum (yellow body). As it heals, it produces
the hormones estrogen and, in larger amounts, progesterone which is
necessary for the maintenance of a pregnancy. the later stages of
healing, if the uterus is not pregnant, the follicle turns white and is
called the corpus albicans.
Estrogen and progesterone are sometimes called "female" hormones,
but both men and women have them, just in different concentrations.
Progesterone causes the surface of the uterine lining, the endometrium,
to become covered with mucous, secreted from glands within the lining
itself. If fertilization and implantation do not occur, the spiral arteries of
the lining close off, stopping blood flow to the surface of the lining. The
blood pools into "venous lakes" which, once full, burst and, with the
endometrial lining, form the menstrual flow. Most periods last 4 to 8
days but this length varies over the course of a lifetime.
Some researchers view menses as the natural monthly cleansing of the
uterus and vagina of sperm and bacteria they carried.
Cramps and Other Sensations
Women can experience a variety of sensations before, during or after
their menses. Common complaints include backache, pain in the inner
thighs, bloating, nausea, diarrhea, constipation, headaches, breast
tenderness, irritability, and other mood changes. Women also
experience positive sensations such as relief, release, euphoria,
connection with nature, creative energy, increased sex drive and more
intense orgasms.
Uterine cramping is one of the most common uncomfortable sensations
women may have during menstruation. There are two kinds of cramping.
Spasmodic cramping is probably caused by prostaglandins, chemicals
that affect muscle tension. Some prostaglandins cause relaxation, and
some cause constriction. A diet high in linoleic and liblenic acids, found
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in vegetables and fish, increases the prostaglandins for aiding muscle
relaxation.
Congestive cramping causes the body to retain fluids and salt. To
counter congestive cramping, avoid wheat and dairy products, alcohol,
caffeine, and refined sugar.
Natural options to alleviate cramping:
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Increase exercise. This will improve blood and oxygen circulation
throughout the body, including the pelvis.
Try not using tampons. Many women find tampons increase
cramping. Don't select an IUD (intrauterine device) as your birth
control method.
Avoid red meat, refined sugars, milk, and fatty foods.
Eat lots of fresh vegetables, whole grains (especially if you
experience constipation or indigestion), nuts, seeds and fruit.
Avoid caffeine. It constricts blood vessels and increases tension.
Meditate, get a massage.
Have an orgasm (alone or with a partner).
Drink ginger root tea (especially if you experience fatigue).
Put cayenne pepper on food. It is a vasodilator and improves
circulation.
Breathe deeply, relax, notice where you hold tension in your body
and let it go.
Ovarian Kung Fu alleviates or even eliminates menstrual cramps
and PMS, it also ensures smooth transition through menopause
Take time for yourself!
-Anecdotal information suggests eliminating Nutra-Sweet from the diet
will significantly relieve menstrual cramps. If you drink sugar-free sodas
or other forms of Nutra-Sweet, try eliminating them completely for two
months and see what happens.
The hormones in our bodies are especially sensitive to diet and
nutrition. PMS and menstrual cramping are not diseases, but rather,
symptoms of poor nutrition.
Premenstrual Syndrome or PMS
-PMS has been known by women for many years. However, within the
past 30 or so years, pharmaceutical companies have targeted and
created a market to treat this normal part of a woman's cycle as a
disease. These companies then benefit from the sale of drugs and
treatments.
-Premenstrual syndrome refers to the collection of symptoms or
sensations women experience as a result of high hormone levels before,
and sometimes during, their periods.
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-One type of PMS is characterized by anxiety, irritability and mood
swings. These feelings are usually relieved with the onset of bleeding.
Most likely, this type relates to the balance between estrogen and
progesterone. If estrogen predominates, anxiety occurs. If there's more
progesterone, depression may be a complaint.
-Sugar craving, fatigue and headaches signify a different type of PMS. In
addition to sugar, women may crave chocolate, white bread, white rice,
pastries, and noodles. These food cravings may be caused by the
increased responsiveness to insulin related to increased hormone levels
before menstruation. In this circumstance, women may experience
symptoms of low blood sugar; their brains are signaling a need for fuel.
A consistent diet that includes complex carbohydrates will provide a
steady flow of energy to the brain and counter the ups and downs of
blood sugar variations.
-It's true that most women will have cycles that are around 28 days. But,
a woman can be healthy and normal and have just 3 or 4 cycles a year.
[However, while variations might be healthy and normal, they could also
be a sign of a serious underlying problem. For example, a recent news
article suggested that irregular menstrual cycles may predict Type 2
Diabetes.]
-Ovulation occurs about 14-16 days before women have their period (not
14 days after the start of their period). The second half of the cycle,
ovulation to menstruation, is fairly consistently the same length, but the
first part changes from person to person and from cycle to cycle. In rare
cases, a women may ovulate twice in a month, once from each ovary.
-Conception/Fertilization of an egg, can only occur after ovulation. The
egg stays alive for about 24 hours once released from the ovary. Sperm
can stay alive inside a woman's body for 3-4 days, but possibly as long
as 6-7 days. If a couple has intercourse before or after ovulation occurs,
they can get pregnant, since the live sperm are already inside the
woman's body when ovulation occurs. Thus a woman can become
pregnant from intercourse for about 7-10 days in the middle of her cycle.
-Fertility Awareness is a birth control method where women monitor
their cycles daily to identify ovulation. They are learning to predict
ovulation to prevent or encourage pregnancy. It requires training and
diligent record keeping.
From our work providing abortion services, we know that some women
can be pregnant and continue to have periods at the same time. We also
know of cases where women have gotten pregnant during their
menstrual period.
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Common Menstrual Problems
-Most issues teens confront when they start menstruating are
completely normal. In fact, many girls and women have had to deal with
one or more of them at one time or another:
-Premenstrual Syndrome (PMS)
PMS includes both physical and emotional symptoms that many females
get right before their periods, such as:
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acne
bloating
fatigue
backaches
breasts tenderness.
headaches
constipation
diarrhea
food cravings
depression or feeling blue
irritability
difficulty concentrating
difficulty handling stress
-Different girls may have some or all of these symptoms in varying
combinations. PMS is usually at its worst during the 7 days before the
period starts and disappears soon after it begins. But girls usually don't
develop symptoms associated with PMS until several years after
menstruation starts — if ever.
-Although the exact cause of PMS is unknown, it seems to occur
because of changing hormone levels, and their effect on chemicals in
the brain. During the second half of the menstrual cycle, the amount of
progesterone in the body increases. Then, about 7 days before the
period starts, levels of both progesterone and estrogen drop.
Some girls' bodies seem to be more sensitive to these hormone
changes than others. Talk to your daughter's doctor if her symptoms are
severe or interfere with her normal activities.
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Cramps:
-Many girls experience abdominal cramps during the first few days of
their periods. They're caused by prostaglandin, a chemical in the body
that makes the smooth muscle in the uterus contract. These involuntary
contractions can be either dull or sharp and intense.
-The good news is that cramps usually only last a few days. But call
your daughter's doctor if she has severe cramps that keep her home
from school or from doing stuff with her friends.
Irregular Periods
-It can take 2 to 3 years from a girl's first period for her body to develop
a regular cycle. During that time, the body is essentially adjusting to the
influx of hormones unleashed by puberty. And what's "regular" varies
from person to person. The typical cycle of an adult female is 28 days,
although some are as short as 21 days and others are as long as 45.
-Changing hormone levels might make a girl's period last a short time
during one month (just a few days) and a long time the next (up to a
week). She may skip months, get two periods almost right after each
other, or alternate between heavy and light bleeding from one month to
another.
-But any girl who's sexually active and skips a period should see a
doctor to make sure she's not pregnant. And if your daughter's period
still hasn't settled into a relatively predictable pattern after 3 years, or if
she has four or five regular periods and then skips her period or
becomes irregular, make an appointment with her doctor to check for
possible problems. Also let your daughter's doctor know if her cycle is
less than 21 days or more than 45 days, or if she doesn't get a period for
3 months at any time after first beginning to menstruate.
Delayed Menarche
-Girls go through puberty at different rates. Some reach menarche (the
medical term for the first period or the beginning of menstruation) as
early as 9 or 10 years old and others don't have their first periods until
they're well into their teen years. So, if your daughter is a "late bloomer,"
it doesn't necessarily mean there's something wrong with her.
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-When girls get their periods actually depends a lot on genetics. Girls
often start menstruating at approximately the same age their mothers or
grandmothers did. Also, certain ethnic groups, on average, go through
puberty earlier than others. For instance, African-American girls, on
average, start puberty and get their periods before Caucasian girls do.
-Let your daughter's doctor know if she hasn't gotten her period by age
15, or by 3 years after starting puberty.
Problems That May Be Cause for Concern
-Although most period problems are harmless, a few conditions can be
more serious and require medical attention:
Amenorrhea (the Absence of Periods)
Girls who haven't started their periods by the time they're 16 years old
or 3 years after they've shown the first signs of puberty have primary
amenorrhea, which is usually caused by a genetic abnormality, a
hormone imbalance, or a structural problem. Hormones are also often
responsible for secondary amenorrhea, which is when a girl who had
normal periods suddenly stops menstruating for more than 6 months or
three of her usual cycles.
-Since pregnancy is the most common cause of secondary amenorrhea,
it should always be ruled out when a girl skips periods. In addition to
hormone imbalances, other things that can cause both primary and
secondary amenorrhea include:
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stress
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significant weight loss or gain
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anorexia (amenorrhea can be a sign that a girl is losing too much
weight and may have anorexia)
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stopping birth control pills
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thyroid conditions
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ovarian cysts
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other conditions that can affect hormone levels
-Something that can also cause primary and secondary amenorrhea
is excessive exercising (often distance running ) combined with a poor
diet, which usually results in inappropriate weight loss or failure to gain
weight during growth. But this doesn't include the usual gym class or
school sports team, even those that practice often. To exercise so much
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that she delays her period, a girl would have to train vigorously for
several hours a day, most days of the week, and not get enough
calories, vitamins, and minerals.
Menorrhagia:
(Extremely Heavy, Prolonged Periods)
-It's normal for a girl's period to be heavier on some days than others.
But signs of menorrhagia (excessively heavy or long periods) can
include soaking through at least one sanitary (pad) an hour for several
hours in a row or periods that last longer than 7 days. Girls with
menorrhagia sometimes stay home from school or social functions
because they're worried they won't be able to control the bleeding in
public.
-The most frequent cause of menorrhagia is an imbalance between the
levels of estrogen and progesterone in the body, which allows the
endometrium (the lining of the uterus) to keep building up. When the
endometrium is finally shed during menstruation, the resulting bleeding
is particularly heavy.
-Because many adolescents have slight hormone imbalances during
puberty, menorrhagia isn't uncommon in teens. But in some cases,
heavy menstrual bleeding can be caused by problems such as:
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fibroids (benign growths) or polyps in the uterus
thyroid conditions
clotting disorders
inflammation or infection in the vagina or cervix
-If your daughter has heavy periods, or periods that last longer than 7
days, talk to her doctor.
Dysmenorrhea (Painful Periods)
-There are two types of dysmenorrhea, which is severely painful
menstruation that can interfere with a girl's ability to attend school,
study, or sleep:
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1.
Primary dysmenorrheal:
- is very common in teens and is not caused by a disease or other
condition. Instead, the culprit is prostaglandin, the same chemical
behind cramps. Large amounts of prostaglandin can lead to nausea,
vomiting, headaches, backaches, diarrhea, and severe cramps.
Fortunately, these symptoms usually last for only a day or two.
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Secondary dysmenorrhea :
-is pain caused by some physical condition like polyps or fibroids in the
uterus, endometriosis, pelvic, or adenomyosis (uterine tissue growing
into the muscular wall of the uterus).
-Having cramps for a day or two each month is common, but if your
daughter has symptoms severe enough to keep her from her normal
activities, discuss it with her doctor.
Endometriosis:
In this condition, tissue normally found only in the uterus starts to grow
outside the uterus — in the ovaries, fallopian tubes, or other parts of the
pelvic cavity. It can cause abnormal bleeding, dysmenorrheal, and
general pelvic pain.
Treating Menstrual Problems;
-To determine whether a problem requires treatment, the doctor will ask
several questions and do a thorough physical exam. The doctor may do
a pelvic exam, a Pap smear, blood tests (to check hormone levels), or
urine tests. If there might be a structural problem or some sort of
growth, an ultrasound or CT scan may be performed. Together, these
tests can help the doctor determine how a condition should be handled.
-Growths such as polyps or fibroids can often be removed and
endometriosis can often be treated with medications or surgery. If a
hormone imbalance is to blame, the doctor will likely suggest hormone
therapy with birth control pills or other hormone-containing
medications.
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-And for menstrual pain with no underlying medical cause, antiinflammatory medicines are the most effective treatment. Conditions like
clotting disorders or thyroid problems may require treatment with
medications as well.
When to Call the Doctor?
-Although most period problems aren't cause for alarm, certain
symptoms do call for a trip to the doctor. This is particularly true if a
girl's normal cycle changes. So take your daughter to her doctor if she:
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hasn't started her period by the time she's 15 or her period hasn't
become regular after 3 years of menstruating. The most likely cause
is a hormone imbalance (which may need treatment), but this also
might point to another medical problem.
stops getting her period or it becomes irregular after it has been
regular. Also let your daughter's doctor know if her cycle is less than
21 days or more than 45 days, or if she doesn't get a period for 3
months at any time after first beginning to menstruate.
has heavy or long periods, especially if she gets her period
frequently. In some cases, significant blood loss can cause irondeficiency anemia. Also, heavy bleeding could be a sign of a growth
in the uterus, a thyroid condition, an infection, or a blood clotting
problem.
has very painful periods. Having cramps for a couple of days is
normal, but if your daughter isn't able to participate in her normal
activities, let the doctor know. She might have a medical problem,
such as endometriosis, causing the pain.
-Helping Your Daughter….
-When your daughter's experiencing a particularly bad bout of PMS or
cramps, you can help make her more comfortable. Suggest that she:
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eat a balanced diet with lots of fresh fruit and vegetables
reduce her intake of salt (which can cause water retention) and
caffeine (which can make her jumpy and anxious)
include foods with calcium, which may reduce the severity of her
PMS symptoms
try over-the-counter pain relievers like acetaminophen or
ibuprofen for cramps, headaches, or back pain
take a brisk walk or bike ride to relieve stress and aches
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soak in a warm bath or put a hot water bottle on her abdomen,
which may help her relax
-If you notice that your daughter's usual periods are causing her great
discomfort and interfering with her life, talk to her doctor to make sure
nothing else is causing the problem and to see if anything can help.
Sometimes, hormone treatment, usually in the form of birth control pills,
can help ease many symptoms associated with uncomfortable periods.
-But the most important way you can help your daughter feel more at
ease about her period is to talk to her and explain that most annoying or
uncomfortable conditions that accompany menstruation are normal and
may improve over time. And be understanding when she's cranky and
unhappy. After all, no one's at her best all the time — including you.
Toxic shock syndrome (TSS)
- is a serious but uncommon bacterial infection. TSS was originally
linked to the use of tampons, but is now also known to be associated
with the contraceptive sponge and diaphragm birth control methods.
TSS has also resulted from wounds secondary to minor trauma or
surgery incisions where bacteria have been able to enter the body and
cause the infection.
-The symptoms of TSS include sudden high fever, a faint feeling, watery
diarrhea, headache, and muscle aches. There are two types of this
condition. The first, toxic shock syndrome, is caused
by Staphylococcus aureus bacteria and has been associated with the
use of tampons. (TSS was initially linked to a particular type of tampon,
which has since been taken off the market.) Although the exact
connection is still not clear, researchers suspect that certain types of
high-absorbency tampons provided a moist, warm home where the
bacteria could thrive.
-TSS can affect anyone who has any type of staph infection, including
pneumonia, abscess, skin or wound infection, a blood infection called
septicemia, or a bone infection called osteomyelitis.
-The second type of related infection, streptococcal toxic shock
syndrome, or STSS, is caused by streptococcus bacteria. Most often
STSS appears after streptococcus bacteria have invaded areas of
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injured skin, such as cuts and scrapes, surgical wounds, and even
chickenpox blisters.
Toxic shock syndrome from staphylococcus starts suddenly with
vomiting, high fever (temperature at least 102° Fahrenheit [38.8°
Celsius]), a rapid drop in blood pressure (with lightheadedness or
fainting), watery diarrhea, headache, sore throat, and muscle aches.
Within 24 hours, a sunburn-like rash appears. There also may be
bloodshot eyes and an unusual redness under the eyelids or inside the
mouth (and vagina in females). After that, broken blood vessels may
appear on the skin. Other symptoms may include: confusion or other
mental changes; decreased urination; fatigue and weakness; thirst;
weak and rapid pulse; pale, cool, moist skin; and rapid breathing.
Prevention:
-The bacteria that cause toxic shock syndrome can be carried on
unwashed hands and prompt an infection anywhere on the body. So
hand washing is extremely important.
-Girls can reduce their risk of TSS by either avoiding tampons or
alternating them with sanitary napkins. Girls who use only tampons
should choose ones with the lowest absorbency that will handle
menstrual flow and change the tampons frequently. Between menstrual
periods, store tampons away from heat and moisture (where bacteria
can grow) — for example, in a bedroom rather than in a bathroom closet.
-Because staphylococcus bacteria are often carried on dirty hands, it's
important for girls to to wash their hands thoroughly before and after
inserting a tampon. If your daughter is just starting her menstrual
period, she should know about taking these precautions. Any female
who has recovered from TSS should check with her doctor before using
tampons again
Diagnosis and Treatment:
-Doctors typically diagnose TSS and STSS by doing a physical exam
and conducting blood tests that assess a child's liver and kidney
function. In toxic shock syndrome, doctors may want to rule out
conditions like measles or Rocky Mountain spotted fever, which can
produce similar symptoms. A doctor may also take samples of fluid
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from an abscess, boil, or infected wound to look for a possible source of
staphylococcus or streptococcus infection.
-Doctors typically treat TSS with antibiotics. If there is a pocket of
infection, like an abscess, a doctor also may need to drain the infected
area. A child who has TSS is monitored for signs of shock until the
condition has stabilized and seems to be improving. Steroids are also
sometimes used to treat severe cases of TSS.
-As with TSS, doctors typically treat STSS with antibiotics and give
intravenous fluids and medications to maintain normal blood pressure.
Surgery is sometimes necessary to remove areas of dead skin and
muscle around an infected wound.
When to Call the Doctor:
Call your doctor immediately if your child has any of the following signs
and symptoms:
1-Signs of shock:
- Go to the emergency department immediately or call an ambulance if
your child has cold hands and feet; a pulse that is fast and weak;
confusion or other mental changes; pale, moist skin; shortness of
breath; abnormally fast breathing; or a strong feeling of anxiety or fear.
2-Signs of TSS:
- Look for fever; rash (especially a rash that looks like sunburn); nausea
and vomiting; watery diarrhea; confusion or other mental changes; and
decreased urination. If your daughter uses tampons, ask her to tell you
immediately if she notices any unusual vaginal discharge, especially if it
smells strange or bad. Most of the time that will be due to other causes,
but no matter the cause, it still rates evaluation.
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Signs of STSS: Look for the symptoms of shock listed above, plus
a fever; blotchy rash; and an area of infected skin that is red, swollen,
and painful.
-Once you realize that something is wrong, it's important to get medical
attention right away. The sooner your child gets treatment, the quicker
the recovery will be.
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Endometriosis
(from endo, "inside", and metra, "womb")
Definition:
is a gynecological medical condition in women in which endometriallike cells appear and flourish in areas outside the uterine
, most commonly on the ovaries. The uterine cavity is lined by
endometrial cells, which are under the influence of female hormones.
These endometrial-like cells in areas outside the uterus (endometriosis)
are influenced by hormonal changes and respond in a way that is similar
to the cells found inside the uterus. Symptoms often worsen with the
menstrual cycle.
-Endometriosis is typically seen during the reproductive years; it has
been estimated that endometriosis occurs in roughly 5-10% of women.
Symptoms may depend on the site of active endometriosis. Its main but
not universal symptom is pelvic pain in various manifestations.
Endometriosis is a common finding in women with infertility.
Signs and symptoms
Pelvic pain
A major symptom of endometriosis is recurring pelvic pain. The pain
can be mild to severe cramping that occurs on both sides of the pelvis,
in the lower back and rectal area, and even down the legs. The amount
of pain a woman feels is not necessarily related to the extent or stage (1
through 4) of endometriosis. Some women will have little or no pain
despite having extensive endometriosis or endometriosis with scarring.
On the other hand, women may have severe pain even though they have
only a few small areas of endometriosis. However, pain does typically
correlate to the extent of the disease. Symptoms of endometriosisrelated pain may include:
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dysmenorrhea – painful, sometimes disabling cramps during
menses; pain may get worse over time (progressive pain), also lower
back pains linked to the pelvis
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chronic pelvic pain – typically accompanied by lower back pain or
abdominal pain
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dyspareunia – painful sex
dysuria – urinary urgency, frequency, and sometimes painful
voiding
Throbbing, gnawing, and dragging pain to the legs are reported more
commonly by women with endometriosis. Compared with women with
superficial endometriosis, those with deep disease appears to be more
likely to report shooting rectal pain and a sense of their insides being
pulled down. Individual pain areas and pain intensity appears to be
unrelated Other to the surgical diagnosis, and the area of pain unrelated
to area of endometriosis
Other symptoms may be present, including:
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Constipation
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chronic fatigue
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heavy or long uncontrollable menstrual periods with small or
large blood clots
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gastrointestinal problems including diarrhea, bloating and painful
defecation
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extreme pain in legs and thighs
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back pain
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mild to extreme pain during intercourse
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pain from adhesions which may bind an ovary to the side of the
pelvic wall, or they may extend between the bladder and the bowel,
uterus, etc.
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extreme pain with or without the presence of menses
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premenstrual spotting
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mild to severe fever
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headaches
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depression
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hypoglycemia (low blood sugar)
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anxiety
In addition, women who are diagnosed with endometriosis may have
gastrointestinal symptoms that mimic irritable bowel syndrome
Patients who rupture an endometriotic cyst may present with an acute
abdomen as a medical emergency.
-Occasionally pain may also occur in other regions. Cysts can occur in
the bladder (although rare) and cause pain and even bleeding during
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urination. Endometriosis can invade the intestine and cause painful
bowel movements or diarrhea.
-In addition to pain during menstruation, the pain of endometriosis can
occur at other times of the month and doesn't have to be just on the
date on menses. There can be pain with ovulation, pain associated with
adhesions, pain caused by inflammation in the pelvic cavity, pain during
bowel movements and urination, during general bodily movement i.e.
exercise, pain from standing or walking, and pain with intercourse. But
the most desperate pain is usually with menstruation and many women
dread having their periods. Also the pain can start a week before
menses, during and even a week after menses, or it can be constant.
There is no known cure for endometriosis
Cause
While the exact cause of endometriosis remains unknown, many
theories have been presented to better understand and explain its
development. These concepts do not necessarily exclude each other.
1. Estrogens: Endometriosis is a condition that is estrogendependent and thus seen primarily during the reproductive years.
In experimental models, estrogen is necessary to induce or
maintain endometriosis. Medical therapy is often aimed at
lowering estrogen levels to control the disease. Additionally, the
current research into aromatase, an estrogen-synthesizing
enzyme, has provided evidence as to why and how the disease
persists after menopause and hysterectomy.
2. Retrograde menstruation: The theory of retrograde menstruation,
first proposed by John A. Sampson, suggests that during a
woman's menstrual flow, some of the endometrial debris exits the
uterus through the fallopian tubes and attaches itself to the
peritoneal surface (the lining of the abdominal cavity) where it
can proceed to invade the tissue as endometriosis. While most
women may have some retrograde menstrual flow, typically their
immune system is able to clear the debris and prevent
implantation and growth of cells from this occurrence. However,
in some patients, endometrial tissue transplanted by retrograde
menstruation may be able to implant and establish itself as
endometriosis. Factors that might cause the tissue to grow in
some women but not in others need to be studied, and some of
the possible causes below may provide some explanation, e.g.,
hereditary factors, toxins, or a compromised immune system. It
17
can be argued that the uninterrupted occurrence of regular
menstruation month after month for decades is a modern
phenomenon, as in the past women had more frequent menstrual
rest due to pregnancy and lactation. Sampson's theory certainly
is not able to explain all instances of endometriosis, and it needs
additional factors such as genetic or immune differences to
account for the fact that many women with retrograde
menstruation do not have endometriosis. In addition, at least one
study found that endometriotic lesions are biochemically very
different from transplanted ectopic tissue, which casts doubt on
Sampson's theory.
3. Müllerianosis: A competing theory states that cells with the
potential to become endometrial are laid down in tracts during
embryonic development and organogenesis. These tracts follow
the female reproductive (Mullerian) tract as it migrates caudally
(downward) at 8–10 weeks of embryonic life. Primitive
endometrial cells become dislocated from the migrating uterus
and act like seeds or stem cells. This theory is supported by fetal
autopsy
4. Coelomic Metaplasia: This theory is based on the fact
that coelomic epithelium is the common ancestor
of endometrial andperitoneal cells and hypothesizes that
later metaplasia (transformation) from one type of cell to the other
is possible, perhaps triggered by inflammation. This theory is
further supported by laboratory observation of this
transformation.
5. Genetics: Hereditary factors play a role. It is well recognized that
daughters or sisters of patients with endometriosis are at higher
risk of developing endometriosis themselves; for example, low
progesterone levels may be genetic, and may contribute to a
hormone imbalance. There is an about 10-fold increased
incidence in women with an affected first-degree relative. A 2005
study published in the American Journal of Human
Genetics found a link between endometriosis and chromosome
10q26One study found that in female siblings of patients with
endometriosis the relative risk of endometriosis is 5.7:1 versus a
control population. Transplantation: It is accepted that in specific
patients endometriosis can spread directly. Thus endometriosis
18
has been found in abdominal incisional scars after surgery for
endometriosis. It can also grow invasively into different tissue
layers, i.e., from thecul-de-sac into the vagina. On rare occasions
endometriosis may be transplanted by blood or by the lymphatic
system into peripheral organs such as the lungs and brain.
6. Immune system: Research is focusing on the possibility that
the immune system may not be able to cope with the cyclic
onslaught of retrograde menstrual fluid. In this context there is
interest in studying the relationship of endometriosis
toautoimmune disease, allergic reactions, and the impact
of toxins. It is still unclear what, if any, causal relationship exists
between toxins, autoimmune disease, and endometriosis.
7. Environment: There is a growing suspicion that environmental
factors may cause endometriosis, specifically some plastics and
cooking with certain types of plastic containers with microwave
ovens. Other sources suggest that pesticides and hormones in
our food cause a hormone imbalance.
8. Birth Defect: In rare cases where imperforate hymen does not
resolve itself prior to the first menstrual cycle and goes
undetected, blood and endometrium are trapped within the uterus
of the patient until such time as the problem is resolved by
surgical incision. Many health care practitioners never encounter
this defect, and due to the flu-like symptoms it is often
misdiagnosed or overlooked until multiple menstrual cycles have
passed. By the time a correct diagnosis has been made,
endometrium and other fluids have filled the uterus and fallopian
tubes with results similar to retrograde menstruation resulting in
endometriosis. The initial stage of endometriosis may vary based
on the time elapsed between onset and surgical procedure.
Cause of pain
The way endometriosis causes pain is the subject of much research.
Because many women with endometriosis feel pain during or around
their periods and may spill further menstrual flow into the pelvis with
each menstruation, some researchers are trying to reduce menstrual
events in patients with endometriosis.
Endometriosis lesions react to hormonal stimulation and may "bleed" at
the time of menstruation. The blood accumulates locally, causes
19
swelling, and triggers inflammatory responses with the activation
of cytokines. It is thought that this process may cause pain.
Pain can also occur from adhesions (internal scar tissue) binding
internal organs to each other, causing organ dislocation. Fallopian
tubes, ovaries, the uterus, the bowels, and the bladder can be bound
together in ways that are painful on a daily basis, not just during
menstrual periods.
Smoking
Smokers tend to be at a lower risk for endometriosis. Smoking causes
decreased estrogens with increased breakthrough bleeding and
shortened luteal phases. Smokers have an earlier than normal (by about
1.5–3 years) menopause which suggests that there is some toxic effect
of smoking on the follicles directly. Chemically, nicotine has been
shown to concentrate in cervical mucous and metabolites have been
found in follicular fluid and been associated with delayed follicular
growth and maturation. Finally, there is some effect on tubal motility
because smoking is associated with an increased incidence of ectopic
pregnancy as well as an increased spontaneous abortion rate.
Pregnancy
Aging brings with it many effects that may reduce fertility. Depletion
over time of ovarian follicles affects menstrual regularity. Endometriosis
has more time to produce scarring of the ovary and tubes so they
cannot move freely or it can even replace ovarian follicular tissue if
ovarian endometriosis persists and grows. Leiomyomata (fibroids) can
slowly grow and start causing endometrial bleeding that disrupts
implantation sites or distorts the endometrial cavity which affects
carrying a pregnancy in the very early stages. Abdominal adhesions
from other intraabdominal surgery, or ruptured ovarian cysts can also
affect tubal motility needed to sweep the ovary and gather an ovulated
follicle (egg).
Endometriosis in postmenopausal women does occur and has been
described as an aggressive form of this disease characterized by
complete progesterone resistance and extraordinarily high levels of
aromatase expression. In less common cases, girls may have
endometriosis symptoms before they even reach menarche.
Co-morbidity
20
Endometriosis bears no relationship to endometrial cancer. Current
research has demonstrated an association between endometriosis and
certain types of cancers, notably ovarian cancer, non-Hodgkin's
lymphoma and brain cancer. Endometriosis often also coexists
with leiomyoma or adenomyosis, as well as autoimmune disorders. A
1988 survey conducted in the US found significantly
more Hypothyroidism, fibromyalgia, chronic fatigue
syndrome, autoimmune diseases, allergies and asthma in women with
endometriosis compared to the general population.
Complications
Complications of endometriosis include:

Internal scarring

Adhesions

Pelvic cysts

Chocolate cyst of ovaries

Ruptured cyst

Blocked bowel/bowel obstruction
Infertility can be related to scar formation and anatomical distortions
due to the endometriosis; however, endometriosis may also interfere in
more subtle ways: cytokines and other chemical agents may be released
that interfere with reproduction.
Other complications of endometriosis include bowel and ureteral
obstruction resulting from pelvic adhesions. Also, peritonitis from bowel
perforation can occur.
21
Ovarian endometriosis may complicate pregnancy by decidualization,
abscess and/or rupture, It is the most common adnexal mass detected
during pregnancy, being present in 0.52% of deliveries as studied in the
period 2002 to 2007. Still, ovarian endometriosis during pregnancy can
be safely observed conservatively.
Diagnosis
Micrograph showing endometriosis (right) and ovarian stroma
(left). H&E stain.
A health history and a physical examination can in many patients lead
the physician to suspect endometriosis. Surgery is the gold standard in
diagnosis. However, in the United States most insurance plans will not
cover surgical diagnosis unless the patient has already attempted to
become pregnant and failed. Use of imaging tests may identify
endometriotic cysts or larger endometriotic areas. It also may identify
free fluid often within the cul-de-sac. The two most common imaging
tests are ultrasound and magnetic resonance imaging (MRI). Normal
results on these tests do not eliminate the possibility of endometriosis.
Areas of endometriosis are often too small to be seen by these tests.
The only way to diagnose endometriosis is by laparoscopy or other
types of surgery with lesion biopsy. The diagnosis is based on the
characteristic appearance of the disease, and should be corroborated by
a biopsy. Surgery for diagnoses also allows for surgical treatment of
endometriosis at the same time.
Although doctors can often feel the endometrial growths during a pelvic
exam, and your symptoms may be telltale signs of endometriosis,
diagnosis cannot be confirmed without performing a laparoscopic
procedure. Often the symptoms of ovarian cancer are identical to those
of endometriosis. If a misdiagnosis of endometriosis occurs due to
failure to confirm diagnosis through laparoscopy, early diagnosis of
ovarian cancer, which is crucial for successful treatment, may have
been missed.
Staging
22
possible locations of endometriosis
Surgically, endometriosis can be staged I–IV (Revised Classification of
the American Society of Reproductive Medicine). The process is a
complex point system that assesses lesions and adhesions in the pelvic
organs, but it is important to note staging assesses physical disease
only, not the level of pain or infertility. A patient with Stage I
endometriosis may have little disease and severe pain, while a patient
with Stage IV endometriosis may have severe disease and no pain or
vice versa. In principle the various stages show these findings:

Stage I (Minimal)
Findings restricted to only superficial lesions and possibly a few
filmy adhesions

Stage II (Mild)
In addition, some deep lesions are present in the cul-de-sac

Stage III (Moderate)
As above, plus presence of endometriomas on the ovary and
more adhesions

Stage IV (Severe)
As above, plus large endometriomas, extensive adhesions.
Treatments
While there is no cure for endometriosis, in many patients menopause
(natural or surgical) will abate the process. In patients in the
reproductive years, endometriosis is merely managed: the goal is to
provide pain relief, to restrict progression of the process, and to restore
or preserve fertility where needed. In younger women with unfulfilled
23
reproductive potential, surgical treatment attempts to remove
endometrial tissue and preserving the ovaries without damaging normal
tissue. In women who do not have need to maintain their reproductive
potential, hysterectomy and/or removal of the ovaries may be an option;
however, this will not guarantee that the endometriosis and/or the
symptoms of endometriosis will not come back, and surgery may
induce adhesions which can lead to complications.
In general, the diagnose of endometriosis is confirmed during surgery,
at which time ablative steps can be taken. Further steps depend on
circumstances: patients without infertility can be managed with
hormonal medication that suppress the natural cycle and pain
medication, while infertile patients may be treated expectantly after
surgery, with fertility medication, or with IVF.
Sonography is a method to monitor recurrence of endometriomas
during treatments.
Treatments for endometriosis in women who do not wish to become
pregnant include:
Hormonal medication

Progesterone or Progestins: Progesterone counteracts estrogen
and inhibits the growth of the endometrium. Such therapy can reduce
or eliminate menstruation in a controlled and reversible fashion.
Progestins are chemical variants of natural progesterone.

Avoiding products with xenoestrogens, which have a similar
effect to naturally produced estrogen and can increase growth of the
endometrium.

Hormone contraception therapy: Oral contraceptives reduce the
menstrual pain associated with endometriosis. They may function by
reducing or eliminating menstrual flow and providing estrogen
support. Typically, it is a long-term approach.
Recently Seasonalewas FDA approved to reduce periods to 4 per
year. Other OCPs have however been used like this off label for
years. Continuous hormonal consists of the use of combined oral
contraceptive pills without the use of placebo pills, or the use
ofNuvaRing or the contraceptive patch without the break week. This
eliminates monthly bleeding episodes.
24

Danazol (Danocrine) and gestrinone are suppressive steroids with
some androgenic activity. Both agents inhibit the growth of
endometriosis but their use remains limited as they may
cause hirsutism and voice changes.

Gonadotropin Releasing Hormone (GnRH) agonist: These agents
work by increasing the levels of GnRH. Consistent stimulation of the
GnRH receptors results in downregulation, inducing a
profound hypoestrogenism by decreasing FSH and LH levels. While
effective in some patients, they induce unpleasant menopausal
symptoms, and over time may lead to osteoporosis. To counteract
such side effects some estrogen may have to be given back (addback therapy). These drugs can only be used for six months at a
time.


Lupron depo shot is a GnRH agonist and is used to lower
the hormone levels in the woman's body to prevent or reduce
growth of endometriosis. The injection is given in 2 different
doses a once a month for 3 month shot with the dosage of
(11.25 mg) or a once a month for 6 month shot with the dosage of
(3.75 mg)
Aromatase inhibitors are medications that block the formation of
estrogen and have become of interest for researchers who are
treating endometriosis. Other medication

NSAIDs Anti-inflammatory. They are commonly used in
conjunction with other therapy. For more severe cases narcotic
prescription drugs may be used. NSAID injections can be helpful for
severe pain or if stomach pain prevents oral NSAID use.

MST Morphine sulphate tablets and other opioid painkillers work
by mimicking the action of naturally occurring pain-reducing
chemicals called "endorphins". There are different long acting and
short acting medications that can be used alone or in combination to
provide appropriate pain control.

Diclofenac in suppository or pill form. Taken to reduce
inflammation and as an analgesic reducing pain.
Surgery
Procedures are classified as

25
conservative when reproductive organs are retained,


semi-conservative when ovarian function is allowed to continue,
and
radical when the uterus and ovaries are removed.
Conservative therapy consists of removal, excision (called cystectomy)
or ablation of endometriosis, adhesions, resection of endometriomas,
and restoration of normal pelvic anatomy as much as is possible. There
are combinations as well, notably one consisting of cystectomy
followed by ablative surgery using a CO2 laser to vaporize the remaining
10%–20% of the endometrioma wall close to the hilus.
Radical therapy in endometriosis removes the uterus (hysterectomy)
and tubes and ovaries (bilateral salpingo-oophorectomy) and thus the
chance for reproduction. Radical surgery is generally reserved for
women with chronic pelvic pain that is disabling and treatmentresistant. Not all patients with radical surgery will become pain-free.
Semi-conservative therapy preserves a healthy appearing ovary, and
yet, it also increases the risk of recurrence.
For patients with extreme pain, a presacral neurectomy may be
indicated where the nerves to the uterus are cut. However, strong
clinical evidence showed that presacral neurectomy is more effective in
pain relief if the pelvic pain is midline concentrated, and not as effective
if the pain extends to the left and right lower quadrants of the
abdomen. This is due to the fact that the nerves to be transected in the
procedure are innervating the central or the midline region in the female
pelvis. Furthermore, women who had presacral neurectomy have higher
prevalence of chronic constipation not responding well to medication
treatment because of the potential injury to the parasympathetic nerve
in the vicinity during the procedure.
Comparison of medicinal and surgical interventions
Efficacy studies show that both medicinal and surgical interventions
produce roughly equivalent pain-relief benefits. Recurrence of pain was
found to be 44 and 53 percent with medicinal and surgical interventions,
respectively. However, each approach has its own advantages and
disadvantages.
Advantages of medicinal interventions
1. Decrease initial cost
2. Empirical therapy (i.e. Can be easily modified as needed)
26
3. Effective for pain control
Disadvantages of medicinal interventions
1. Adverse effects are common
2. Not likely to improve fertility
3. Some can only be used for limited periods of time
Advantages of surgery
1. Has significant efficacy for pain control. Has increased efficacy
over medicinal intervention for infertility treatment
2. Combined with biopsy, it is the only way to achieve a definitive
diagnosis
3. Can often be carried out as a minimal invasive (laparoscopic)
procedure to reduce morbidity and minimalize the risk of postoperative adhesions
Disadvantages of surgery
1. Cost
2. Risks are "poorly defined... and probably underestimated." In one
study, 3-10% experienced major complications from surgery.
3. Efficacy is questionable. In the same study, substantial short-term
pain relief was experienced by approximately 70-80% of the
subjects. However, at 1 year follow-up, approximately 50% of the
subjects needed analgesics or hormonal treatments
Treatment of infertility
While roughly similar to medicinal interventions in treating pain, the
efficacy of surgery is especially significant in treating infertility. One
study has shown that surgical treatment of endometriosis approximately
doubles the fecundity (pregnancy rate). The use of medical suppression
after surgery for minimal/mild endometriosis has not shown benefits for
patients with infertility Use of fertility medication that stimulates
ovulation (clomiphene citrate, gonadotropins) combined
with intrauterine insemination (IUI) enhances fertility in these patients.
In-vitro fertilization (IVF) procedures are effective in improving fertility in
many women with endometriosis. IVF makes it possible to combine
sperm and eggs in a laboratory and then place the resulting embryos
into the woman's uterus. The decision when to apply IVF in
endometriosis-associated infertility takes into account the age of the
27
patient, the severity of the endometriosis, the presence of other
infertility factors, and the results and duration of past treatments.
Other treatments

One theory above suggests that endometriosis is an auto-immune
condition and if the immune system is compromised with a food
intolerance, then removing that food from the diet can, in some
people, have an effect. Common intolerances in people with
endometriosis are wheat, sugar, meat and dairy Avoiding foods high
in hormones and inflammatory fats also appears to be important in
endometriosis pain management. Eating foods high in indole-3carbinol, such as cruciferous vegetables appears to be helpful in
balancing hormones and managing pain, as do omega 3 fatty acids,
particularly EPA. The use of soy has been reported to both alleviate
pain and to aggravate symptoms, making its use questionable.

Physical therapy for pain management in endometriosis has been
investigated in a pilot study suggesting possible benefit. Physical
exertion such as lifting, prolonged standing or running does
exacerbate pelvic pain. Use of heating pads on the lower back area,
may provide some temporary relief.

Laboratory studies indicate that heparin may alleviate
endometriosis-associated fibrosis.

Prognosis
Proper counseling of patients with endometriosis requires attention to
several aspects of the disorder. Of primary importance is the initial
operative staging of the disease to obtain adequate information on
which to base future decisions about therapy. The patient's symptoms
and desire for childbearing dictate appropriate therapy. Not all therapy
works for all patients. Some patients have recurrences after surgery or
pseudo-menopause. In most cases, treatment will give patients
significant relief from pelvic pain and assist them in achieving
pregnancy. It is important for patients to be continually in contact with
their physician and keep an open dialog throughout treatment. This is a
disease without a cure but with the proper communication, a woman
with endometriosis can attempt to live a normal, functioning life. Using
cystectomy and ablative surgery, pregnancy rates are approximately
40%.
Recurrence
28
The underlying process that causes endometriosis may not cease after
surgical or medical intervention, and the annual recurrence rate is given
as 5–20 % per year reaching eventually about 40% unless hysterectomy
is performed or menopause reached, Monitoring of patients consists of
periodic clinical examinations and sonography. Also, the CA 125 serum
antigen levels have been used to follow patients with endometriosis.
With combined cystectomy and ablative surgery, one study showed
recurrence of a small endometrioma in only one case among fifty-two
women (2%) at a mean follow-up of 8.3 months.
Vaginal parturition decreases recurrence of endometriosis. In contrast,
endometriosis recurrence rates have been shown to be higher in women
who do not have vaginal parturition, such as in Cesarean section.
Sexually Transmitted Diseases Overview (STDs)
-Sexually transmitted diseases (STDs, venereal diseases) are among the
most common infectious diseases in the United States today. STDs are
sometimes referred to as sexually transmitted infections, since these
conditions involve the transmission of an infectious organism between
sex partners. More than 20 different STDs have been identified, and
about 19 million men and women are infected each year in the United
States, according to the CDC (2010).
-Depending on the disease, the infection can be spread through any
type of sexual activity involving the sex organs, the anus, or the mouth;
an infection can also be spread through contact with blood during
sexual activity. STDs are infrequently transmitted by any other type of
contact (blood, body fluids or tissue removed from an STD infected
person and placed in contact with an uninfected person); however,
people that share unsterilized needles markedly increase the chance to
pass many diseases, including STD's (especially hepatitis B), to others.
Some diseases are not considered to be officially an STD (for example,
hepatitis types A, C, E) but are infrequently noted to be transferred
during sexual activity. Consequently, some authors include them as
STD's, others do not. Consequently, lists of STD's can vary, depending
on whether the STD is usually transmitted by sexual contact or only
infrequently transmitted.
29
in women (for example, Chlamydia, genital herpes or gonorrhea). This
can also occur in some men.
-term consequences from STDs tend to be
more severe for women than for men. Some STDs can cause pelvic
infections such as pelvic inflammatory disease (PID), which may cause a
tubo-ovarian abscess. The abscess, in turn, may lead to scarring of the
reproductive organs, which can result in an ectopic pregnancy (a
pregnancy outside the uterus), infertility or even death for a woman.
Human papillomavirus infection (HPV infection), an STD, is a known
cause of cancer of the cervix.
an be passed from a mother to her baby before, during,
or immediately after birth.
person often obtains more than one pathogenic organism at a time. For
example, many people (about 50%) are infected at a single sexual
contact with both gonorrhea and Chlamydia.
STDs caused by bacteria

Chancroid (Haemophilus ducreyi)

Chlamydia (Chlamydia trachomatis)

Gonorrhea (Neisseria gonorrhea)

Granuloma inguinale (Calymmatobacterium granulomatis)

Lymphogranuloma venereum (Chlamydia trachomatis)

Syphilis (Treponema pallidum)
STDs caused by viruses

Genital herpes (herpes simplex virus)

Genital warts (human papillomavirus virus [HPV])

Hepatitis B and D, and infrequently, A*,C*,E* (hepatitis viruses,
types A-E)

HIV/AIDS (human immunodeficiency virus [HIV virus])

Molluscum contagiosum* (poxvirus)
STD caused by protozoan

30
Trichomoniasis (Trichomonas vaginalis)
STD's* caused by fungi

Jock itch (Tenia cruris)*

Yeast infections* (Candida albicans)
STD's caused by parasites

Pubic lice or crabs (Pediculosis pubis)

Scabies* Sarcoptes scabiei
For details about the pathogens that cause the diseases, the reader is
urged to search the specific disease by simply clicking on it.
Trichomoniasis,
common cause of vaginitis. It is a sexually transmitted disease, and is
caused by the single-celled protozoan parasite Trichomonas vaginalis
producing mechanical stress on host cells and then ingesting cell
fragments after cell death.[1] Trichomoniasis is primarily an infection of
the urogenital tract; the most common site of infection is the urethra
and the vagina in women.
Symptoms
Typically, only women experience symptoms associated with
Trichomonas infection. Symptoms include inflammation of the cervix
(cervicitis), urethra (urethritis), and vagina (vaginitis) which produce an
itching or burning sensation. Discomfort may increase during
intercourse and urination. There may also be a yellow-green, itchy,
frothy foul-smelling ("fishy" smell) vaginal discharge. In rare cases,
lower abdominal pain can occur. Symptoms usually appear in women
within 5 to 28 days of exposure. In many cases, men may hold the
parasite for some years without any signs (dormant). Some sexual
health specialists have stated that the condition can probably be carried
in the vagina for years, despite standard tests being negative . While
symptoms are most common in women, some men may temporarily
exhibit symptoms such as an irritation inside the penis, mild discharge,
or slight burning after urination or ejaculation
Diagnosis
Trichomoniasis is diagnosed by visually observing the trichomonads via
a microscope. In women, the examiner collects the specimen during a
pelvic examination by inserting a speculum into the vagina and then
using a cotton-tipped applicator to collect the sample.
31
Treatment
Treatment for both pregnant and non-pregnant patients usually utilizes
metronidazole (Flagyl) but with caution especially in early stages of
pregnancy
Complications
Research has shown a link between trichomoniasis and two serious
sequelæ. Data suggest that:




Trichomoniasis is associated with increased risk of transmission
of HIV.
Trichomoniasis may cause a woman to deliver a low-birth-weight
or premature infant.
Trichomoniasis is also associated with increased chances of
cervical cancer
Evidence implies that infection in males potentially raises the
risks of prostate cancer
Prevention
Because trichomoniasis is a sexually transmitted disease, abstinence is
the preferred method to avoid contraction of this disease. Safe sex and
hygiene practices may also help prevent trichomonas infection.

