A woman’s reproductive age begins with menarche (her first period) and ends with menopause (her last). Reproductive age refers to the ability of the woman to reproduce and give birth to a child. However, female reproductive system does not always function smoothly because it is directly linked to many other processes in the body. This may result in different gynecological problems that affect women in their reproductive age. 

Your Period

     

Normal Cycle

A woman's normal menstrual cycle involves a complex series of hormonal events. An egg is released from the ovary; either the egg is fertilized by a sperm and implants in the uterus, or the lining of the uterus is shed each month as the menstrual period. This shedding causes normal menstrual bleeding. Menstrual blood flows from the uterus through the small opening in the cervix and passes out of the body through the vagina. Menstrual periods vary; the menstrual flow may be light, moderate or heavy lasting 3 to 5 days. Anywhere from 2 to 7 days is normal. It is helpful to track on a calendar when your period starts, ends, how the flow is (light, moderate, or heavy), and any cramping or passing of clots. Keeping a menstrual diary helps to track any conditions related to your period such as heavy bleeding, premenstrual syndrome and irregular periods.

Heavy Bleeding

Unexpected bleeding is always a concern for a woman at any stage of life. Bleeding other than a normal menstrual period and even an abnormally heavy period can be great cause for alarm. The medical term for excessive or prolonged vaginal bleeding that occurs at the regular time of the menstrual cycle is known as menorrhagia. Metrorrhagia is the term used to refer to uterine bleeding at irregular intervals, particularly between the expected menstrual periods.

Menometrorrhagia is the combination of the two, excessive uterine bleeding, both at the usual time of menstrual periods and at other irregular intervals.

It is important to understand exactly what is causing the bleeding, its origin (uterus, vagina, or some other organ or tissue), and to make decisions about how to control or stop the bleeding. 

Additional Information:

  • Abnormal Uterine Bleeding - ACOG
  • In this video Dr. Dignan Moore, OB-GYN at Springfield Clinic, discusses heavy bleeding issues for women. View video
  • Overly heavy bleeding is more than just an inconvenience -- it can affect your day to day life. Some women deal with prolonged and excessive bleeding with each period, but aren't ready for or do not want a hysterectomy. Dr. Richard Eden, OB-GYN at Springfield Clinic, discusses this procedure in this video. View video

PMS

What is premenstrual syndrome (PMS)?

Most women have breast tenderness, bloating and muscle aches a few days before they start their menstrual period. These are normal premenstrual symptoms. But when they affect your daily life, they are called premenstrual syndrome. PMS can affect your body as well as your mood days or week leading up to your period. Sometimes it can change the way you act.

Emotional and behavioral symptoms:

  • Tension or anxiety
  • Depressed mood
  • Crying spells
  • Mood swings and irritability or anger
  • Appetite changes and food cravings
  • Trouble falling asleep (insomnia)
  • Social withdraw
  • Poor concentration

Physical signs and symptoms:

  • Joint or muscle pain
  • Headache
  • Fatigue
  • Weight gain related to fluid retention
  • Abdominal bloating
  • Breast tenderness
  • Acne flare-ups
  • Breast tenderness
  • Constipation or diarrhea

Potential causes of PMS?

Knowing what exactly causes PMS is unknown, but several factors may contribute to the condition:

  • Cyclic changes in hormones
  • Chemical changes in the brain
  • Depression
  • Stress
  • Poor eating habits

A few lifestyle changes will probably help you feel better.

  • Eat a variety of healthy foods, including whole grains, protein, low-fat dairy, fruits, and vegetables.
  • Get plenty of exercise.
  • Take a multivitamin.
  • Cut back on caffeine, alcohol, chocolate, and salt.
  • For pain try Ibuprofen or Aleve, these work better than Tylenol.

When to see a doctor?

If you have had no luck managing your PMS with lifestyle changes, and signs and symptoms are affecting your health and daily activities, contact your physician.
Some women with PMS have disabling symptoms every month. This form of PMS is called premenstrual dysphoric disorder (PMDD). PMDD is a severe form of PMS characterized by severe depression, feelings of hopelessness, anger, anxiety, low self-esteem, difficulty concentrating, irritability and tension.

There are no unique physical findings or laboratory tests to positively diagnose premenstrual syndrome. To help establish a pattern it is important to keep a diary. Record your signs and symptoms on a calendar or in a diary for at least two menstrual cycles. Note the day that you first notice PMS symptoms, as well as the day they disappear. Include the day your period starts and ends. 

Irregular Periods

When is a period irregular?

A normal menstrual cycle lasts 28 days, plus or minus seven days. Menstrual bleeding is considered irregular if it occurs more frequently than 21 days or lasts longer than 8 days. To determine whether your menstruation is irregular, count from the last day of your previous period and stop counting on the first day of your next.

