For most women, normal periods occur every 21-35 days, last no longer than 7 days, and are not so heavy that they require changing a super-plus tampon or maxi-pad more than every couple of hours. If your period falls outside of these guidelines, or if you have bleeding between periods (any amount) or bleeding after intercourse (any amount), it may be the sign of a problem. In addition, once you are post-menopausal (have had no period for a year), you should never have any bleeding at all.
If you have any abnormal bleeding, please alert your practitioner. Depending on your age and any medications you are taking, testing to determine the cause is often the best course of action. Once the cause is determined, all appropriate treatment options can be considered.
For heavy periods, options other than hysterectomy include contraceptive methods containing estrogen and progesterone, medication called Lysteda, a progesterone IUD or endometrial ablation.
The breasts are composed of fat, fibrous tissue, and glands that can produce milk. Breast tissue responds to hormonal changes during the menstrual cycle and pregnancy. Common breast problems include pain, nipple discharge and lumps. Cancer is not usually the cause of symptoms but, because early detection and treatment of breast cancer is thought to be critical, all breast concerns should be taken seriously. Scaly skin changes in the area of the nipple, and/or new nipple inversion are particularly concerning and should be brought to your practitioner’s attention as soon as possible.
It is important for you to know that if there is a new breast lump and it is not found to be a cyst on ultrasound, additional testing should be done even if a mammogram is done and is read as normal. Your doctor may suggest that you see a surgeon to determine whether or not a biopsy should be done.
A full range of reversible and permanent birth control methods is available through our office, including intrauterine devices (containing either progesterone or copper), diaphragms, injections (Depo-provera), implants (Nexplanon), pills, rings (NuvaRing), patches (Orthoevra), and permanent sterilization – by laparoscopy in the operating room.
A fibroid is a non-cancerous mass of the uterus that arises from a single uterine muscle cell that keeps multiplying. Fibroids can grow, especially when estrogen levels are high as with pregnancy. They generally get smaller after menopause when estrogen levels are much lower. Most women who develop fibroids never have any problems from them and may never know they have them. Others will have fibroids that are so large or numerous that they cause symptoms. Depending on the size and location of the fibroid(s), symptoms may include pain or pressure, urinary, intestinal and/or fertility problems and menstrual issues. Hysterectomy is one treatment option. However, there are also non-surgical management choices such as uterine artery embolization for women with symptoms. Ask your practitioner if you would like additional information.
Hereditary Cancer Syndrome Risks
Having a family history of certain cancers may significantly increase your risk of getting those cancers. There are now multiple known mutations for which blood work testing is available but very costly. Testing is only covered by some insurance companies and only for certain high risk patients. However, there are companies making testing available for an out of pocket cost as low as $145 for anyone interested – like nearly everything else, they can even be ordered on Amazon. High risk patients are encouraged to start with genetic counseling. There is a well-established program at Main Line Health, Cancer Risk Assessment and Genetics Program. Anyone thinking about being tested should carefully weigh the pros and cons of learning about their carrier status. For a list of what are considered high risk categories and other important considerations before getting tested, please see Testing for Hereditary Cancer Syndromes.
Menopause is defined as having no periods for one year. The average age of menopause in the U.S. is 51, and it usually occurs between the ages of 45 and 55. Some women are fortunate enough to have only very mild symptoms related to the decreased production of estrogen by the ovaries. However, most women will have at least one or two symptoms that can interfere with daily life in a major way. The most common problems include hot flashes, sleep disorders, vaginal dryness and emotional swings. Memory lapses and difficulty concentrating may occur. Symptoms may persist indefinitely or gradually decrease in frequency and severity over time. There are treatments ranging from lifestyle changes to medications that will help, though all have pros and cons. Medication options include herbal remedies, non-hormonal therapies and hormone replacement (HRT), including bio-identicals. HRT is the most effective treatment and comes in several different delivery systems including tablets, patches and other topical forms. We can help you take your personal and family history into account to determine if the benefits of a particular treatment outweigh the risks for you.