Wear condoms.

Wash before and after intercourse.

Don't share swimsuits or towels. (Trichomonads survive for up to
45 minutes outside the body.)

Shower immediately after swimming in a public pool.
urinary incontinence
-this embarrassing little problem is urinary incontinence, and lots of
women -- regardless of age -- are secretly dealing with it. More than 13
million Americans have incontinence, and women are twice as likely to
have it as men, according the Agency for Healthcare Research and
Quality. About 25% to 45% of women suffer from urinary incontinence,
defined as leakage at least once in the past year. The rates of urinary
incontinence increase with age: 20%-30% of young women , 30%-40% of
middle-aged women, and up to 50% of older women suffer from urinary
incontinence.
-"It's embarrassing, and it can really affect your quality of life - your
emotional state, body, sexuality," Yet many put up with incontinence
32
needlessly, Brubaker tells WebMD. "People don't realize it's a medical
condition, and that there's help. Many women think it's normal, part of
having children or going into menopause."
Though incontinence is "more common than you might think," it's not
normal says Brubaker, who sees teens, and women in their 20s, 30s, or
older with this issue. "You don't have to put up with it. There are often
simple solutions that work."
Understanding Urinary Incontinence in Women
4 Types of Urinary Incontinence
When you can't control the release of your urine, you have urinary
incontinence. For some the problem can be as minor as the rare dribble,
for others as problematic as wetting your clothes. There are four kinds
of these plumbing problems, according to the Mayo Clinic:

Stress incontinence is that little leak that happens when
you cough, laugh, sneeze -- any motion that stresses or puts too much
pressure on the bladder.
Stress incontinence can result from pregnancy and childbirth, when
pelvic muscles and tissues can get stretched and damaged. It can also
occur from high-impact sports, as a result of aging, or from
being overweight.

Urge incontinence aka "overactive bladder," is a bit different - it's
the urgent need to go, followed by an involuntary loss of urine -- with
anything from a few seconds to a minute's warning. It is thought to be
due to spasms of the bladder muscles.
Conditions such as multiple sclerosis, Parkinson's disease, or a urinary
tract infection can cause urge incontinence.

Mixed incontinence means you have more than one type of
incontinence, with stress and urge incontinence being the typical mix.
"I think most women have both types," adds Brubaker. "I don't believe
there's as much distinction between the two types as we might think."

Overflow incontinence . If you can't empty your bladder every time
you go to the bathroom and experience a frequent or constant dribbling
of urine, you have overflow incontinence.
Certain medications can cause this problem, and people with nerve
damage from diabetes or men with prostate issues can also experience
this type of incontinence. It is due to impaired bladder muscle
contractions or bladder obstructions.
33
If you think urinary incontinence only affects older women, think again.
Bladder control issues affect younger, active women, too -- are you one
of them?
Incontinence a Big Problem for Young Women
-Among teens and young women, incontinence problems are typically
related to sports injuries" Women in high-impact sports are at highest
risk -- parachuters, gymnasts, runners," "In these sports, you're hitting
the ground hard, which can damage pelvic muscles and connective
tissue that support the bladder."
-Many young women have pre-existing biological reasons putting them
at higher risk, "It runs in families," . "Just as bad eyesight runs in
families, so can weak pelvic muscles. It's not that they've been
overdoing it with exercise. It's just that they've reached the tolerance of
their own tissues."
-For these girls and women, simply wearing a tampon or pessary -- a
device similar to a diaphragm -- during exercise is a good solution,.
"They just need a little something to support those pelvic tissues,
something to put pressure on the urethra."
Coping With Incontinence: Lifestyle Changes
-But for most women, a little absorbent pad is their first weapon, a
lifestyle change their second.
-For many women the change may be as simple as drinking less water.
"You can't drink two big bottles of water at one time, because it comes
through your system as one big [wave] of fluid," "If you have a little at a
time, it's much easier for the bladder."
-"Also, caffeine is a diuretic, so Cokes, coffee, any drink with caffeine
make you leak more," . Perhaps you just need to urinate more frequently
- especially before getting onto the tennis court, for example.
-You may also simply learn to brace yourself when you laugh or cough,
tightening your pelvic muscles to prevent leaks.
"Women are smart...". "They try a bunch of things on their own before
they get the gumption to talk to someone about it."
Incontinence Treatments
-When basic changes aren't enough, several treatments are available.
"Start with the most conservative, least-expensive treatment," Options
include:
Muscle training:
-For stress incontinence, learning muscle control can help manage
leakage. That means regularly practicing pelvic muscle (Kegel)
exercises.
"You learn to feel the muscle that controls the bladder, and build
strength in that muscle," says . "If you're going to play tennis, and it's
your backhand that makes you leak, you learn to tighten those muscles
at that instant."
34
-There's also a traditional Chinese therapy involving vaginal weights,
which Galloway says are very effective.
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Related to Incontinence & Overactive Bladder
America Asks About OAB
Bladder Control
Diabetes
Menopause
Multiple Sclerosis
Parkinson’s Disease
Side Effects of Diuretics
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Common Treatments for Incontinence & Overactive Bladder
Biofeedback
Bladder Surgery
Detrol
Ditropan
Enablex
Flomax
Kegel Exercises
More Drugs
Pessary
Incontinence Treatments
-"They are a means to strengthen muscles in the pelvis that control
urination. The patient puts the egg in her vagina, and works to hold it
there without dropping it," he says. "As her pelvic muscles strengthen,
she uses a heavier weight to increase that strength."
-Bladder training: By lengthening the time between trips to the
bathroom, bladder training can help women with urge incontinence.
-You start by urinating frequently -- every 30 minutes or so -- and
increasing the time gradually until you're going every three to four
hours.
-Relaxation exercises -- breathing slowly and deeply when the urge
strikes -- may also help. Once the urge passes, wait five minutes and go
to the bathroom even if you don't feel like you need to anymore. Slowly
increase the amount of waiting time.
-Electrical stimulation: This can be used to strengthen muscles with
stress incontinence or calm overactive muscles with urge incontinence.
-A small probe inserted in the vagina gives quick doses of electrical
stimulation to the vaginal wall, Brubaker explains. "It has the same
effect as Kegel exercises... and it works as well as medication but
without side effects."
35
-Biofeedback: This involves becoming attuned to your body's
functioning, to gain control over muscles to suppress urges.
-Biofeedback typically involves wearing sensors to track certain bodily
functions such as muscle tension, then learning how to control those
functions. It can be very effective in controlling bladder muscles, says
Brubaker.
-Hormone Creams: Estrogen creams are intended to restore the tissue
of the vagina and urethra to their normal thickness, says Galloway - but
they don't really help incontinence.
-"Hormone creams are more effective with vaginal dryness than they are
with resolving incontinence," he tells WebMD. "Some [studies]
demonstrate significant improvements using hormone creams and
others have not shown a benefit."
-Bladder Training With Scheduled Toilet Trips: With this technique the
clock dictates your toilet visits, not your bladder. Using this method you
take routine, planned bathroom trips, usually every two to four hours.
-Implants: When collagen or other materials are injected into tissues
around the urethra, it provides pressure that helps prevent leakage.
"These injectables have significantly lower side effects and
complications compared to medications," Brubaker explains. "The
injection needs to be repeated every 12 to 18 months. Some insurance
covers injectables, depending on the material used."
-Medications: No drug helps with stress incontinence, but a class called
anticholinergics does help with urge incontinence.
These drugs include Detrol, Oxytrol, , all with similar effectiveness and
similar side effects, like dry mouth and constipation
A transdermal patch called Oxytrol has also been effective, , who adds
that skin irritation at the patch site does occur in some patients.
-Surgery: There are 300 surgical options to treat incontinence.
-"The hard part is picking the surgery that has the best chance of
working well for that woman long-term," he says. "Surgery can create
problems. It can cause difficulty in urinating, worsen an urge
incontinence problem, or it can do nothing to solve the problem."
-A large NIH study is examining the use of a sling -- a medical device
that is surgically inserted into the vagina and positioned underneath the
urethra, says Brubaker.
-"It helps the urethral sphincter remain closed when abdominal pressure
tries to open it. At least, we think that's how it works," he says. "We
have only five-year outcomes on one group of these devices. But they
look promising."
-"Before having any surgery, ask your doctor for names of other
patients who have had the procedure in question," says Galloway.
36
-"Talk to them, find out how it worked. You'll be in a much better
position to decide what to do."
Pelvic inflammatory disease:
- (PID) is a generic term for inflammation of the uterus, fallopian tubes,
and/or ovaries as it progresses to scar formation with adhesions to
nearby tissues and organs.
-This may lead to infections. PID is a vague term and can refer to viral,
fungal, parasitic, though most often bacterial infections. PID should be
classified by affected organs, the stage of the infection, and the
organism(s) causing it. Although an STI is often the cause, many other
routes are possible, including lymphatic, postpartum, postabortal(either
miscarriage or abortion) or intrauterine device (IUD) related,
and hematogenous spread. Two thirds of patients
with laparoscopic evidence of previous PID were not aware they had
PID.
Epidemiology
In the United States, more than a million women are affected by PID
each month, and the rate is highest with teenagers and first time
mothers. PID causes over 100,000 women to become infertile in the US
each year. N. gonorrhea is isolated in 40-60% of women with
acute salpingitis. trachomatis is estimated to be the cause in about 60%
of cases of salpingitis, which may lead to PID. However, not all PID is
caused solely by STIs; organisms that are considered normal vaginal
flora can be involved, and individual cases of PID can be due to either a
single organism or a co-infection of many different species. 10% of
women in one study had asymptomatic Chlamydia trachomatis infection
and 65% had asymptomatic infection with Neisseria gonorrhoeae. It was
noted in one study that 10-40% of untreated women with N. gonorrhoea
develop PID and 20-40% of women infected with C.
trachomitis developed PID. PID is the leading cause of infertility. "A
single episode of PID results in infertility in 13% of women, This rate of
37
infertility increases with each infection.
Diagnosis
Symptoms in PID range from sub clinical (asymptomatic) to severe. If
there are symptoms then fever, cervical motion tenderness, lower
abdominal, new or different discharge, painful intercourse, or
irregular menstrual bleeding may be noted. It is important to note that
even asymptomatic PID can and does cause serious harm.
Laparoscopic identification is helpful in diagnosing tubal disease, 6590% positive predictive value in patients with presumed
PID. Regular Sexually Transmitted Infection (STI) testing is important for
prevention. Treatment is usually started empirically because of the
serious complications that may result from delayed treatment. Definitive
criteria include:histopathologic evidence of endometritis, thickened
filled fallopian tubes, or laparoscopic findings. Gram-stain/smear
becomes important in identification of rare and possibly more serious
organisms.
Differential diagnosis;
-Appendicitis, ectopic pregnancy, septic abortion, hemorrhagic or
ruptured ovarian cysts or tumors, twisted ovarian cyst, degeneration of
amyoma, and acute enteritis must be considered. Pelvic inflammatory
disease is more likely to occur when there is a history of pelvic
inflammatory disease, recent sexual contact, recent onset of menses, or
an IUD in place or if the partner has a sexually transmitted infection.
-Acute pelvic inflammatory disease is highly unlikely when recent
intercourse has not taken place or an IUD is not being used. A sensitive
serum pregnancy test should be obtained to rule out ectopic pregnancy.
Culdocentesis will differentiate hem peritoneum (ruptured ectopic
pregnancy or hemorrhagic cyst) from pelvic sepsis (salpingitis, ruptured
pelvic abscess, or ruptured appendix).
-Pelvic and vaginal ultrasounds are helpful in the differential diagnosis
of ectopic pregnancy of over six weeks. Laparoscopy is often utilized to
diagnose pelvic inflammatory disease, and it is imperative if the
diagnosis is not certain or if the patient has not responded to antibiotic
therapy after 48 hours.
38
-Although the PID infection itself may be cured, effects of the infection
may be permanent. This makes early identification by someone who can
prescribe appropriate curative treatment very important in the
prevention of damage to the reproductive system. Since early
gonococcal infection may be asymptomatic, regular screening of
individuals at risk for common agents (history of multiple partners,
history of any unprotected sex, or people with symptoms) or because of
certain procedures (post pelvic
operation, postpartum, miscarriage or abortion). Prevention is also very
important in maintaining viable reproduction capabilities.
-If the initial infection is mostly in the lower tract, after treatment the
person may have few difficulties. If the infection is in the fallopian tubes
or ovaries, more serious complications are more likely to occur.
Complications;
-PID can cause scarring inside the reproductive organs, which can later
cause serious complications, including chronic pelvic
pain, infertility,ectopic pregnancy (the leading cause of pregnancyrelated deaths in adult females), and other dangerous complications of
pregnancy. Occasionally, the infection can spread to in
the peritoneum causing inflammation and the formation of scar tissue
on the external surface of the liver (Fitz-Hugh-Curtis syndrome). Multiple
infections and infections that are treated later are more likely to result in
complications.
-Fertility may be restored in women affected by PID.
Traditionally tuboplastic surgery was the main approach to correct tubal
obstruction or adhesion formation, however success rates tended to be
very limited. In vitro fertilization (IVF) has been used to bypass tubal
problems and has become the main treatment for patients who want to
become pregnant.
Treatment:
-Treatment depends on the cause and generally involves use
of antibiotic therapy. If the patient has not improved within two to three
days after beginning treatment with the antibiotics, they should return to
the hospital for further treatment. Drugs should also be given orally
39
and/or intravenously to the patient while in the hospital to begin
treatment immediately, and to increase the effectiveness of antibiotic
treatment. Hospitalization may be necessary if the patient has Tuboovarian abscesses; is very ill, immunodeficient, pregnant, or
incompetent; or because a life-threatening condition cannot be ruled
out. Treating partners for STIs is a very important part of treatment and
prevention. Anyone with PID and partners of patients with PID since six
months prior to -diagnosis should be treated to prevent reinfection.
Psychotherapy is highly recommended to women diagnosed with PID as
the fear of redeveloping the disease after being cured may exist. It is
important for a patient to communicate any issues and/or uncertainties
they may have to a doctor, especially a specialist such as a
gynecologist, and in doing so, to seek follow-up care.
-A systematic review of the literature related to PID treatment was
performed prior to the 2006 CDC sexually transmitted infections
treatment guidelines. Strong evidence suggests that neither site nor
route of antibiotic administration affects the short or long-term major
outcome of women with mild or moderate disease. Data on women with
severe disease was inadequate to influence the results of the study.
-Regimens
:include cefoxitin or cefotetan plus, doxycycline, clindamycin plus, gent
amicin, ampicillin and sulbactam plus doxycycline,
andceftriaxone or cefoxitin plus doxycycline.
Prevention;
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Risk reduction against sexually transmitted infections
through barrier methods such as condoms or abstinence; see human
sexual behavior for other listings.

Going to the doctor immediately if symptoms of PID, sexually
transmitted infections appear, or after learning that a current or
former sex partner has, or might have had a sexually transmitted
infection.

Getting regular gynecological (pelvic) exams with STI testing to
screen for symptom less PID.
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Discussing sexual history with a trusted physician in order to get
properly screened for sexually transmitted diseases.
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Regularly scheduling STI testing with a physician and discussing
which tests will be performed that session.

Getting a STI history from your current partner and insisting they
be tested and treated before intercourse.

Understanding when a partner says that they have been STI
tested they usually mean Chlamydia and gonorrhea in the US, but
that those are not all of the sexually transmissible infections.

Treating partners to prevent reinfection or spreading the infection
to other people.