Factors that can trigger irregular or missed periods:

  • Extreme exercise or dieting-Exercising too much, being underweight, dieting, eating disorders or illness can cause missed cycles or periods.
  • Stress-Chronic stress or even short-term anxiety can cause hormonal imbalances causing a missed period or irregular cycle.
  • Birth control pills can make your periods lighter, or can cause you to have less or more frequent periods, or can cause you to have no periods at all.
  • Polycystic ovary syndrome (PCOS)-causes tiny cysts to form on ovaries, interfering with regular ovulation.
  • Other medical illnesses-Thyroid disorders can cause irregular periods if blood levels of the thyroid hormone are too low or too high. Other health conditions that may cause irregular cycles include sexually transmitted diseases, diabetes, fibroids, eating disorders and endometriosis.
  • Obesity-Some overweight women will also have irregular cycles. This may be related to polycystic ovaries or may just be as a result of their weight.
  • Age-When teens first start having periods, their menstrual cycles may not always be on the same schedule every month. It may take several years to settle into a pattern. In addition, missed periods and lighter or heavier periods are common as women near menopause.

It is important to keep track of your periods. A couple of missed periods a year are usually nothing to worry about. Any more than that and you should see a doctor to be sure an ovulation problem or health condition is not the cause. 

Additional Information:

Vaginal Discharge

Vaginal discharge refers to secretions from the vagina. Such discharge can vary in:

  • Consistency (thick, pasty, thin) 
  • Color (clear, cloudy, white, yellow, green) 
  • Smell (normal, odorless, bad odor)

Having some amount of vaginal discharge is normal, especially if you are of childbearing age. Glands in the cervix produce clear mucus. These secretions may turn white or yellow when exposed to the air. These are normal variations.

The amount of mucus produced by the cervical glands varies throughout the menstrual cycle. This is normal and depends on the amount of estrogen circulating in your body. It is also normal for the walls of the vagina to release some secretions. The amount depends on hormone levels in the body. Changes in normal discharge can occur for many reasons, including menstrual cycle, emotional stressors, nutritional status, pregnancy, usage of medications - including birth control pills, and sexual arousal.

Signs of Abnormal Discharge

Any changes in color or amount of discharge may be a sign of a vaginal infection. Vaginal infections are very common. If you experience any of the symptoms below, this may be a sign of vaginal infection:

  • Discharge accompanied by itching, rash or soreness
  • Persistent, increased discharge
  • Burning on skin during urination
  • White, clumpy discharge (somewhat like cottage cheese)
  • Grey/white or yellow/green discharge with a foul odor

Vaginal discharge that suddenly differs in color, odor, or consistency, or significantly increases or decreases in amount, may indicate an underlying problem and should call your healthcare provider.

Vaginal Infections

Pelvic Pain

What is pelvic pain?

Pelvic pain is pain in the lowest part of your abdomen and pelvis. In women, pelvic pain may refer to symptoms arising from the reproductive or urinary systems, or from musculoskeletal sources. Depending on its source, pelvic pain may be dull or sharp. The pain may be constant or off and on, mild, moderate or severe. Pelvic pain can sometimes radiate to your lower back, buttocks or thighs. Pelvic pain can occur suddenly, sharply and briefly(acute), or over long term (chronic). Chronic pelvic pain refers to any constant or intermittent pelvic pain that has been present for more than a few months. Sometimes you may notice pelvic pain only at certain times, such as when you urinate or during intercourse.

What are the symptoms related to pelvic pains?

  • Menstrual cramps
  • Menstrual pain
  • Vaginal bleeding, spotting or discharge
  • Painful or difficult urination
  • Constipation or diarrhea
  • Bloating or gas
  • Blood seen with a bowel movement
  • Pain during intercourse
  • Fever or chills
  • Pain in the hip area
  • Pain in the groin area

When should you be evaluated for pelvic pain & how is pelvic pain treated?

If you suddenly develop severe pelvic pain, it may be a medical emergency and you should seek medical attention promptly. If you experience pelvic pain that is new, if it disrupts your daily life, or if it has gotten worse over time be sure to see your physician. The treatment of pelvic pain varies by what the cause is, how intense the pain is, and how often the pain occurs. Sometimes pelvic pain is treated with medicine. If the pain results from a problem with one of the pelvic organs, the treatment might involve surgery or other procedures. 

Additional Information:

Endometriosis

The lining of the uterus is called the endometrium. Sometimes, endometrial tissue grows elsewhere in the body. When this happens it is called endometriosis. Most often endometriosis is found on the ovaries, fallopian tubes, tissues that hold the uterus in place, surface of the uterus, cul-de-sac (the space behind the uterus), vagina, cervix, vulva, bowel, rectum, bladder and ureters. In very rare cases, it may also be found in other parts of the body, especially abdominal wall scars.

In endometriosis, displaced endometrial tissue continues to act as it normally would — it thickens, breaks down and bleeds with each menstrual cycle. Because this displaced tissue has no way to exit your body, it becomes trapped. When endometriosis involves the ovaries, cysts called endometriomas may form. Surrounding tissue can become irritated, eventually developing scar tissue and adhesions — abnormal tissue that binds organs together. No one is certain of the cause of endometriosis.

