Download Menstrual Cycles:

The Islamic university of Gaza
Faculty of nursing
Midwifery department
Gynecology
Lecturer: wafa Abeid
Aug.2016
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Contents
Menstrual Cycles: .......................................................................................................... 3
Premenstrual Syndrome or PMS .................................................................................... 7
Dysmenorrhea (Painful Periods) .................................................................................. 12
Toxic shock syndrome (TSS)....................................................................................... 14
Endometriosis .............................................................................................................. 18
Sexually Transmitted Diseases Overview (STDs) ........................................................ 28
Trichomoniasis ............................................................................................................. 30
urinary incontinence..................................................................................................... 32
Pelvic inflammatory disease: ....................................................................................... 38
Epidemiology.......................................................................................................... 38
Diagnosis ................................................................................................................ 39
Differential diagnosis; ....................................................................................... 39
Complications; ....................................................................................................... 40
Treatment: .............................................................................................................. 40
Prevention; ............................................................................................................. 41
-An ovarian cyst: .......................................................................................................... 43
Polycystic Ovary Syndrome (PCOS) ........................................................................... 49
Dysfunctional uterine bleeding: ............................................................................... 55
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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.
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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 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
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
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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 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.
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Natural options to alleviate cramping:

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.
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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.
-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
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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.
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:

acne

bloating

fatigue

backaches

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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.
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.
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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.
-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.
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-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:

stress

significant weight loss or gain

anorexia (amenorrhea can be a sign that a girl is losing too much
weight and may have anorexia)

stopping birth control pills

thyroid conditions

ovarian cysts

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 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.
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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:

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:
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,
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backaches, diarrhea, and severe cramps. Fortunately, these symptoms usually
last for only a day or two.
2.
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).
Treating Menstrual Problems;
-To determine whether a problem requires treatment, 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.
for menstrual pain with no underlying medical cause, anti-inflammatory
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?
If the period hasn't started at the expected time for example if 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. The midwife need to take good history for
the following conditions
If the woman stops getting the period or it becomes irregular after it has
been regular. If the cycle is less than 21 days or more than 45 days, or if a
period for 3 months stopped at any time after first beginning to menstruate.
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If the woman has heavy or long periods, significant blood loss can cause
iron-deficiency anemia. Also, heavy bleeding could be a sign of a growth in
the uterus, a thyroid condition, an infection, or a blood clotting problem.
is very painful periods. Having cramps for a couple of days is normal, but if
the woman 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.
Things help during the PMS
-When the woman experiencing a particularly bad PMS or cramps, you can
help make her to feel more comfortable by suggest that she:

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

soak in a warm bath or put a hot water bottle on her abdomen, which
may help her relax
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.
Possible signs and symptoms of toxic shock syndrome include:
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
A sudden high fever

Low blood pressure (hypotension)

Vomiting or diarrhea

A rash resembling a sunburn, particularly on your palms and soles

Confusion

Muscle aches

Redness of your eyes, mouth and throat

Seizures

Headaches
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 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
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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.
The risk of TSS can be reduced 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
Risk factors
Toxic shock syndrome can affect anyone. About half the cases of toxic shock
syndrome occur in menstruating women; the rest occur in older women, men
and children.
Toxic shock syndrome has been associated with:

Having cuts or burns on your skin

Having had recent surgery

Using contraceptive sponges, diaphragms or superabsorbent tampons

Having a viral infection, such as the flu or chickenpox
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Diagnosis and Treatment:
-There's no one test for toxic shock syndrome. You may need to provide blood
and urine samples to test for the presence of a staph or strep infection. Your
vagina, cervix and throat may be swabbed for samples for laboratory analysis.
Because toxic shock syndrome can affect multiple organs, your doctor may
order other tests, such as a CT scan, lumbar puncture or chest X-ray, to
assess the extent of your illness
Treatment:
Antibiotics while doctors seek the infection source
Receive medication to stabilize your blood pressure if it's low (hypotension)
and fluids to treat dehydration
Receive supportive care to treat other signs and symptoms
The toxins produced by the staph or strep bacteria and accompanying
hypotension may result in kidney failure. If your kidneys fail, you may need
dialysis.
Surgery may be necessary to remove nonliving tissue (debridement) from the
site of infection or to drain the infection
Prevention
Manufacturers of tampons sold should no longer use the materials or designs
that were associated with toxic shock syndrome.
If you use tampons, read the labels and use the lowest absorbency tampon
you can. Change tampons frequently, at least every four to six hours.
Toxic shock syndrome can recur. People who've had it once can get it again.
If you've had toxic shock syndrome or a prior serious staph or strep infection,
don't use tampons.
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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 endometriallike 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
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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 endometriosis-related pain may include:
What are the symptoms?
Dysmenorrhea - recurrent painful periods
Dyspareunia - painful intercourse
Chronic lower abdominal and back pain
Non-cyclic or cyclic pelvic pain
Adnexal masses
Subfertility
Other symptoms may be present, including:

Constipation

chronic fatigue

heavy or long uncontrollable menstrual periods with small or large
blood clots

gastrointestinal problems including diarrhea, bloating and painful
defecation

extreme pain in legs and thighs

back pain

mild to extreme pain during intercourse

mild to severe fever

headaches

depression

hypoglycemia (low blood sugar)

anxiety
In addition, women who are diagnosed with endometriosis may have
gastrointestinal symptoms that mimic irritable bowel syndrome
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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 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
Complications
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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.
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
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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
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
22
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.
Treatment of endometriosis


What are the medical treatment options?
Oral contraceptives
Progestins
Androgenic agents
¨ All suppress ovarian activity and menses and cause atrophy of the
endometriotic implants.
Base decision of treatment on side effect profile.
Endometriomas are not amenable to medical treatment.
¨ Randomized controlled trials that compare excision or drainage
and ablation of endometriomas >3 cm reported recurrence rates
reduced and improved spontaneous pregnancy rates.
What does surgical management entail?
Laparoscopy or open procedures.
Requires excision or ablation (by laser or cautery) of the implants.
Surgical excision of endometriosis results in improved pain relief
and improved quality of life after 6 months compared with
diagnostic laparoscopy alone.
23
How often does endometriosis recur after surgery?
n Rate of recurrence is ~20% after 5 years.
What are the unanswered questions?
Is medical or surgical management more effective?
Does long term medical management reduce the recurrence of
endometriosis?
What is the benefit of surgery for rectovaginal disease?
Surgery
Procedures are classified as

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 treatment-resistant. 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
24
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)
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
25
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 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-3-carbinol, 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
26
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 endometriosisassociated 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
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.
27
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.
women (for example, Chlamydia, genital herpes or gonorrhea). This can also
occur in some men.
28
-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.
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)
29

HIV/AIDS (human immunodeficiency virus [HIV virus])

Molluscum contagiosum* (poxvirus)
STD caused by protozoan

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
30
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 cottontipped applicator to collect the sample.
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
31
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 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."
32
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.
34
"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."
-There's also a traditional Chinese therapy involving vaginal weights, which
Galloway says are very effective.
Related to Incontinence & Overactive Bladder

America Asks About OAB

Bladder Control

Diabetes

Menopause

Multiple Sclerosis

Parkinson’s Disease

Side Effects of Diuretics
Common Treatments for Incontinence & Overactive Bladder

Biofeedback

Bladder Surgery

Detrol

Ditropan

Enablex

Flomax

Kegel Exercises

More Drugs

Pessary
35
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."
-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
36
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."
37
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 coinfection 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 infertility increases with each infection.
38
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,
65-90% 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
39
hours.
-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
operation, postpartum, miscarriage or abortion).
Prevention
(post
is
also
pelvic
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 pregnancy-related 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
40
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 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 Tubo-ovarian abscesses;
is very ill, immunodeficient, pregnant, or incompetent; or because a lifethreatening 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, gentamicin,
ampicillin and sulbactam plus doxycycline,
andceftriaxone or cefoxitin plus doxycycline.
Prevention;

Risk reduction against sexually transmitted infections through barrier
methods such as condoms or abstinence; see human sexual behavior for
other listings.

41
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.

Discussing sexual history with a trusted physician in order to get
properly screened for sexually transmitted diseases.

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
42
-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.
- 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.
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.
43
Polycystic-appearing ovary is different from the polycystic ovarian syndrome,
which includes other symptoms in addition to the presence of ovarian cysts.
Signs and symptoms:
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

ncreased 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
44
-About 95% of ovarian cysts are benign, meaning they are not cancerous.
-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 postmenopausal 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.
- 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.
45
-Ovarian cysts are fluid-filled sacs, similar to blisters, that are common among
women during their reproductive years. They form on the ovaries, the almondsized 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

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.

Cystadenoma/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
46
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.
47
-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 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.
48
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.
*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.
49
*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 the normal
menstrual cycle and may lead to infertility, excess body hair and acne.
these factors likely play a role:
50

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.