Diligence in avoiding vaginal activity, particularly intercourse,
after the end of a pregnancy (delivery, miscarriage, or abortion) or
certain gynecological procedures, to ensure that the cervix closes.

Salpingitis, any inflammation of the fallopian tubes

Tubo-ovarian abscess an abscess of the fallopian tube and ovary

Endometritis

Pelvic peritonitis
-An ovarian cyst:
- is any collection of fluid, surrounded by a very thin wall, within
an ovary.
-Any ovarian that is larger than about two centimeters is termed an
ovarian cyst. An ovarian cyst can be as small, or large.
-Most ovarian cysts are functional in nature, and harmless (benign) In
the US, ovarian cysts are found in nearly all premenopausal women, and
in up to 14.8% of postmenopausal women.
-Ovarian cysts affect women of all ages.
41
- They occur most often, however, during a woman's childbearing years.
-Some ovarian cysts cause problems, such as bleeding and pain.
- Surgery may be required to remove cysts larger than 5 centimeters in
diameter.
Classification:
Non-functional cysts
There are several other conditions affecting the ovary that are described
as types of cysts, but are not usually grouped with the functional cysts.
(Some of these are more commonly or more properly known by other
names.) These include:

Dermoid cyst

Chocolate cyst of ovary:
An endometrioma, endometrioid
cyst, endometrial cyst, or chocolate cyst is
caused by endometriosis, and formed when a
tiny patch of endometrial tissue (the mucous
membrane that makes up the inner layer of the
uterine wall) bleeds, sloughs off, becomes
transplanted, and grows and enlarges inside the
ovaries.
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A polycystic-appearing ovary is diagnosed
based on its enlarged size — usually twice
normal —with small cysts present around the
outside of the ovary. It can be found in "normal"
women, and in women with endocrine
disorders. An ultrasound is used to view the
ovary in diagnosing the condition. Polycysticappearing ovary is different from the polycystic
ovarian syndrome, which includes other
symptoms in addition to the presence of ovarian
cysts.
Signs and symptoms:
42
Some or all of the following symptoms may be present, though it is
possible not to experience any symptoms:

Dull aching, or severe, sudden, and sharp pain
or discomfort in the lower abdomen (one or
both sides), pelvis, vagina, lower back, or
thighs; pain may be constant or intermittent—
this is the most common symptom

Fullness, heaviness, pressure, swelling,
or bloating in the abdomen

Breast tenderness

Pain during or shortly after beginning or end of
menstrual period.

Irregular periods, or abnormal uterine bleeding
or spotting

Change in frequency or ease of urination (such
as inability to fully empty the bladder), or
difficulty with bowel movements due to
pressure on adjacent pelvic anatomy

Weight gain

Nausea or vomiting

Fatigue

Infertility

Increased level of hair growth

Increased facial hair or body hair

Headaches

Strange pains in ribs, which feel muscular

Bloating

Strange nodules that feel like bruises under the
layer of skin
Diagnosis
Ovarian cysts are usually diagnosed by either ultrasound or CT scan.
treatment
-About 95% of ovarian cysts are benign, meaning they are not
cancerous.
43
-Treatment for cysts depends on the size of the cyst and symptoms. For
small, asymptomatic cysts, the wait and see approach with regular
check-ups will most likely be recommended.
Pain caused by ovarian cysts may be treated with:

pain relievers,
including acetaminophen/paracetamol (Tylenol),
no steroidal anti-inflammatory drugs such
as ibuprofen (Motrin, Advil), or narcotic pain
medicine (by prescription) may help reduce
pelvic pain. NSAIDs usually work best when
taken at the first signs of the pain.

a warm bath, or heating pad, or hot water
bottle applied to the lower abdomen near the
ovaries can relax tense muscles and relieve
cramping, lessen discomfort, and stimulate
circulation and healing in the ovaries. combined methods of hormonal
contraception such as the combined oral
contraceptive pill – the hormones in the pills
may regulate the menstrual cycle, prevent the
formation of follicles that can turn into cysts,
and possibly shrink an existing cyst.
-Also, limiting strenuous activity may reduce the risk of cyst rupture or
torsion.
-Cysts that persist beyond two or three menstrual cycles, or occur in
post-menopausal women, may indicate more serious disease and
should be investigated -through ultrasonography and laparoscopy,
especially in cases where family members have had ovarian cancer.
Such cysts may require surgical biopsy. Additionally, a blood test may
be taken before surgery to check for elevated CA-125, a tumor marker,
which is often found in increased levels in ovarian cancer, although it
can also be elevated by other conditions resulting in a large number of
false positives.
-For more serious cases where cysts are large and persisting, doctors
may suggest surgery.
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- Some surgeries can be performed to successfully remove the cyst(s)
without hurting the ovaries, while others may require removal of one or
both ovaries.
-Ovarian cysts are fluid-filled sacs, similar to blisters, that are common
among women during their reproductive years. They form on the
ovaries, the almond-sized organs on each side of the uterus. Most types
of ovarian cysts are harmless and go away without any treatment.
What Causes Ovarian Cysts?
The normal function of the ovaries is to produce an egg each month.
During the process of ovulation, a cyst-like structure called a follicle is
formed inside the ovary. The mature follicle ruptures when an egg is
released during ovulation. A corpus luteum forms from the empty
follicle, and if pregnancy does not occur, the corpus luteum dissolves.
Sometimes, however, this process does not conclude appropriately,
causing the most common type of ovarian cyst -- functional ovarian
cysts.
Abnormal ovarian cysts, such as polycystic ovarian disease, may occur
as the result of an imbalance of female hormones (estrogen and
progesterone).
Types of Ovarian Cysts
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Functional Cysts
These normal cysts will often shrink and disappear within two or
three menstrual cycles. Because this type of cyst is formed during
ovulation, it rarely occurs in menopausal women because eggs
are no longer being produced.
Dermoid Cysts
These are ovarian cysts that are filled with various types of
tissues, including hair and skin.
Endometrioma Cysts
These cysts are also known as the "chocolate cysts" of
endometriosis, and they form when tissue similar to the lining of
the uterus attaches to the ovaries.
Cyst adenoma Cysts
These are ovarian cysts that develop from cells on the outer
surface of the ovaries.
Polycystic Ovarian Disease
This disease refers to cysts that form from a build up of follicles.
These cysts cause the ovaries to enlarge and create a thick outer
covering, which may prevent ovulation from occurring, and are
often the cause of fertility problems.
What are the Symptoms of Ovarian Cysts?
Ovarian cysts often cause no symptoms; however, when symptoms are
present, ovarian cysts may cause a dull ache or a sense of fullness or
pressure in the abdomen. Pain during intercourse and at other times can
also indicate the presence of ovarian cysts.
Pain or pressure is caused by a number of factors, such as size,
bleeding or bursting of a cyst, which irritates the abdominal tissues.
Pain can also be caused when a cyst is twisted (called torsion), which
can block the flow of blood to the cyst.
Other possible symptoms of ovarian cysts include delayed, irregular, or
unusually painful periods. If you experience any of these symptoms,
notify your doctor as soon as possible.
How are Ovarian Cysts Diagnosed?
Unless symptoms are present, ovarian cysts are typically diagnosed
during an annual pelvic examination.
Other diagnostic tests, such as ultrasound and laparoscopy, may be
done if your physician detects any abnormalities.
What are the Treatments for Ovarian Cysts?
Treatment of ovarian cysts depends on several factors, including:




the size and type of cyst
the woman's age and general health
her future pregnancy plans
what symptoms she is experiencing
-The earlier ovarian cysts are found, the less invasive the treatment.
-Often, young women who are not experiencing any symptoms are
advised to wait two or three months to see if the cysts dissolve on their
own. In most cases, functional ovarian cysts will dissolve without any
medical intervention or treatment.
-Occasionally, physicians opt to prescribe oral contraceptives or
hormones to shrink functional ovarian cysts. (Functional cysts are rare
in women who use oral contraceptives since this method of birth control
prevents ovulation.) Oral contraceptives are not an effective treatment
for other types of benign ovarian cysts, but they do offer some
protection against malignant ovarian cysts (ovarian cancer).
Surgery is sometimes necessary to treat ovarian cysts that are
unresponsive to hormonal treatment. Cases that could require surgery
46
include ovarian cysts that do not disappear after a few menstrual
cycles and extremely large cysts.
Ovarian cysts that are found in post menopausal women, cause
symptoms such as severe pain or bleeding, or have become twisted
often require a surgical procedure.
The specific surgical procedure required depends on a number of
factors, but typically the earlier ovarian cysts are discovered, the less
extensive the surgery. Surgery can involve anything from simply
removing the cyst to removing the ovary. In some severe cases,
hysterectomy is recommended.
Although your physician will discuss the planned procedure with you,
you should keep in mind that the exact extent of the surgery may be
unknown until the operation is in progress.
-Things to Remember About Ovarian Cysts
Because ovarian cysts often cause no symptoms, it is especially
important for women who have previously had cysts to have
regular pelvic examinations. Women who have previously had ovarian
cysts are at a greater risk of developing further cysts.
In addition, endometriosis may be worsened by the presence of ovarian
cysts, and your chance of needing to have your ovaries removed
increases.
In the unusual case of malignant ovarian cysts, early treatment offers
the best hope for recovery. Women who develop ovarian cysts after
menopause are more likely to have malignancies.
Remember, if you experience any fullness, pressure, or discomfort in
your pelvic region phone your physician immediately for his advice. The
earlier ovarian cysts are discovered and treated, the better your chance
of complete recovery.
Polycystic Ovary Syndrome (PCOS)
- is one of the most common female endocrine disorders affecting
approximately 5%-10% of women of reproductive age (12–45 years old)
and is thought to be one of the leading causes of female infertility. The
exact cause of polycystic ovary syndrome is unknown.
-PCOS can present in any age during the reproductive years. Due to its
often vague presentation it can take years to reach a diagnosis.
Symptoms:Signs and symptoms vary from person to person, in both type and
severity.
47
*Menstrual abnormality This is the most common characteristic.
Examples of menstrual abnormality include Oligomenorrhea,
amenorrhea — irregular, few, or absent menstrual periods
*Excess androgen Elevated levels of male hormones (androgens) may
result in physical signs, such as excess facial and body hair (hirsutism);
adult acne or severe adolescent acne .
*Polycystic ovaries Enlarged ovaries containing numerous small cysts
can be detected by ultrasound. Despite the condition's name, polycystic
ovaries alone do not confirm the diagnosis. To be diagnosed with PCOS,
you must also have abnormal menstrual cycles or signs of androgen
excess.
*Infertility Women with polycystic ovary syndrome may have trouble
becoming pregnant because they experience infrequent ovulation or a
lack of ovulation. PCOS is the most common cause of female infertility.
*Obesity About half the women with polycystic ovary syndrome are
obese women with PCOS are more likely to be overweight or obese.
*type 2 diabetes. Many women with polycystic ovary syndrome are
insulin resistant, which impairs the body's ability to use insulin
effectively to regulate blood sugar. This can result in high blood sugar
and type 2 diabetes.
*Acanthosis Nigerians. This is the medical term for darkened, velvety
skin on the nape of your neck, armpits, inner thighs, vulva or under your
breasts. This skin condition is a sign of insulin resistance.
Causes:The exact cause of polycystic ovary syndrome is unknown.
-normal reproductive cycle is regulated by changing levels of hormones
produced by the pituitary gland in brain and by ovaries. The pituitary
gland produces follicle-stimulating hormone (FSH) and luteinizing
hormone (LH), which control the growth and release of eggs (ovulation)
in the ovaries. During a monthly cycle, ovulation occurs about two
weeks before period.
ovaries secrete the hormones estrogen and progesterone, which
prepare the lining of the uterus to receive a fertilized egg. The ovaries
also produce some male hormones (androgens), such as testosterone. If
pregnancy doesn't occur, estrogen and progesterone secretion decline
and the lining of the uterus is shed during menstruation.
-In polycystic ovary syndrome, the pituitary gland may secrete high
levels of LH and the ovaries may make excess androgens. This disrupts
48
the normal menstrual cycle and may lead to infertility, excess body hair
and acne.
these factors likely play a role:




Excess insulin. Insulin is the hormone produced in the pancreas
that allows cells to use sugar (glucose), your body's primary
energy supply. If you have insulin resistance, your ability to use
insulin effectively is impaired, and your pancreas has to secrete
more insulin to make glucose available to cells. The excess
insulin is thought to boost androgen production by your ovaries.
Low-grade inflammation. body's white blood cells produce
substances to fight infection in a process called inflammation.
Eating certain foods can trigger an inflammatory response in
some predisposed people. When this happens, white blood cells
produce substances that can lead to insulin resistance and
cholesterol accumulation in blood vessels (atherosclerosis).
Atherosclerosis causes cardiovascular disease. Research has
shown that women with PCOS have low-grade inflammation.
Heredity. If mother or sister has PCOS, you might have a greater
chance of having it.
Abnormal fetal development. New research shows that excessive
exposure to male hormones (androgens) in fetal life may
permanently prevent normal genes from working the way they're
supposed to — a process known as gene expression. This may
promote a male pattern of abdominal fat distribution, which
increases the risk of insulin resistance and low-grade
inflammation. Research continues to establish to what extent
these factors might contribute to PCOS.
Tests and diagnosis :There's no specific test to definitively diagnose polycystic ovary
syndrome. The diagnosis is one of exclusion, which means your doctor
considers all of your signs and symptoms and then rules out other
possible disorders.




49
Medical history. Your doctor may ask questions about your
menstrual periods, weight changes and other symptoms.
Physical examination. During your physical exam, your doctor will
note several key pieces of information, including your height,
weight and blood pressure.
Pelvic examination. During a pelvic exam, your doctor visually
and manually inspects your reproductive organs for signs of
masses, growths or other abnormalities.
Blood tests. Your blood may be drawn to measure the levels of
several hormones to exclude possible causes of menstrual
abnormalities or androgen excess that mimic PCOS. Additional
blood testing may include fasting cholesterol and triglyceride
levels and a glucose tolerance test, in which glucose levels are

measured while fasting and after drinking a glucose-containing
beverage.
Pelvic ultrasound. A pelvic ultrasound( abdominal and transvaginal ultrasound ) can show the appearance of the ovaries and
the thickness of the lining of the uterus.
Treatments and drugs :Polycystic ovary syndrome treatment generally focuses on management
of individual main concerns, such as infertility, hirsutism, acne or
obesity.
Schedule regular checkups Long term, managing cardiovascular
risks, such as obesity, high blood cholesterol, type 2 diabetes and
high blood pressure, is important. To help guide ongoing treatment
decisions.
Adjusting lifestyle habits Making healthy-eating choices and getting
regular exercise is the first treatment approach your doctor might
recommend, particularly if you're overweight. Obesity makes insulin
resistance worse. Weight loss can reduce both insulin and androgen
levels, and may restore ovulation.
Regulate menstrual cycle doctor may prescribe low-dose birth
control pills that contain a combination of synthetic estrogen and
progesterone. They decrease androgen production and give your
body a break from the effects of continuous estrogen. This
decreases risk of endometrial cancer and corrects abnormal
bleeding.
An alternative approach is taking progesterone for 10 to 14 days
each month. This regulates periods and offers protection against
endometrial cancer, but it doesn't improve androgen levels.
doctor also may prescribe metformin (Glucophage, Glucophage
XR), an oral medication for type 2 diabetes that lowers insulin
levels. This drug improves ovulation and leads to regular
menstrual cycles. Metformin also slows the progression to type 2
diabetes
Reduce excessive hair growth doctor may recommend birth control
pills to decrease androgen production, or another medication called
spironolactone (Aldactone) that blocks the effects of androgens on the
skin. Because spironolactone can cause birth defects, effective
contraception is required when using the drug, and it's not
recommended if you're pregnant or planning to become pregnant.
Eflornithine (Vaniqa) is another medication possibility; the cream slows
facial hair growth in women.
50
Shaving, waxing and depilatory creams are nonprescription hair
removal options. Results may last several weeks, and then you
need to repeat treatment.
For longer lasting hair removal, your doctor might recommend a
procedure that uses electric current (electrolysis) or laser energy
to destroy hair follicles and control unwanted new hair growth.
-Use medication to induce ovulation If woman trying to become
pregnant, may need a medication to induce ovulation. Clomiphene
citrate (Clomid, Serophene) is an oral anti-estrogen medication that
taken in the first part of your menstrual cycle. If Clomiphene citrate
alone isn't effective, may add metformin to help induce ovulation.
Also may recommend using gonadotropins — follicle-stimulating
hormone (FSH) and luteinizing hormone (LH) medications that are
administered by injection.
surgery If medications don't help you become pregnant, an
outpatient surgery called laparoscopic ovarian drilling is an option
for some women with PCOS
In this procedure, a surgeon makes a small incision in the
abdomen and inserts a tube attached to a tiny camera
(laparoscope). The camera provides the surgeon with detailed
images of the ovaries and neighboring pelvic organs. The
surgeon then inserts surgical instruments through other small
incisions and uses electrical or laser energy to burn holes in
follicles on the surface of the ovaries. The goal is to induce
ovulation by reducing androgen levels.
Complications
Having polycystic ovary syndrome makes the following conditions more
likely, especially if obesity also is a factor:
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51
Type 2 diabetes
High blood pressure
Cholesterol abnormalities, such as high triglycerides or low highdensity lipoprotein (HDL) cholesterol, the so-called "good"
cholesterol
Elevated levels of C-reactive protein, a cardiovascular disease
marker
Metabolic syndrome, a cluster of signs and symptoms that
indicate a significantly increased risk of cardiovascular disease
Sleep apnea
Abnormal uterine bleeding
Cancer of the uterine lining (endometrial cancer), caused by
exposure to continuous high levels of estrogen