Bones are constantly undergoing the process of breaking down and rebuilding. Until about age 30, the build up of bone occurs more rapidly than the break down. After that the opposite occurs, and with enough bone loss, osteoporosis results. This significantly raises the likelihood of having a fracture. In fact, 50% of women over 50 years old will at some point in their lives have a fracture related to osteoporosis. Besides pain, there is a high risk of complications after fracture. Strength and balance exercises are protective. Adequate dietary calcium and vitamin D are recommended. Certain medications including estrogen can decrease bone loss. A baseline bone density scan to check for osteoporosis is recommended at age 65, or earlier given risk factors in addition to age such as low body mass, use of corticosteroids or treatment for underactive thyroid.
Ovarian cysts are very common in women during their childbearing years. Most cysts cause no symptoms, are harmless and go away without treatment. For women not on hormonal birth control, normal functional cysts (egg follicles) come and go regularly with the menstrual cycle. Cysts can cause pain by stretching the capsule around the ovary as they get bigger, by leaking fluid, or by twisting on themselves (torsion). When ovarian cysts do not resolve over the course of a couple of months, or if they cause severe pain, surgery (usually laparoscopy) may be needed to remove the cyst or, less likely, the entire ovary. Certain ovarian cysts have characteristics on ultrasound that raise the question of ovarian cancer. When that is the case, a gyn cancer specialist is consulted to help provide the best possible care.
The possible causes of pelvic pain are numerous, and include non-gyn causes from the urinary, intestinal and musculoskeletal systems. Common gynecological causes of pelvic pain include the following.
In women having periods, the lining of the uterus builds up and sheds monthly. Most of the menstrual blood takes the path of least resistance as vaginal bleeding. Some, however, may go out through the fallopian tubes into the pelvis and abdomen. If microscopic bits of uterine lining tissue implant outside of the uterus (endometriosis), they may continue to respond to the normal cyclical hormonal changes. This can cause pain, especially with menses or intercourse. It can also cause formation of scar tissue (adhesions), and/or fertility problems. Endometriosis is not usually detectable on pelvic or ultrasound examination unless a cyst called an endometrioma forms on the ovary. The presence of endometriosis may be confirmed with laparoscopy but is not always visible. It does have a genetic component, so a family history may be important. It is more common in women who have not had children but can even occur in adolescents. About 75% of women with chronic pelvic pain and 30% of women with infertility are found to have endometriosis. There are medical and surgical therapies that can control the symptoms until menopause when they usually stop.
When the uterine lining tissue grows in the muscle layer of the uterus, it is called adenomyosis. This can cause the uterus to become soft and enlarged and is often responsible for heavy, crampy periods. For years, pelvic MRI was the only reliable test available for identifying adenomyosis but because of the expense was rarely used for that purpose. Generally the diagnosis can be made on the basis of symptoms and pelvic examination. As the quality of imaging technology continues to improve, more patients with adenomyosis are being found using ultrasound.
In some patients, the healing process after a pelvic infection or surgery causes the formation of scar tissue (adhesions) which can also be a result of endometriosis. Adhesions cause organs that aren’t normally attached to one another to stick together. Various activities or movements that put tension on the connections can cause pain which may be experienced as a ripping or tearing sensation. Adhesions can only be diagnosed by directly looking at the internal organs (usually with laparoscopy). Sometimes the tissues can be safely separated and wrapped in a dissolvable barrier to decrease the chance that the organs will stick together again.
Other Causes of Pelvic Pain
Other gyn causes of pain include ovulation, infection, ovarian cysts and fibroids. If you have pain, the more specific you can be with regards to its location, intensity, timing, duration, what makes it better and worse and any associated symptoms like fevers, the easier it will be for your doctor to identify the cause and provide appropriate treatment.
Pelvic Support Problems
One of several ill effects of gravity on the female body is a weakening of the pelvic floor muscles that support the abdominal contents when one is not lying down. Some women have a genetic predisposition to this problem, and it is often worsened by childbirth. Over time a type of hernia may occur, allowing the bladder, rectum, and or small intestines to bulge into the vagina. This is called prolapse. Sometimes the uterus itself drops lower into the vagina, or even protrudes outside. After hysterectomy, the vagina (or cervix if still present) may protrude. Prolapse can cause discomfort that may be aggravated by lifting and other activities that increase the pressure inside the abdomen. Though some women opt for pelvic floor exercises ( kegel exercises or physical therapy), treatment options include pessaries and surgery.
