Symptoms of Gynecologic Disorders

The most common symptoms of gynecologic disorders include vaginal itching, a vaginal discharge, abnormal bleeding from the vagina, pain in the pelvic area, and breast pain and lumps. The significance of gynecologic symptoms often depends on the age of the woman because symptoms may be related to the hormonal changes that occur with aging.

Vaginal Discharge
A small amount of vaginal discharge is usually normal. The discharge consists of secretions (mucus) produced by the cervix and of fluid that seeps through the walls of the vagina. Estrogen stimulates this production.
The discharge is usually milky white or thin and clear. Its amount and appearance may change as women age. Typically, the discharge has no odor. It is not accompanied by itching, burning, irritation, or rash. Newborn girls normally have a vaginal discharge of mucus, often mixed with a small amount of blood. This discharge occurs because estrogen is absorbed from the mother through the placenta before birth. After birth, the level of estrogen decreases rapidly, causing a small amount of bleeding in the first 1 to 2 weeks of life. Normally, older infants and girls do not have any significant vaginal discharge until puberty, when estrogen levels increase.
During a woman's reproductive years, the amount and appearance of the normal vaginal discharge vary with the menstrual cycle. For example, at the middle of the cycle (at ovulation), the cervix produces more mucus and the mucus is thinner. Pregnancy, use of oral contraceptives, and sexual arousal also affect the amount and appearance of the discharge. After menopause, the estrogen level decreases, often reducing the amount of normal discharge.
A vaginal discharge is considered abnormal if it is
* Heavier than usual
* Thicker than usual
* Puslike
* White and clumpy (like cottage cheese)
* Grayish, greenish, yellowish, or blood-tinged
* Foul- or fishy-smelling
* Accompanied by itching, burning, a rash, or soreness

Causes:
A discharge may indicate inflammation of the vagina (vaginitis), which may be due to an infection or to irritation by a chemical (as for vaginal itching). In young girls, a foreign object in the vagina can cause inflammation of the vagina, with a discharge that may contain blood. Most commonly, the foreign object is a piece of toilet paper that has worked its way into the vagina. Sometimes it is a toy. Irritation may also result from spermicides, vaginal lubricants or creams, diaphragms, or, for women who are allergic to latex, latex condoms. After menopause, the vagina becomes thinner and dryer, increasing the chance of inflammation.
A white, gray, or yellowish cloudy discharge with a fishy odor is caused by bacterial vaginosis. A thick, white, and clumpy discharge (which looks like cottage cheese), often accompanied by itching, is typically caused by candidiasis, a yeast infection. A heavy, greenish yellow, frothy discharge that may have a bad odor is typically caused by trichomoniasis, a protozoan infection. A greenish or yellowish discharge may be due to cervical infection with gonorrhea or chlamydia. Gonorrhea, chlamydial infections, and trichomoniasis are sexually transmitted.
A watery, blood-tinged discharge may be caused by cancer of the vagina, cervix, or lining of the uterus (endometrium) . Radiation therapy to the pelvis may also cause an abnormal discharge.

Evaluation:
Clues to the cause of the abnormal discharge include its appearance, the woman's age, and other symptoms. A sample of the discharge is examined under a microscope to check for an infection and to identify it.
Yeast infections and trichomoniasis can usually be diagnosed with this information alone. To diagnose gonorrhea and chlamydial infections, family physicians have the sample cultured (grown in a laboratory) or tested for DNA, particularly for women who are sexually active and thus at risk of sexually transmitted diseases.

Treatment:
Treatment depends on the cause. Changing underwear and bathing or showering daily may help relieve symptoms but do not eliminate the infection. If a product (such as a cream, powder, soap, or brand of condom) consistently causes irritation, it should not be used. Douching and using feminine hygiene sprays should be discouraged. These products do not eliminate the discharge and may make it worse, and douching may increase the risk of pelvic inflammatory disease.