Gestational diabetes or pregnancy-induced high blood pressure,
if you do become pregnant
Nomenclature
Other names for this syndrome include polycystic ovarian syndrome
(also PCOS), polycystic ovary disease (PCOD), functional ovarian
hyperandrogenism, Stein-Leventhal syndrome (original name, not used
in modern literature), ovarian hyperthecosis and sclerocystic ovary
syndrome.
Dysfunctional uterine bleeding:
-Abnormal uterine bleeding is a common presenting problem . (DUB) is
defined as abnormal uterine bleeding in the absence of organic disease.
Dysfunctional uterine bleeding is the most common cause of abnormal
vaginal bleeding during a woman's reproductive years. Dysfunctional
uterine bleeding can have a substantial financial and quality-of-life
burden. It affects women's health both medically and socially.
- Terms frequently used to describe abnormal uterine bleeding:
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Menorrhagia - Prolonged (>7 d) or excessive (>80 mL daily)
uterine bleeding occurring at regular intervals
Metrorrhagia - Uterine bleeding occurring at irregular and more
frequent than normal intervals
Menometrorrhagia - Prolonged or excessive uterine bleeding
occurring at irregular and more frequent than normal intervals
Intermenstrual bleeding - Uterine bleeding of variable amounts
occurring between regular menstrual periods
Midcycle spotting - Spotting occurring just before ovulation,
typically from declining estrogen levels
Postmenopausal bleeding - Recurrence of bleeding in a
menopausal woman at least 6 months to 1 year after cessation of
cycles
Amenorrhea - No uterine bleeding for 6 months or longer
-Dysfunctional uterine bleeding is a diagnosis of exclusion. It is
ovulatory or anovulatory bleeding, diagnosed after pregnancy,
medications, iatrogenic causes, genital tract pathology, malignancy, and
systemic disease have been ruled out by appropriate investigations.
Approximately 90% of dysfunctional uterine bleeding cases result from
an ovulation, and 10% of cases occur with ovulatory cycles.
-Anovulatory dysfunctional uterine bleeding results from a disturbance
of the normal hypothalamic-pituitary-ovarian axis and is particularly
common at the extremes of the reproductive years. When ovulation
52
does not occur, no progesterone is produced to stabilize the
endometrium; thus, proliferative endometrium persists. Bleeding
episodes become irregular, and amenorrhea, metrorrhagia, and
menometrorrhagia are common. Bleeding from anovulatory
dysfunctional uterine bleeding is thought to result from changes in
prostaglandin concentration, increased endometrial responsiveness to
vasodilating prostaglandins, and changes in endometrial vascular
structure.
-In ovulatory dysfunctional uterine bleeding, bleeding occurs cyclically,
and menorrhagia is thought to originate from defects in the control
mechanisms of menstruation. It is thought that, in women with ovulatory
dysfunctional uterine bleeding, there is an increased rate of blood loss
resulting from vasodilatation of the vessels supplying the endometrium
due to decreased vascular tone, and prostaglandins have been strongly
implicated. Therefore, these women lose blood at rates about 3 times
faster than women with normal menses.4
-Mortality/Morbidity
Morbidity is related to the amount of blood loss at the time of
menstruation, which occasionally is severe enough to
cause hemorrhagic shock. Excessive menstrual bleeding accounts for
two thirds of all hysterectomies and most endoscopic endometrial
destructive surgery. Menorrhagia has several adverse effects, including
anemia and iron deficiency, reduced quality of life, and increased
healthcare costs.1
-Race
Dysfunctional uterine bleeding has no predilection for race; however,
black women have a higher incidence of leiomyomas and, as a result,
they are prone to experiencing more episodes of abnormal vaginal
bleeding.
-Age
Dysfunctional uterine bleeding is most common at the extreme ages of a
woman's reproductive years, either at the beginning or near the end, but
it may occur at any time during her reproductive life.
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53
Most cases of dysfunctional uterine bleeding in adolescent girls
occur during the first 2 years after the onset of menstruation,
when their immature hypothalamic-pituitary axis may fail to
respond to estrogen and progesterone, resulting in an ovulation.
Abnormal uterine bleeding affects up to 50% of perimenopausal
women. In the perimenopausal period, dysfunctional uterine
bleeding may be an early manifestation of ovarian failure causing
decreased hormone levels or responsiveness to hormones, thus
also leading to anovulatory cycles. In patients who are 40 years or
older, the number and quality of ovarian follicles diminishes.
Follicles continue to develop but do not produce enough estrogen
in response to FSH to trigger ovulation. The estrogen that is
produced usually results in late-cycle estrogen breakthrough
bleeding.
-History
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54
Patients often present with complaints of amenorrhea,
menorrhagia, metrorrhagia, or menometrorrhagia. The amount
and frequency of bleeding and the duration of symptoms, as well
as the relationship to the menstrual cycle, should be established.
Ask patients to compare the number of pads or tampons used per
day in a normal menstrual cycle to the number used at the time of
presentation. The average tampon or pad absorbs 20-30 mL or
vaginal effluent. Personal habits vary greatly among women;
therefore, the number of pads or tampons used is unreliable. The
patient should be questioned about the possibility of pregnancy.3
A reproductive history should always be obtained, including the
following:
o Age of menarche and menstrual history and regularity
o Last menstrual period (LMP), including flow, duration, and
presence of dysmenorrhea
o Postcoital bleeding
o Gravida and para
o Previous abortion or recent termination of pregnancy
o Contraceptive use, use of barrier protection, and sexual
activity (including vigorous sexual activity or trauma)
o History of sexually transmitted diseases (STDs) or ectopic
pregnancy
Questions about medical history should include the following:
o Signs and symptoms of anemia or hypovolemia (including
fatigue, dizziness, and syncope)
o Diabetes mellitus
o Thyroid disease
o Endocrine problems or pituitary tumors
o Liver disease
o Recent illness, psychological stress, excessive exercise, or
weight change
o Medication usage, including exogenous hormones,
anticoagulants, aspirin, anticonvulsants, and antibiotics
An international expert panel including obstetrician/gynecologists
and hematologists has issued guidelines to assist physicians to
better recognize bleeding disorders, such as von Will brand
disease, as a cause of menorrhagia and postpartum hemorrhage
and to provide disease-specific therapy for the bleeding
disorder.5Historically, a lack of awareness of underlying bleeding
disorders has led to under diagnosis in women with abnormal
reproductive tract bleeding. The panel provided expert consensus
recommendations on how to identify, confirm, and manage a
bleeding disorder. If a bleeding disorder is suspected, evaluation
for a coagulation problem is required and consultation with a
hematologist is suggested. An underlying bleeding disorder
should be considered when a patient has any of the following:
o Menorrhagia since menarche
o Family history of bleeding disorders
o Personal history of 1 or several of the following:
 Notable bruising without known injury
 Bleeding of oral cavity or GI tract without obvious
lesion
 Epistaxis >10 min duration (possibly necessitating
packing or cautery)
-Physical
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55
Vital signs, including postural changes, should be assessed.
Initial evaluation should be directed at assessing the patient's
volume status and degree of anemia. Examine for pallor and
absence of conjunctival vessels to gauge anemia.
An abdominal examination should be performed. Femoral and
inguinal lymph nodes should be examined. Stool should be
evaluated for the presence of blood.
Patients who are hemodynamically stable require a pelvic
speculum, bimanual, and rectovaginal examination to define the
etiology of vaginal bleeding. A careful physical examination will
exclude vaginal or rectal sources of bleeding. The examination
should look for the following:
o The vagina should be inspected for signs of trauma,
lesions, infection, and foreign bodies.
o The cervix should be visualized and inspected for lesions,
polyps, infection, or intrauterine device (IUD).
o Bleeding from the cervical os
o A rectovaginal examination should be performed to
evaluate the cul-de-sac, posterior wall of the uterus, and
uterosacral ligaments.
Uterine or ovarian structural abnormalities, including leiomyoma
or fibroid uterus, may be noted on bimanual examination.
Patients with hematologic pathology may also have cutaneous
evidence of bleeding diathesis. Physical findings include
petechiae, purpura, and mucosal bleeding (eg, gums) in addition
to vaginal bleeding.
Patients with liver disease that has resulted in a coagulopathy
may manifest additional symptomatology because of abnormal
hepatic function. Evaluate patients for spider angioma, palmar
erythema, splenomegaly, ascites, jaundice.
Women with polycystic ovary disease present with signs of
hyperandrogenism, including hirsutism, obesity, acne, palpable
enlarged ovaries, and acanthosis nigricans (hyper pigmentation
typically seen in the folds of the skin in the neck, groin, or axilla)