PMS (Pre-menstrual Syndrome)
At least 85% of women who have periods will routinely get one or more symptoms of PMS during the prior 1-2 weeks. Physical symptoms can include cramping, low back pain, breast soreness, headache, fluid retention, intestinal bloating, increased appetite and food cravings. Some people find it more difficult to concentrate, or to get good quality sleep. There can be emotional ups and downs including irritability, anxiety and depression. When symptoms are so severe that they significantly disrupt personal and/or work relationships, PMS is called Premenstrual Dysphoric Disorder (PMDD). Fortunately, effective medical treatments are now available.
Symptoms that occur throughout the whole menstrual cycle rather than just pre-menstrually are not PMS. It can be helpful to keep a menstrual diary or calendar to note exactly which symptoms you are having and when they are occurring in relation to your periods.
Polycystic Ovarian Syndrome (PCOS)
It is estimated that 10% of women have polycystic ovarian syndrome, a genetic disorder that has significant implications for long-term health. Signs of PCOS include acne, scalp hair loss, excess body hair elsewhere, irregular or missed periods, obesity, and fertility issues. There is no blood test specifically for PCOS but certain lab results may be more or less consistent with the diagnosis. Sometimes PCOS can be diagnosed with pelvic ultrasound. The ovaries may become enlarged and filled with many tiny cysts that line up to look like a string of pearls. Often, though, the ovaries look normal. With PCOS the ovaries produce more estrogen and testosterone and less progesterone than normal, resulting in the typical symptoms.
Patients with PCOS are at increased risk of diabetes, high blood pressure, heart disease, and uterine cancer. Exercise, diet and weight control are important parts of the management of PCOS, and can significantly decrease those risks. Medications can also be helpful, either to decrease the signs of PCOS or to enable pregnancy to occur.
A decrease in the desire to have sex is the most common sexual complaint for women and occurs in women of all ages. It may be related to physical, emotional and/or relationship issues. On the other hand, many women find that the stresses of daily living just make sex a lower priority for them than it is for their partner. If that becomes problematic for the relationship, it often helps to have an open honest discussion to relieve worries and clear up conflicts. Sexual counselors are available when the help of a third party to facilitate communication is needed. The likelihood of having decreased libido does increase with age. It is very common after menopause because the ovaries stop making testosterone, the hormone believed to be most responsible for maintaining libido. Although testosterone is also made by the adrenal glands, menopause results in a 50% decrease in production. Testosterone supplements are available but can cause unwanted side effects and are not always helpful. Please note, insurance companies generally will not cover testosterone lab testing because the results do not help guide treatment.
Pain with Intercourse (Dyspareunia)
Up to 75% of women will have pain with intercourse at some time in their lives. Causes range from temporary problems like vaginal infections and ovarian cysts to long term problems including endometriosis and pelvic support issues. Pain may be cyclical, random or with every sexual encounter, or may depend on the position used to have sex. It may be superficial (involving the area surrounding the opening of the vagina) or deep inside. Pain may be generalized or localized to one specific area. One of the most common causes of superficial pain is decreased lubrication, which can be improved with the use of over the counter vaginal moisturizers and lubricants or sometimes with vaginal estrogen. There are some chronic skin conditions such as lichen sclerosis that can be associated with vulvar itching and/or pain. Vulvodynia is a chronic or recurrent hypersensitivity to touch that causes sometimes very severe pain. Pain can also be caused by involuntary contractions of the pelvic floor muscles (vaginismus) that can be so strong that vaginal penetration is impossible.
Less common sexual concerns include difficulties becoming aroused and the inability to achieve orgasm. Whatever the specifics, sexual difficulties can have a long lasting negative impact on the quality of your life and your intimate relationships. Please let us know if you have any of these concerns.
STIs (Sexually Transmittable Infections)
Unfortunately, it only takes one exposure with one partner to get a sexually transmittable infection. Often there are no symptoms to alert women to the need for treatment, and without treatment some of these infections can lead to significant problems.