Vaginal Itching
Vaginal itching may involve the area containing the external genital organs (vulva) as well as the vagina. Many women have occasional vaginal itching that resolves without treatment. Itching is considered a problem only when it is persistent, is severe, recurs, or is accompanied by a discharge that looks or smells abnormal.

Causes:
Vaginal itching may result from the following:

• Infections: Bacterial vaginosis, candidiasis (a yeast infection), andtrichomoniasis (a protozoan infection) can cause itching. These infectionstend to also cause a discharge.
• Irritation: Chemicals that come in contact with the vagina or vulva may irritate them. Examples are the chemicals in laundry detergents, bleaches, fabric softeners, synthetic fibers, bubble baths, soaps, feminine hygiene sprays, perfumes, menstrual pads, fabric dyes, toilet tissue, vaginal creams, douches, condoms, and contraceptive foams.
• Changes in the skin or lining of the vagina: Hormonal changes at menopause can cause vaginal dryness, which leads to itching. Skin disorders such as psoriasis or lichen sclerosus can cause itching. Lichen sclerosus is characterized by thin white areas on the vulva around the opening of the vagina. If untreated, lichen sclerosus can cause scarring and may increase the risk of cancer of the vulva.
  

Evaluation:
Family physicians can usually determine the cause by asking about symptoms and by examining the vulva and vagina. If the woman has a discharge, tests are needed.
Treatment: The cause is treated when possible. Changing underwear and bathing or showering once daily help keep the vagina and vulva clean. A nonallergenic soap should be used. These measures may minimize exposure to irritants that cause itching. More frequent washing may cause excessive dryness, which can increase itching. Using a mild (low-strength) corticosteroid cream such as hydrocortisone may provide temporary relief.
For severe itching, an oral antihistamine may help temporarily. If a product (such as a cream, powder, soap, or brand of condom) consistently causes irritation and itching, it should not be used. Feminine hygiene sprays and douches should not be used. Treatment of lichen sclerosus consists of a cream or an ointment containing a high-strength corticosteroid, available by prescription.

Pelvic Pain
Many women experience pelvic pain-pain that occurs in the lowest part of the abdomen, between the hipbones. The pain may be sharp, intermittent, or crampy (like menstrual cramps). It may be sudden and excruciating, or it may be dull, constant, or both. The pain may gradually increase in intensity, sometimes occurring in waves. Often, the pain is cyclical, occurring with menstrual periods or during ovulation. The pelvic area may feel tender to the touch. The pain may be accompanied by fever, nausea, or vomiting.

Causes:
Pelvic pain may be caused by disorders related to any of the organs in the pelvis: the reproductive organs (uterus, fallopian tubes, ovaries, and vagina), bladder, rectum, or appendix. However, pelvic pain sometimes originates in organs outside the pelvis, such as the abdominal wall, intestine, kidneys, ureters, or lower part of the aorta. Psychologic factors, especially stress and depression, may contribute to any kind of pain (including pelvic pain) but, by themselves, rarely cause pelvic pain. Evaluation and Treatment: When a woman has sudden, very severe pain in the lower abdomen or pelvis, family physicians must quickly decide whether the cause requires emergency surgery. Examples of emergencies are appendicitis, a perforated ulcer, a bulge in the aorta (aortic aneurysm), a twisted ovarian cyst, a ruptured abscess (collection of pus) in the pelvis, or a pregnancy that develops outside of the uterus (ectopic pregnancy), usually in a fallopian tube.
Information about the pain, including its timing-when it occurs in relation to the menstrual cycle, eating, sleeping, sexual intercourse, activity, urination, and defecation-may help family physicians determine the cause, as may information about any other factors that worsen or ease the pain. Family physicians gently feel the entire abdomen and do a pelvic examination. This evaluation helps family physicians determine which organs are affected and whether an infection is present. A pregnancy test is done. Depending on which disorders are suspected, other tests may include cultures (growing organisms in a laboratory, or other tests to check for infections such as gonorrhea and chlamydial infection, urinalysis and urine culture, ultrasonography, computed tomography (CT), and a complete blood cell count. Sometimes surgery using a laparoscope (a viewing telescope to examine the interior of the abdomen and pelvis) is needed to identify the cause of the pain. A larger incision may also be required.
Treating the disorder causing the pain, if identified, may relieve the pain. If needed, analgesics can help relieve pain. Family physicians may ask about stress, depression, and other psychologic factors to determine whether these factors may contribute to pain, especially when pain is persistent.