Hyperactive and hypoactive thyroid can cause menstrual
irregularities. Patients may have varying degrees of characteristic
vital sign abnormalities, eye findings, tremors, changes in skin
texture, and weight change. Goiter may be present.
-Causes;
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Systemic disease,
including thrombocytopenia, hypothyroidism, hyperthyroidism, C
ushing disease, liver disease, diabetes mellitus, and adrenal and
other endocrine disorders, can present as abnormal uterine
bleeding.
Pregnancy and pregnancy-related conditions may be associated
with vaginal bleeding.
Trauma to the cervix, vulva, or vagina may cause abnormal
bleeding.
Carcinomas of the vagina, cervix, uterus, and ovaries must always
be considered in patients with the appropriate history and
physical examination findings. Endometrial cancer is associated
with obesity, diabetes mellitus, anovulatory cycles, nulliparity,
and age older than 35 years.
Other causes of abnormal uterine bleeding include structural
disorders, such as functional ovarian
cysts,cervicitis, endometritis, salpingitis, leiomyomas, and
adenomyosis. Cervical dysplasia or other genital tract pathology
may present as postcoital or irregular bleeding.
Polycystic ovary disease results in excess estrogen production
and commonly presents as abnormal uterine bleeding.
Primary coagulation disorders, such as von Will brand
disease, myeloproliferative disorders, and immune
thrombocytopenia, can present with menorrhagia.
Excessive exercise, stress, and weight loss cause hypothalamic
suppression leading to abnormal uterine bleeding due to
disruption along the hypothalamus-pituitary-ovarian pathway.
Bleeding disturbances are common with combination oral
contraceptive pills as well as progestin-only methods of birth
control. However, the incidence of bleeding decreases
significantly with time. Therefore, only counseling and
reassurance are required during the early months of use.
Contraceptive intrauterine devices (IUDs) can cause variable vaginal
bleeding for the first few cycles after placement and intermittent
spotting subsequently. The progesterone impregnated IUD (Mirena) is
associated with less menometrorrhagia and usually results in secondary
amenorrhea
. Differential Diagnoses
Abortion, Complete
56
Fibroids (leiomyomata)
Abortion, Incomplete
Foreign body
Abortion, Inevitable
Hydatidiform Mole
Abortion, Missed
Hyperthyroidism
Abortion, Threatened
Hypothyroidism
Abruptio Placentae
Intrauterine devices
Adenomyosis
Liver disease
An ovulation
Mullerian Duct Anomalies
Anticoagulants
Oral contraceptives
Antipsychotic
Ovarian Cysts
Arteriovenous Malformations Pelvic Inflammatory Disease
Cervical Cancer
Placenta Previa
Cervicitis
Platelet Disorders
Coagulopathies
Polycystic Ovarian Syndrome
Cushing Syndrome
Pregnancy, Ectopic
Endocervical Polyp
Prolactinoma
Endometrial Carcinoma
Renal disease
Endometrial Polyp
Trauma
Endometriosis
von Will brand Disease
Estrogen Therapy
Vulvovaginitis
Laboratory Studies
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When evaluating a woman of reproductive age with vaginal
bleeding, pregnancy must always be ruled out by urine or serum
human chorionic gonadotropin.
In a patient with any hemodynamic instability, excessive bleeding,
or clinical evidence of anemia, a complete blood count is
essential.
Coagulation studies should be considered when indicated by the
history or physical examination findings and in patients with
underlying liver disease or other coagulopathies.
In patients with suspected endocrine disorders, other laboratory
studies such as thyroid function tests and prolactin levels may be
helpful, although these results may not be available from the ED.
Imaging Studies
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57
Pelvic ultrasonography is an important imaging modality for
nonpregnant patients with abnormal vaginal bleeding. It may
determine the etiology of the bleeding such as a fibroid uterus,
endometrial thickening, or a focal mass.
o Thickened endometrium may indicate an underlying lesion
or excess estrogen and may be suggestive of malignancy.
 An endometrial stripe measuring less than 4 mm
thick is unlikely to have endometrial hyperplasia or
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cancer, and biopsy is often considered unnecessary
before treatment.
 Women with a normal endometrial stripe (5–12 mm)
may require biopsy, particularly if they have risk
factors for endometrial cancer.
 When the endometrial stripe is larger than 12 mm, a
biopsy should be performed.6
o Depending on the urgency to determine the etiology of
bleeding and on the reliability of outpatient follow-up,
ultrasonography may be deferred for outpatient evaluations
because for the majority of nonpregnant patients,
ultrasonographic findings do not immediately affect ED
decision-making.3
Transvaginal ultrasonography may be particularly helpful in
further delineating ovarian cysts and fluid in the cul-de-sac.
Computed tomography is used primarily for evaluation of other
causes of acute abdominal or pelvic pain.
Magnetic resonance imaging is used primarily for cancer staging.
Procedures
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Before instituting therapy, many consulting gynecologists
perform endometrial sampling or biopsy to diagnose intrauterine
pathology and to exclude endometrial malignancy.
Endometrial biopsy is indicated for the following patients with
abnormal uterine bleeding6 :
o Women older than 35 years
o Obese patients
o Women who have prolonged periods of unopposed
estrogen stimulation
o Women with chronic an ovulation
Hysteroscopy is the definitive way to detect intrauterine lesions. It
offers a more complete examination of the surface of the
endometrium. However, it is usually reserved for treating lesions
that were detected by other less invasive means.
Treatment
Emergency Department Care
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Hemodynamically unstable patients with uncontrolled bleeding
and signs of significant blood loss should have aggressive
resuscitation with saline and blood as with other types of
hemorrhagic shock.
o Evaluate ABCs and address the priorities.
o Initiate 2 large-bore intravenous lines (IVs), oxygen, and
cardiac monitor.
o If bleeding is profuse and the patient is unresponsive to
initial fluid management, consider administration of IV
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59
conjugated estrogen (Premarin) 25 mg IV every 4-6 hours
until the bleeding stops.
o In women with severe, persistent uterine bleeding, an
immediate dilation and curettage (D&C) procedure may be
necessary.
Combination oral contraceptive pills may be used in women who
are not pregnant and have no anatomic abnormalities. An oral
contraceptive with 35 mcg of ethinyl estradiol can be taken twice
a day until the bleeding stops for up to 7 days, at which time the
dose is decreased to once a day until the pack is completed. They
provide the additional benefits of reducing dysmenorrhea and
providing contraception. Side effects include nausea and
vomiting.
Progesterone alone can be used to stabilize an immature
endometrium. It is usually successful in the treatment of women
with anovulatory dysfunctional uterine bleeding (DUB) because
these women have unopposed estrogen stimulation.
Medroxyprogesterone acetate 10 mg is taken orally once daily for
10 days, followed by withdrawal bleeding 3-5 days after
completion of the course. Currently, there is not enough evidence
comparing the effect of either progesterone alone or in
combination with estrogens for the treatment of dysfunctional
uterine bleeding.7
No steroidal anti-inflammatory drugs (NSAIDs) are generally
effective for the treatment of dysfunctional uterine bleeding
and dysmenorrhea. NSAIDs inhibit cyclooxygenase in the
arachidonic acid cascade, thus inhibiting prostaglandin synthesis
and increasing thromboxane A2 levels. This leads to
vasoconstriction and increased platelet aggregation. These
medications may reduce blood loss by 20-50%. NSAIDs are most
effective if used with the onset of menses or just prior to its onset
and continued throughout its duration.
Danazol creates a hypoestrogenic and hyper androgenic
environment, which induces endometrial atrophy resulting in
reduced menstrual loss. Side effects include musculoskeletal
pain, breast atrophy, hirsutism, weight gain, oily skin, and acne.
Because of the significant androgenic side effects, this drug is
usually reserved as a second-line treatment for short-term use
prior to surgery.
Gonadotropin-releasing hormone agonists may be helpful for
short-term use in inducing amenorrhea and allowing women to
rebuild their red blood cell mass. They produce a profound
hypoestrogenic state similar to menopause. Side effects include
menopausal symptoms and bone loss with long-term use.
Tranexamic acid is an antifibrinolytic drug that exerts its effects
by reversibly inhibiting plasminogen. It diminishes fibrinolytic
activity within endometrial vessels to prevent bleeding. It has
been shown effective in reducing bleeding in up to half of women
with dysfunctional uterine bleeding. Tranexamic acid is not
approved for the treatment of dysfunctional uterine bleeding in
the United States.6
Consultations
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Seek an emergency gynecologic consultation for patients
requiring hemodynamic stabilization. If parenteral therapy does
not completely arrest vaginal bleeding in the hemodynamically
unstable patient, an emergency D&C may be warranted.
Consultation with or urgent referral to a gynecologist for surgical
treatment may be necessary for patients who do not desire
fertility and in whom medical therapy fails. Both endometrial
ablation and hysterectomy are effective treatments in women with
dysfunctional uterine bleeding with comparable patient
satisfaction rates.
o Endometrial ablation may be performed using laser,
electrocautery, or roller ball. Amenorrhea is seen in
approximately 35% of women treated, and decreased flow is
seen in another 45%; although, treatment failures increase
with time following the procedure due to endometrial
regeneration. A substantial number of patients receiving
endometrial ablation require reoperation (30% by 48
months).
o Hysterectomy is the most effective treatment for bleeding.
However, it is associated with more frequent and severe
adverse events compared with either conservative medical
or ablation procedures. Operating time, hospitalization,
recovery times, and costs are also greater. Hence,
hysterectomy is reserved for selected patient populations.
Medication
The goals of pharmacotherapy are to control the bleeding, reduce
morbidity, and prevent complications.
Steroid hormones
These agents may help control bleeding. Some of them are used when
bleeding is profused and the patient is unresponsive to initial fluid
management.
Ethinyl estradiol 35 μg and norethindrone 1mg (Necon 1/35, Nortrel 1/35,
Ortho-Novum 1/35, Norinyl 1 + 35)
Reduces secretion of LH and FSH from pituitary by decreasing amount
of GnRH.
Contraceptive pills containing estrogen and progestin have been
advocated for nonsmoking patients with DUB who desire contraception.
Therapy also used to treat acute hemorrhagic uterine bleeding but not
60
as effective as other treatments perhaps because may take longer to
induce endometrial proliferation when progestin is present.
Suggested mechanisms by which hormonal therapy might affect
bleeding include improvement in coagulation, alterations in the
microvascular circulation, and improvements in endothelial integrity. In
long-term management of DUB, combination oral contraceptives are
very effective.
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Dosing
Interactions
Contraindications
Precautions
Adult
1 tab PO bid for 1 wk until bleeding stops, followed by 1 tab PO qd for 2
wk; followed by a week of inactive pills, during which a withdrawal bleed
generally occurs.
Pediatric
Not established
Danazol
Synthetic steroid analog, derived from ethisterone, with strong
antigonadotropic activity (inhibits LH and FSH) and weak androgenic
action without adverse virilizing and masculinizing effects. Increases
levels of C4 component of the complement. May push the resting
hematopoietic stem cells into cycle, making them more responsive to
differentiation by hematopoietic growth factors. May also stimulate
endogenous secretion of erythropoietin.
May impair clearance of immunoglobulin-coated platelets and decreases
autoantibody production.
Certain androgenic preparations have been used historically to treat
mild-to-moderate bleeding, particularly in ovulatory patients with
abnormal uterine bleeding. These regimens offer no real advantage over
other regimens and might cause irreversible signs of masculinization in
the patient. They seldom are used for this indication today.
Use of androgens might stimulate erythropoiesis and clotting efficiency.
Androgens alter endometrial tissue so that it becomes inactive and
atrophic.
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Dosing
Interactions
Contraindications
Precautions
Adult
100-200 mg/d PO in divided doses
Pediatric
Not established
61
Estrogens, conjugated (Premarin)
Causes vasospasm of uterine arteries and initiates several coagulationrelated functions, which decrease uterine bleeding. Use in
pharmacologic doses also causes rapid growth of endometrial tissue
over denuded and raw epithelial surface.
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Dosing
Interactions
Contraindications
Precautions
Adult
Severe uncontrolled bleeding with problems of hemostasis: 25 mg IV
slowly over 10-15 min q4-6h until bleeding stops; not to exceed 4 doses
Moderate bleeding: 2.5 mg PO qd for days 1-25, followed by
progesterone on days 16-25
Pediatric
Not established; use judiciously in children whose bone growth is not
yet complete because of effects on epiphyseal closure
Medroxyprogesterone acetate (Provera)
DOC for most patients with anovulatory DUB. After acute bleeding
episode controlled, can be used alone in patients with adequate
amounts of endogenous estrogen to cause endometrial growth.
Progestin therapy in adolescents produces regular cyclic withdrawal
bleeding until positive feedback system matures. Progestins stop
endometrial growth and support and organize endometrium to allow
organized sloughing after their withdrawal. Bleeding ceases rapidly
because of an organized slough to the basalis layer. These drugs
usually do not stop acute bleeding episodes, yet produce a normal
bleeding episode following their withdrawal.
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Dosing
Interactions
Contraindications
Precautions
Adult
10 mg PO qd for first 10-12 d of menstrual cycle
Depo-medroxyprogesterone (Depo-Provera) as 150 mg IM q3mo
Progestin-only oral contraceptive pills: Daily after acute phase of
bleeding
For acute moderate bleeding: Oral contraceptive pills qid for 5-7 d or
until bleeding stops
Pediatric
Not recommended
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Nonsteroidal Anti-inflammatory Drugs (NSAIDs)
These agents can decrease DUB through inhibition of prostaglandin
synthesis. NSAIDs only need to be taken during menstruation.
Naproxen (Naprosyn, Aleve, Naprelan)
For relief of mild to moderate pain; inhibits inflammatory reactions and
pain by decreasing activity of cyclooxygenase, which is responsible for
prostaglandin synthesis.
NSAIDs decrease intraglomerular pressure and decrease proteinuria.
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Dosing
Interactions
Contraindications
Precautions
Adult
For moderate bleeding: 500 mg PO bid (with foods)
Pediatric
<12 years: Not established
>12 years: 2.5 mg/kg/dose PO; not to exceed 10 mg/kg/d
Gonadotropin Releasing Hormone Analog
These agents are generally used for short-term use to induce
amenorrhea and allow the rebuilding of the red blood cell mass.
Leuprolide acetate (Lupron, Eligard)
Suppresses ovarian and testicular steroid genesis by decreasing LH and
FSH levels.
Works by reducing concentration of GnRH receptors in the pituitary via
receptor down regulation and induction of post receptor effects, which
suppress gonadotropin release. After an initial gonadotropin release
associated with rising estradiol levels, gonadotropin levels fall to
castrate levels, with resultant hypogonadism. This form of medical
castration is very effective in inducing amenorrhea, thus breaking
ongoing cycle of abnormal bleeding in many anovulatory patients.
Because prolonged therapy with this form of medical castration is
associated with osteoporosis and other postmenopausal side effects,
many practitioners add a form of low-dose hormonal replacement to the
regimen. Because of the expense of these drugs, they usually are not
used as a first-line approach but can be used to achieve short-term relief
63
from a bleeding problem, particularly in patients with renal failure or
blood dyscrasia.
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Dosing
Interactions
Contraindications
Precautions
Adult
3.5-7.5 mg IM qmo; not to exceed 6 mo without addition of low-dose
estrogen and progestin therapy
Pediatric
Not established
Follow-up
Further Inpatient Care

Patients with severe, acute abnormal uterine bleeding and
hemodynamic instability will require urgent gynecologic
consultation and hospitalization.
Further Outpatient Care

Most patients with abnormal uterine bleeding without
hemodynamic compromise should be referred to a gynecologist
for definitive management on an outpatient basis.
Inpatient & Outpatient Medications
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
Patients with bleeding heavy enough to decrease hematocrit may
be given ferrous sulfate tablets (325 mg tid).
Hormone regimens, including combination oral contraceptives
and cyclic progestins, may be continued for several months under
the supervision of the consulting gynecologist.
Complications
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
Anemia (may become severe)
Adenocarcinoma of the uterus (if prolonged, unopposed estrogen
stimulation)
Prognosis
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64
Hormonal contraceptives reduce blood loss by 40-70% when used
long term.
Although medical therapy is generally used first, over half of
women with menorrhagia undergo hysterectomy within 5 years of
referral to a gynecologist.[2 ]
Patient Education
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Instruct patients to continue prescribed medications, although
bleeding may still be occurring during the early part of the cycle.
Also, patients should be told to expect menses after cessation of
the regimen.
Young patients with small amounts of irregular bleeding need
reassurance and observation only prior to instituting a drug
regimen. Express to patients that pharmacologic intervention will
not be necessary once menstrual cycles become regular.
Discuss ways the patient can avoid prolonged emotional stress
and maintain a normal body mass index.
For excellent patient education resources, visit medicine's
Women's Health Center. Also, see medicines' patient education
articles Vaginal Bleeding and Mittelschmerz.
Uterine Prolapse
-Uterine prolapse ("dropped uterus") is a condition in which a woman's
uterus (womb) sags or slips out of its normal position. The uterus may
slip enough that it drops partially into the vagina (the birth canal),
creating a perceptible lump or bulge. This is called incomplete prolapse.
In a more severe case—known as complete prolapse—the uterus slips
to such a degree that some of the tissue drops outside of the vagina.
-Prolapse Definition
Prolapse literally means "to fall out of place." In medicine, prolapse is a
condition where organs, such as the uterus, fall down or slip out of
place. It is generally reserved for organs protruding through the vagina,
or for the misalignment of the valves of the heart.
-Anatomy of the Vagina
-The vaginal vault has three compartments: an anterior compartment
(consisting of the anterior vaginal wall), a middle compartment (cervix),
65
and a posterior compartment (posterior vaginal wall). Uterine prolapse
involves the cervix.
Signs & Symptoms
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-Women with mild cases of uterine prolapse may have no obvious
symptoms. However, as the slipped uterus falls further out of position, it
can place pressure on other pelvic organs—such as the bladder or
bowel—causing a variety of symptoms, including:
Pelvic pressure: a feeling of heaviness or pressure in the pelvis
Pelvic pain: discomfort in the pelvis, abdomen or lower back
Pain during intercourse
A protrusion of tissue from the opening of the vagina
Recurrent bladder infections
Unusual or excessive discharge from the vagina
Constipation
Difficulty with urination, including involuntary -loss of urine
(female incontinence), or urinary frequency or urgency 1
Symptoms may be worsened by prolonged standing or walking, due to
added pressure placed on the pelvic muscles by gravity.
Causes of Uterine Prolapse
-Trauma incurred during the birthing process, particularly with large
babies or after a difficult labor and delivery, is one of the main causes of
the muscle weakness that leads to uterine prolapse. Reduced muscle
tone from aging, as well as lowered amounts of circulating estrogen
after menopause, may also form contributing factors in pelvic organ
prolapses. In rare circumstances, uterine prolapse may be caused by a
tumor in the pelvic cavity.
Genetics also may play a role; women of Northern European descent
experience a higher incidence of uterine prolapse than do women of
Asian and African heritage. Finally, increased intra-abdominal pressure,
stemming from such diverse conditions as obesity, chronic lung
disease and asthma, can be contributing factors in uterine prolapse.
Risk Factors

One or more pregnancies and vaginal births
Giving birth to a large baby
Increasing age
Frequent heavy lifting
Chronic coughing
Frequent straining during bowel movements 4
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-Stages of Uterine Prolapse
Four stages of uterine prolapse are commonly defined:
Staging Definitions
Eversion: A turning outward or turning inside out
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Procidentia: A prolapse or falling down
Stage I of uterine prolapse is defined as descent of the uterus to any
point in the vagina above the hymen (or hymenal remnants).
Stage II of uterine prolapse is defined as descent to the hymen.
Stage III of uterine prolapse is defined as descent beyond the hymen.
Stage IV of uterine prolapse is defined as total eversion or procidentia.6
-Uterine prolapse always is accompanied by some degree of vaginal
vault prolapse.
Screening & Diagnosis
-Diagnosing uterine prolapse requires a pelvic examination. You may be
referred to a doctor who specializes in conditions affecting the female
reproductive tract (gynecologist). The doctor will ask about your
medical history, including how many pregnancies and vaginal deliveries
you've had. He or she will perform a complete pelvic examination to
check for signs of uterine prolapse. You may be examined while lying
down and also while standing. Sometimes imaging tests, such as
ultrasound or magnetic resonance imaging (MRI), might be performed to
further evaluate the uterine prolapse. 7
Treatment
-Losing weight, stopping smoking and getting proper treatment for
contributing medical problems, such as lung disease, may slow the
progression of uterine prolapse.
-If you have very mild uterine prolapse, either without symptoms or with
symptoms that aren't highly bothersome, no treatment is necessary.
However, without treatment, you may continue to lose uterine support,
which could require future treatment.
Non-Surgical Options
Surgical Options Hysterectomy is a way of treating problems that affect
the uterus. Many conditions can be cured with hysterectomy. Because it
is major surgery, you may want to explore other treatment options first.
For conditions that have not responded to other treatments, a
hysterectomy may be the best choice. You should be fully informed of
all options before you decide.
This pamphlet explains
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67
reasons for having a hysterectomy
how hysterectomy is performed
risks of hysterectomy
recovery after surgery
Reasons for Hysterectomy
-Hysterectomy is the surgical removal of the uterus. It is the second
most common type of major surgery performed on women of
childbearing age (the most common is cesarean delivery). Hysterectomy
may be done to treat many conditions that affect the uterus:

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Uterine fibroids
Endometriosis
Pelvic support problems (such as uterine prolapsed)
Abnormal uterine bleeding
Cancer
Chronic pelvic pain
Types of Hysterectomy
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-Hysterectomy is major
surgery, and as with any
major surgery, it carries
risks. For many of the
problems listed previously,
other treatments can be
tried first. After
hysterectomy, you no
longer are able to become
pregnant. Discuss all of the
treatment options for your
specific condition with
your health care provider.
There are several kinds of
hysterectomy:

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
Total hysterectomy—
The entire uterus, including the cervix, is removed. In a total
radical hysterectomy, the entire uterus and support structures
around the uterus are removed. It often is done to treat certain
types of cancer.
Supracervical (also called subtotal or partial) hysterectomy—The
upper part of the uterus is removed but the cervix is left in place.
Hysterectomy with removal of the fallopian tubes and ovaries—A
hysterectomy does not include removal of the ovaries and
fallopian tubes. Surgery to remove the ovaries is called an
oophorectomy. Surgery to remove the fallopian tubes is called a
salpingectomy. One or both of these procedures can be done at
the same time as a hysterectomy. Sometimes, only one ovary or
tube is removed.
How Hysterectomy Is Performed
A hysterectomy can be done in different ways. The way a hysterectomy
is performed depends on the reason for the surgery and other factors,
including your general health. You and your doctor will decide which
route is safest and best for your situation Sometimes it is not possible
to know before the surgery how the hysterectomy will be performed. In
these cases, the decision is made after the surgery begins and the
surgeon is able to see whether other problems are present.
Vaginal Hysterectomy
In a vaginal hysterectomy, the uterus is removed through the vagina.
With this type of surgery, you will not have an incision (cut) on your
abdomen. Because the incision is inside the vagina, the healing time
may be shorter than with abdominal surgery. There may be less pain
during recovery. Vaginal hysterectomy causes fewer complications than
the other types of hysterectomy and is a very safe way to remove the
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uterus. It also is associated with a shorter hospital stay and a faster
return to normal activities than abdominal hysterectomy.
A vaginal hysterectomy is not always possible. For example, women
who have adhesions from previous surgery or who have a very large
uterus may not be able to
have this type of surgery.
Laparoscopic Hysterectomy
Abdominal Hysterectomy
In an abdominal
hysterectomy, the doctor
makes an incision through
the skin and tissue in the
lower abdomen to reach the
uterus. The incision may be
vertical or horizontal.
This type of hysterectomy
gives the surgeon a good
view of the uterus and other
organs during the operation.
This procedure may be
chosen if you have large
tumors or if cancer may be
present. Abdominal
hysterectomy may require a
longer healing time than
vaginal or laparoscopic
surgery, and it usually
requires a longer hospital
stay.
Laparoscopic Hysterectomy
In a laparoscopic
hysterectomy, laparoscope is
used to guide the surgery. A
laparoscope is a thin, lighted
tube with a camera that is
inserted into the abdomen
through a small incision in or
around the navel. It allows the
surgeon to see the pelvic
organs on a screen.
Additional small incisions are made in the abdomen for other
instruments used in the surgery.
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There are three kinds of laparoscopic hysterectomy:
1. Total laparoscopic hysterectomy—A small incision is made in the
navel for the laparoscope, and one or more small incisions are
made in the abdomen for other instruments. The uterus is
detached from inside the body. It then is removed in small pieces
through the incisions, or the pieces are passed out of the body
through the vagina. If only the uterus is removed and the cervix is
left in place, it is called a supracervical laparoscopic
hysterectomy.
2. Laparoscopic ally assisted vaginal hysterectomy (LAVH)—A
vaginal hysterectomy is done with laparoscopic assistance. For
example, the ovaries and fallopian tubes may be detached using
laparoscopy, and then the uterus is detached and all of the organs
are removed through the vagina.
3. Robot-assisted laparoscopic hysterectomy—Some surgeons use
a robot attached to the laparoscopic instruments to help perform
the surgery. Experience using this technology is limited. More
information is needed to see if robotic surgery has added benefits
over the other methods.
Laparoscopic surgery has some benefits over abdominal surgery:
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The incisions are smaller, and there may be less pain.
The hospital stay after laparoscopic surgery may be shorter.
You may be able to return to your normal activities sooner.
The risk of infection is lower.
-There also are disadvantages. It often takes longer to perform
laparoscopic surgery compared with abdominal or vaginal surgery. The
longer you are under general anesthesia, the greater the risks for certain
complications. Also, there is an increased risk for bladder injury in this
type of surgery.
*What to Expect
-It is helpful to know what to expect before any major surgery. You will
need to have a physical exam a few weeks before your surgery. Also,
you may need lab tests. Depending on your health and your age, a chest
X-ray or electrocardiography (ECG) may need to be done. Your doctor
may tell you to take a laxative and to eat lightly the day before. On the
day of your surgery, the following things may happen:
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A needle is placed in your arm, wrist, or hand. It is attached to a
tube called an intravenous (IV) line that will supply your body with
fluids, medication, or blood.
You will be given an antibiotic to prevent infection.
Special stockings or devices may be placed on your lower legs to
prevent deep vein thrombosis (DVT). This condition is a risk with
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any surgery. Women at high risk of DVT may be given a drug to
prevent blood clots from forming in the legs.
Monitors will be attached to your body before anesthesia is given.
You may be given general anesthesia, which puts you to sleep,
or regional anesthesia, which blocks out feeling in the lower part
of your body.
.
Before you are given anesthesia, you likely will be asked to state
your name, the type of surgery you are having, or other
information. This standard procedure, called a “time-out,” is done
to ensure that the right surgery is being done on the right patient.
A thin tube called a catheter will be placed in your bladder. The
catheter will drain urine from your bladder during the surgery.
Risks
Hysterectomy is one of the safest surgical procedures. But as with any
surgery, problems can occur:
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Infection
Bleeding during or after surgery
Injury to the urinary tract or nearby organs
Blood clots in the veins or lungs
Problems related to anesthesia
Death
-Some problems related to the surgery may not show up until a few
days, weeks, or even years after surgery. These problems include bowel
blockage from scarring of the intestines or formation of a blood clot in
the wound. These complications are more common after an abdominal
hysterectomy.
-Some people are at greater risk of complications than others. For
example, if you have an underlying medical condition, you may be at
greater risk for problems related to anesthesia. Your health care
provider will assess your risks for complications and may take
preventive measures. You should understand all of your specific risks
before you have a hysterectomy and discuss any concerns you have
with your health care provider.
Your Recovery
-If you have a hysterectomy, you may need to stay in the hospital for a
few days. The length of your hospital stay will depend on the type of
hysterectomy you had and how it was performed.
-You will be urged to walk around as soon as possible after your
surgery. Walking will help prevent blood clots in your legs. You also
may receive medicine or other care to help prevent blood clots.
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-You can expect to have some pain for the first few days after the
surgery. You will be given medication to relieve pain. You will have
bleeding and discharge from your vagina for several weeks. Sanitary
pads can be used after the surgery.
-During the recovery period, it is important to follow your health care
provider’s instructions. Be sure to get lots of rest, and do not lift heavy
objects until your doctor says you can. Do not put anything in your
vagina during the first 6 weeks. That includes douching, having sex, and
using tampons.
-Work with your health care provider to plan your return to normal
activities. As you recover, you may slowly increase activities such as
driving, sports, and light physical work. If you can do an activity without
pain and fatigue, it should be okay. If an activity causes pain, discuss it
with your doctor.
-Even after your recovery, you should continue to see your health care
provider for routine gynecologic exams and general health care.
Depending on the reason for your hysterectomy, you may still
need pelvic exams and Pap tests.
Effects of Hysterectomy
-Hysterectomy can have both physical and emotional effects. Some last
a short time. Others may last a long time. You should be aware of these
effects before having the surgery.
-The ovaries are the glands that produce estrogen, a hormone that
affects the body in many ways. Depending on your age, if your ovaries
are removed during hysterectomy, you will have signs and symptoms
caused by a lack of estrogen
Physical Effect
-After hysterectomy, your periods will stop. If the ovaries are left in
place and you have not yet gone through menopause, they will still
produce estrogen and will continue to do so until they stop functioning
naturally.
Emotional Effects
-It is not uncommon to have an emotional response to hysterectomy.
How you will feel after the surgery depends on a number of factors and
differs for each woman.
-Some women feel depressed because they can no longer have children.
If depression lasts longer than a few weeks, see your health care
provider. Other women may feel relieved because the symptoms they
were having have now stopped.
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Sexual Effects
-Some women notice a change in
their sexual response after a
hysterectomy. Because the
uterus has been removed, uterine
contractions that may have been
felt during orgasm will no longer
occur.
Removal of the Ovaries During
Hysterectomy
If the ovaries are removed before
menopause, you will experience
effects caused by lack of estrogen.
These effects are similar to those of
menopause and include hot flashes,
vaginal dryness, and sleep problems.
However, symptoms may be more
-Some women feel more sexual
intense than what you would
pleasure after hysterectomy. This experience if you went through
may be because they no longer
menopause over a few years, as is
have to worry about getting
normal. You also may be at risk of a
pregnant. It also may be because fracture caused by osteoporosis at
they no longer have the
an earlier age than women who go
discomfort or heavy bleeding
through natural menopause.
caused by the problem leading to
hysterectomy.
Most women who have these intense
symptoms can be treated with
-Some women wish to have a
estrogen therapy. Estrogen therapy
supracervical hysterectomy
is given in several different ways,
because they think it will have
including as a pill, injection, skin
less of an impact on their sexual patch, vaginal cream, or vaginal ring.
response compared with a total
The form chosen depends on your
hysterectomy. Whereas sexual
specific symptoms. It is important to
response is different for every
talk to your health care provider
woman, research comparing
about all of the options and which
women who have had total
ones are right for you.
hysterectomies with those who
have had supracervical hysterectomies has shown that there is no
difference in sexual response and orgasms in women who have had the
two types of surgery.
Finally...
-Hysterectomy is just one way to treat uterine problems. It is major
surgery and carries some risks. For some conditions, other treatment
options are available. For others, hysterectomy is the best choice. Your
health care provider can help you weigh the options and make a
decision.
What is a Pap smear?
A Pap smear (also known as the Pap test) is a medical procedure in
which a sample of cells from a woman's cervix (the end of
the uterus that extends into the vagina) is collected and spread
(smeared) on a microscope slide. The cells are examined under a
microscope in order to look for pre-malignant (before-cancer)
or malignant (cancer) changes.
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Who should have a Pap smear?
Pregnancy does not prevent a woman from having a Pap smear. Pap
smears can be safely done during pregnancy.
Pap smear testing is not indicated for women who have had
a hysterectomy (with removal of the cervix) for benign conditions.
Women who have had a hysterectomy in which the cervix is not
removed, called subtotal hysterectomy, should continue screening
following the same guidelines as women who have not had a
hysterectomy.
What is the sample checked for?
The cells on the slide are checked for signs that they're changing from
normal to abnormal. Cells go through a series of changes before they
turn into cancer. A Pap smear can show if your cells are going through
these changes long before you actually have cancer. If caught and
treated early, cervical cancer is not life-threatening. This is why getting
regular Pap smears is so important.
How is a Pap smear done?
A woman should have a Pap smear when she is not menstruating. The
best time for screening is between 10 and 20 days after the first day of
her menstrual period. For about two days before testing, a woman
should avoid douching or using spermicidal foams, creams, or jellies or
vaginal medicines (except as directed by a physician). These agents
may wash away or hide any abnormal cervical cells.
A Pap smear can be done in a doctor's office, a clinic, or a hospital by
either a physician or other specially trained health care professional,
such as a physician assistant, anurse practitioner, or a nurse midwife.

With the woman positioned on her back, the clinician will often
first examine the outside of the patient's genital and rectal areas,
including the urethra (the opening where urine leaves the body), to
assure that they look normal.
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A speculum is then inserted into the vaginal area (the birth canal).
(A speculum is an instrument that allows the vagina and the cervix to
be viewed and examined.)

A cotton swab is sometimes used to clear away mucus that might
interfere with an optimal sample.

A small brush called a cervical brush is then inserted into the
opening of the cervix (the cervical os) and twirled around to collect a
sample of cells. Because this sample comes from inside the cervix, is
called the endocervical sample ("endo" meaning inside).
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
A second sample is also collected as part of the Pap smear and is
called the ectocervical sample ("ecto" meaning outside).

These cells are collected from a scraping of the area surrounding,
but not entering, the cervical os.

Both the endocervical and the ectocervical samples are gently
smeared on a glass slide and a fixative (a preservative) is used to
prepare the cells on the slide for laboratory evaluation.
What do the results mean?
A normal Pap smear means that all the cells in your cervix are normal
and healthy.
An abnormal Pap smear can be a sign of a number of changes in the
cells on your cervix:
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Inflammation (irritation). This can be caused by an infection of the
cervix, including a yeast infection, infection with the human
papillomavirus (HPV) the herpes virus or many other infections.
Abnormal cells. These changes are called cervical dysplasia. The
cells are not cancer cells, but may be precancerous (which means
they could eventually turn into cancer).
More serious signs of cancer. These changes affect the top layers
of the cervix but don't go beyond the cervix.
More advanced cancer.
What abnormal results mean
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The Pap smear is a screening test. Abnormal values are based on the
test results. The current system divides the results into three main
areas:
ASCUS or AGUS (atypical cells of uncertain significance)
LSIL (low-grade dysplasia) or HSIL (high-grade dysplasia)
Possibly cancerous (malignant)
When a Pap smear shows abnormalities, further testing or follow-up is
needed. The next step depends on the results of the Pap smear, your
previous history of Pap smears, and risk factors you may have
for cervical cancer.
If the Pap smear shows minor cell changes or abnormalities,
a colposcopy-directed biopsy probably will NOT be done right away
unless there is a reason to believe you may be in a high-risk category.
With an ASCUS result, an HPV test is done to check for the
presence of the HPV virus types most likely to cause cancer. If the HPV
test is negative, then colposcopy will not be needed.
For minor cell changes, doctors usually recommend having a
repeat Pap smear in 6 months. With a negative HPV test result, it's
acceptable to have the repeat Pap done in 1 year.
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Which women are at increased risk for having an abnormal Pap smear?
A number of risk factors have been identified for the development of
cervical cancer and precancerous changes in the cervix.

HPV: The principal risk factor is infection with the genital wart
virus, also called the human papillomavirus (HPV), although most
women with HPV infection do not get cervical cancer. About 95%100% of cervical cancers are related to HPV infection. Some women
are more likely to have abnormal Pap smears than other women.

Smoking: One common risk factor forpremalignant and malignant
changes in the cervix is smoking. Although smoking is associated
with many different cancers, many women do not realize that smoking
is strongly linked to cervical cancer. Smoking increased the risk of
cervical cancer about two to four fold.

Weakened immune system: Women whose immune systems are
weakened or have become weakened by medications (for example,
those taken after an organ transplant) also have a higher risk of
precancerous changes in the cervix.
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Medications: Women whose mothers took the
drug diethylstilbestrol (DES) during pregnancy also are at increased
risk.
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Other risk factors: Other risk factors for precancerous changes in
the cervix and an abnormal Pap testing include having multiple sexual
partners and becoming sexually active at a young age.
What the risks are
There are no risks involved.
Special considerations
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The following drugs may affect Pap smears:
Colchicine
Compounds in cigarettes
Estrogen
Podophyllin
Progestins
Silver nitrate
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