Gonorrhea and chlamydia, by causing scarring in the fallopian tubes, can interfere with the ability to get pregnant and can increase the risk of ectopic/tubal pregnancy. Sometimes the infection spreads out of the genital tract into the pelvis and abdomen where abscesses may form. In those cases, women may require major surgery including hysterectomy and/or removal of one or both tubes and ovaries. Testing for these infections can be done by culturing the cervix or the urine, or can be done along with a pap smear. Early infections are easily treatable with antibiotics.
High risk HPV (Human Papilloma Virus) strains cause pre-cancer and cancer of the cervix and less commonly of the vulva, vagina and anus. They have also been found to be responsible for an increasing number of oral cancers in both men and women. Low-risk HPV causes genital warts but not cancer. Although there is currently no cure for HPV and usually no symptoms from it, pre-cancer of the cervix is diagnosable with pap smears and can be successfully treated – most often with a LEEP procedure. There are vaccines available to help prevent infection with some of the high and low risk strains. Three doses of the vaccine are recommended for males and females from ages 15 through 45. From age 9-14, two doses may suffice. The vaccine will not help treat HPV strains to which someone has already been exposed so it is most helpful to complete the vaccine series before having sex for the first time. There is no risk of getting HPV from the vaccine itself. Prior to the availability of the vaccine, the average person’s lifetime risk of viral exposure was estimated to be as high as 90%. About half of the women diagnosed with invasive cervical cancer are under 35 years old. Please let your practitioner know if vaccination for you or someone else in your family is desired.
Herpes Simplex viral (HSV) infections can cause painful ulcerations in the mucus membranes. They can be oral (fever blisters) or genital, and can be transmitted with oral or genital sex. Outbreaks have a classic appearance usually readily identified on the basis of visual inspection alone. The best tests to confirm Herpes infection are blood tests rather than cultures of the skin lesions. Herpes is very common because many people who have been infected never have any visible outbreaks and don’t know they are infected. Herpes cannot be cured but medication is available to decrease the frequency of symptomatic outbreaks, and to decrease the likelihood of infecting a sexual partner.
Syphilis, Hepatitis B and C, and HIV are also sexually transmittable infections. Testing for them requires blood work which we are happy to order at your request. There are other sexually transmittable infections but they are uncommon in the United States.
There are several types of urinary incontinence (leakage) and they may occur in combination. The most common are stress urinary incontinence (SUI) and urge incontinence. SUI is a problem affecting millions of women in the United States. Normally the urethra is supported by strong pelvic floor muscles and healthy connective tissue. Together, they help prevent the involuntary loss of urine. In women with stress urinary incontinence, weakened muscles and connective tissue do not adequately support the urethra. This leads to leakage of urine with activities such as coughing, laughing, sneezing, exercise or other activities that increase the pressure inside the abdomen. Urge incontinence is leakage caused by overactivity of the bladder muscle and is associated with a sudden strong urge to empty. Urinary infections and the use of some medications can cause temporary leakage issues. Bladder irritants like nicotine, caffeine and carbonated beverages can make symptoms worse. Overactivity of the bladder muscles can also cause an urge to urinate even when the bladder is not full, requiring frequent trips to the bathroom even when leakage is not a problem.
Treatment options depend on the specific problem but include lifestyle changes, physical therapy, medications, vaginal devices called incontinence rings, and surgery (TVT). Weight loss is one of the most effective non-surgical remedies for urinary leakage of all kinds. Talk to your doctor or nurse practitioner if you have questions.
The vagina is a mini-ecosystem where certain bacteria are normally found, and from which normal secretions can be shed as normal vaginal discharge. Exposure to irritating substances can cause uncomfortable external symptoms. When there is a change from normal discharge, or the discharge is associated with external itching, burning, irritation, and/or an odor, a vaginal infection may be the cause. Women with symptoms may assume they have yeast (fungal) infections, but studies show that many of them actually have infections caused by bacteria or other organisms. These infections need treatment with antibiotics rather than over the counter or prescription anti-fungal agents. Lab testing can be done, but microscopic examination of the vaginal secretions in the office is often all that is needed for you to get started on the correct treatment as soon as possible.