What Causes Pelvic Pain?

• Disorders related to the reproductive organs
• Menstrual cramps (dysmenorrhea)
• Pregnancy that develops outside the uterus (ectopic pregnancy)
• Miscarriage
• Endometriosis
• Fibroids in the uterus
• Mittelschmerz (pain that occurs in the middle of the menstrual cycle and is caused by ovulation)
• A ruptured, or twisted cyst in an ovary
• Pelvic inflammatory disease
• Tumors (cancerous or noncancerous) in gynecologic organs
• 
  
• Disorders not related to the reproductive organs
• Appendicitis
• Urinary tract infections, such as cystitis
• Diverticulitis
• Gastroenteritis
• Peptic ulcer disease
• Inflammatory bowel disease
• Irritable bowel syndrome
• Inflammation of the lymph nodes in the abdomen (mesenteric lymphadenitis)
• Stones in the urinary tract, such as kidney stones
• Pain in the abdominal wall (the muscles and connective tissue that surround the abdominal cavity)
• Tumors (cancerous or noncancerous) of the digestive tract
  

Vaginal bleeding
Any vaginal bleeding that occurs before puberty, during pregnancy, or after menopause is considered abnormal. During the reproductive years, vaginal bleeding is usually from menstrual periods, although various disorders may cause bleeding or abnormal menstrual periods. Typically, menstrual periods last from 3 to 7 days and occur every 21 to 35 days. The interval in
adolescents is somewhat more variable and may be as long as 45 days.
Menstrual periods may be abnormal if they:

• Become excessively heavy (saturating more than 1 or 2 tampons an hour)
• Last too long (more than 7 days)
• Occur too frequently (usually fewer than 21 days apart)
• Occur too infrequently (usually more than 90 days apart)
  

At any age, prolonged or excessive bleeding can result in iron deficiency and anemia.

Causes:
Bleeding from the vagina may result from a disorder in the vagina or another reproductive organ, particularly the uterus. Common causes include disorders of the reproductive organs, injuries, complications of pregnancy or labor, changes in the normal hormonal control of ovulation (called dysfunctional uterine bleeding), and other hormonal disorders. For example, thyroid disorders can cause menstrual periods to be irregular, to be heavy and occur more frequently, or to occur less frequently (as well as to stop). Some causes are more common among certain age groups. Bleeding in children, which is unusual, is most often due to a vaginal foreign object or an injury. Dysfunctional uterine bleeding is more likely to occur in adolescents (when menstrual periods are just starting) or in women in their late 40s (when periods are nearing an end). Occasionally, pregnancy-related vaginal bleeding occurs in a woman who does not yet know she is pregnant.
Cancer may cause bleeding in women of reproductive age, but not commonly. In postmenopausal women, cancer-of the cervix, vagina, or lining of the uterus (endometrial cancer)-is a more common cause of vaginal bleeding. However, bleeding may also result from age-related thinning of the vagina or thinning or thickening (hyperplasia) of the lining of the uterus.
Common Causes of Abnormal Vaginal Bleeding Infants: Exposure to estrogen from the mother before birth (causing minimal bleeding during the first 1 to 2 weeks of life)
Children:

• Injury (including sexual abuse)
• Infection (including that due to sexual abuse)
• Insertion of a foreign object (such as toilet paper or a toy) in the vagina
• Bulging (prolapse) of the urethra outside the body
• Puberty that occurs too early (precocious puberty) with premature menstrual periods
  

Women of reproductive age:
Complications of pregnancy or labor:

• Miscarriage (actual or threatened)
• Pregnancy located outside the uterus (ectopic pregnancy)
• Placental abnormalities, such as premature separation (abruptio placentae) or a location too near the cervix (placenta previa)
• Incomplete delivery of the placenta
  

Hormonal dysfunction:

• Dysfunctional uterine bleeding (the most common cause)
• Brain dysfunction that affects regulation of reproductive system
• Thyroid disorders
• Tumors of the adrenal gland or ovaries
  

Disorders of the reproductive organs:

• Cancer
• Noncancerous growths (such as polyps, fibroids, cysts, and benign uterine or ovarian tumors)
• Endometriosis
• Injuries
• Infections (such as chlamydial infections and genital warts)
• Pelvic inflammatory disease
  

Factors related to birth control methods:

• Missed or skipped doses of oral contraceptives
• Irregular bleeding during the first few months of taking oral contraceptives
• Use of an intrauterine device (IUD)
  

Postmenopausal women

• Cancer in a reproductive organ
• Noncancerous growths (such as polyps and tumors) in a reproductive organ
• Age-related thinning of the vagina
• Trauma during intercourse
• Thickening of the lining of the uterus (endometrial hyperplasia)
  

Evaluation:
In children, vaginal bleeding should be evaluated by a doctor. Women with very heavy bleeding (for example, more than 1 pad or tampon per hour), pain during bleeding, light-headedness, or difficulty breathing, and those who are pregnant should see a doctor immediately. Family physicians ask about symptoms and do a pelvic examination. In women of reproductive age, a pregnancy test is done. If bleeding is prolonged, excessive, or frequent, a complete blood count may be done, and the iron level in blood may be measured. Other tests may be necessary, depending on the suspected cause.
A physical (including gynecologic) examination is done. Bleeding in children caused by precocious puberty can be easily recognized because pubic hair and breasts also develop. Often, family physicians can recognize disorders of the cervix or vagina on physical examination.
Blood tests to evaluate thyroid function or to check for bleeding disorders may be done. Family physicians often perform ultrasonography, which may be performed transabdominally, or transvaginally, using an ultrasound device inserted into the vagina to look for cancerous and noncancerous growths of the reproductive organs. Other procedures to identify cancer may include a Papanicolaou (Pap) test, a biopsy of the cervix, and dilation and curettage (D and C).
Treatment: Treatment varies depending on the cause. Oral contraceptives or other hormones may be used to treat dysfunctional uterine bleeding. Uterine polyps, fibroids, cancers, and some benign tumors may be surgically removed. Iron deficiency is treated with iron supplements.

Excessive Hairiness (Hirsutism)
Excess body hair, particularly on the face (on the upper lip, chin, or sideburns area), trunk (around the nipples or on the chest or lower abdomen), and limbs, is called hirsutism. Excessive hairiness may not seem like a gynecologic disorder, but it is considered one because it usually results from high levels of male hormones. Sometimes other masculine traits, such as a deepened voice and increased muscle size, develop-a condition called virilization.
Causes: The most common cause of hirsutism is polycystic ovary syndrome). Hirsutism is common among postmenopausal women because levels of female hormones decrease. Rarely, hirsutism is due to a disorder of the pituitary gland or adrenal glands that results in overproduction of male hormones (such as testosterone) . Rarely, hirsutism results from tumors in the ovaries, porphyria cutanea tarda (an enzyme deficiency that affects the skin), or use of certain drugs, such as anabolic steroids, corticosteroids, or minoxidil.
Evaluation and Treatment: Blood tests may be done to measure hormone levels. The disorder causing hirsutism is treated when possible, often with hormone therapy such as oral contraceptives. Drugs that may be the cause are stopped.
Excess hair can be temporarily removed by shaving, plucking, waxing, and using depilatories. Eflornithine, a topical cream available by prescription, is sometimes helpful. It can slow the growth of hair, causing a gradual reduction of unwanted facial hair. Laser phototherapy is temporarilyeffective. The only safe permanent treatment is electrolysis, which destroys hair follicles.
(Merck)