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.
51

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 trans-vaginal
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.
52
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.
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.
53
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:

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
54
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:

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
55
normal hypothalamic-pituitary-ovarian axis and is particularly common at the
extremes of the reproductive years. When ovulation 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.
56

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

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
57
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)
58
-Physical

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
hyperandrogenism,
59
ovary
including
disease present
hirsutism,
obesity,
with
acne,
signs
of
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;

Systemic,disease,
including thrombocytopenia, hypothyroidism, hyperthyroidism, Cushing
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.
60

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
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
61
Endometriosis
von Will brand Disease
Estrogen Therapy
Vulvovaginitis
Laboratory Studies

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

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.
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 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
62
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

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

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
63
Evaluate ABCs and address the priorities.
Initiate 2 large-bore intravenous lines (IVs), oxygen, and cardiac
o
monitor.
If bleeding is profuse and the patient is unresponsive to initial
o
fluid management, consider administration of IV conjugated
estrogen (Premarin) 25 mg IV every 4-6 hours until the bleeding
stops.
In women with severe, persistent uterine bleeding, an immediate
o
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.
64
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 shortterm 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

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
electrocautery,
or
may
roller
be
ball.
performed
Amenorrhea
using
is
laser,
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).
65
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, OrthoNovum 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 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.

Dosing

Interactions

Contraindications

Precautions
66
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-tomoderate 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.

Dosing

Interactions

Contraindications

Precautions
Adult
100-200 mg/d PO in divided doses
Pediatric
Not established
67
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.

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.

Dosing

Interactions

Contraindications

Precautions
68
Adult
10
mg
PO
qd
for
Depo-medroxyprogesterone
first
10-12
d
(Depo-Provera)
as
of
150
menstrual
mg
IM
cycle
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
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.

Dosing

Interactions

Contraindications

Precautions
Adult
For moderate bleeding: 500 mg PO bid (with foods)
Pediatric
<12
years:
Not
>12 years: 2.5 mg/kg/dose PO; not to exceed 10 mg/kg/d
Gonadotropin Releasing Hormone Analog
69
established
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 from a bleeding problem, particularly in patients with
renal failure or blood dyscrasia.

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
70

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

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

Anemia (may become severe)

Adenocarcinoma of the uterus (if prolonged, unopposed estrogen
stimulation)
Prognosis

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

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.
71

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.
72
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), and a
posterior compartment (posterior vaginal wall). Uterine prolapse involves the
cervix.
Signs & Symptoms
-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
73

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
-Stages of Uterine Prolapse
Four stages of uterine prolapse are commonly defined:
Staging Definitions
Eversion: A turning outward or turning inside out
74
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
75
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
76

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:

Uterine fibroids

Endometriosis

Pelvic support problems (such as uterine prolapsed)

Abnormal uterine bleeding

Cancer

Chronic pelvic pain
Types of Hysterectomy
77
-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:

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
78
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 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
79
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.
There are three kinds of laparoscopic hysterectomy:
80
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:

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
81
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:

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 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:
82

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.
-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.
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-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.
Removal
of
Hysterectomy
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the
Ovaries
During
Sexual Effects
If the ovaries are removed before
-Some women notice a change in menopause, you will experience effects
their sexual response after a caused by lack of estrogen. These
hysterectomy. Because the uterus effects are similar to those of
has
been
removed,
uterine menopause and include hot flashes,
contractions that may have been felt vaginal dryness, and sleep problems.
during orgasm will no longer occur. However, symptoms may be more
-Some women feel more sexual
pleasure after hysterectomy. This
may be because they no longer
have
to
worry
about
getting
pregnant. It also may be because
they no longer have the discomfort
or heavy bleeding caused by the
problem leading to hysterectomy.
-Some women wish to have a
supracervical
hysterectomy
because they think it will have less
of
an
impact
on
their
sexual
response compared with a total
hysterectomy.
Whereas
sexual
response is different for every
woman,
women
research
who
have
comparing
had
total
intense than what you would experience
if you went through menopause over a
few years, as is normal. You also may
be
at
risk
of
a
fracture
caused
by osteoporosis at an earlier age than
women
who
go
through
natural
menopause.
Most women who have these intense
symptoms can be treated with estrogen
therapy. Estrogen therapy is given in
several different ways, including as a
pill, injection, skin patch, vaginal cream,
or vaginal ring. The form chosen
depends on your specific symptoms. It
is important to talk to your health care
provider about all of the options and
which 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
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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.
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.
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
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.

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).

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:

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.
87

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
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.
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
88
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.

Medications: Women
whose
mothers
took
the
drug diethylstilbestrol (DES) during pregnancy also are at increased risk.

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
The following drugs may affect Pap smears:

Colchicine

Compounds in cigarettes

Estrogen

Podophyllin

Progestins

Silver nitrate
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