Several factors place you at greater risk of developing endometriosis, such as:

  • Never giving birth 
  • One or more relatives (mother, aunt or sister) with endometriosis 
  • Any medical condition that prevents the normal passage of menstrual flow out of the body 
  • History of pelvic infection 
  • Uterine abnormalities

Endometriosis usually develops several years after the onset of menstruation (menarche). Signs and symptoms of endometriosis end temporarily with pregnancy and end permanently with menopause. It most commonly presents in a woman’s 30’s or 40’s.

Symptoms of endometriosis can include:

The main symptom with endometriosis is pelvic pain especially, before and during the menstrual period. Such pain may occur during or after intercourse. For some women, the pain is mild. For others, it can be severe. Severe endometriosis may also lead to infertility. The amount of pain a woman feels does not correlate with how much endometriosis is present. Some women have no pain, even though their disease affects large areas. Other gynecological symptoms can include very painful menstrual cramps and menstrual bleeding more than once a month.

If endometriosis is present outside the uterus other symptoms may include pain with bowel movements and urination, intestinal pain, fatigue, diarrhea, constipation, bloating, or nausea, especially during menstrual periods. Although these symptoms may be a sign of endometriosis, they can also be signs of other problems. If you have any of these symptoms, contact your healthcare provider.

Diagnosis of Endometriosis:

If you have symptoms of endometriosis, your health care provider may do a physical exam, including a pelvic exam. An ultrasound may be done to get the best view of your reproductive organs. Ultrasound imaging won't definitively tell your doctor whether you have endometriosis, but it can identify cysts associated with endometriosis (endometriomas). However, the only way to tell for sure you may have endometriosis and the extent of endometriosis is a surgical procedure called laparoscopy. With a laparoscopy, sometimes a biopsy is taken of the tissue.

Treatment for endometriosis:

Treatment for endometriosis is usually with medications or surgery. The approach you and your doctor choose will depend on the severity of your signs and symptoms and whether you hope to become pregnant in the future.

In some cases of endometriosis, your healthcare provider may recommend over-the-counter pain medicines (ibuprofen or Aleve) to treat mild pain. When pain medication is not enough hormones may be used to relieve pain. The hormones may also slow the growth of the endometrial tissue and may prevent the growth of new adhesions. It will not make them go away. Hormone treatment is designed to stop the ovaries from releasing hormones. The hormones most often prescribed include oral contraceptives, or gonadotropin-releasing hormone (GnRH) such as Lupron, Danazol.

Surgery is usually the best choice for women with severe endometriosis (many growths, a great deal of pain, or fertility problems). There are minor and more complex surgeries that can help.

Surgery is most often done by a laparoscopy to diagnose and treat the condition. During this surgery, doctors remove growths and scar tissue or burn them away. A laparotomy which is a major abdominal surgery may be needed. This surgery involves a much larger incision in the abdomen than a laparoscopy. This allows the doctor to reach and remove growths of endometriosis in the pelvis or abdomen. In severe cases of endometriosis, surgery to remove the uterus and cervix (total hysterectomy) as well as both ovaries may be the best treatment. Hysterectomy alone is not effective — the estrogen your ovaries produce can stimulate any remaining endometriosis and cause pain to persist. Hysterectomy is typically considered a last resort, especially for women still in their reproductive years. You can't get pregnant after a hysterectomy.

Endometriosis is a long-term condition. Many women have symptoms that occur off and on until menopause. There are many treatment options available. A woman can work with her healthcare provider to determine the right decision for her.

Additional Information:

Polycystic Ovarian Syndrome

Polycystic ovary syndrome (PCOS) is a common hormonal disorder among women of reproductive age. The name comes from the appearance of the ovaries. The ovaries are enlarged and contain numerous small cysts located along the outer edge of each ovary (polycystic appearance). The cause of PCOS is not known. It appears to be several factors working together including insulin resistance, increased androgen levels, and irregular menstrual cycles.

What are the signs and symptoms of PCOS?

Infrequent or prolonged menstrual periods, excess hair growth (hirsutism), acne, infertility, cysts on the ovaries, acanthosis nigricans (dark, velvety patches on the skin) and obesity can all occur in women with polycystic ovary syndrome.

How is it diagnosed?

There are no specific tests for PCOS, rather a series of tests to aid in diagnosis. Diagnosis is made through the medical history, physical exam, pelvic ultrasound and lab tests. Lab tests check for such things as the following: hCG (to rule out pregnancy), testosterone (androgens at high levels can block ovulation and cause, acne, male-type hair growth in the face and body, and hair loss from the scalp), prolactin (can play a part with no periods or infertility), cholesterol and triglycerides (may be unhealthy levels with PCOS), chemistry test (to check for overactive or underactive thyroid), DHEA-S or 17-hydroxyprogesterone (adrenal problems can cause symptoms much like PCOS), glucose and insulin levels (to check for insulin resistance).

What is the treatment?

In women who do not want to become pregnant, combination birth control pills may be prescribed. These help to regulate menstrual period, reduce androgen levels and reduce the risk of endometrial overgrowth or cancer. For overweight women (whether trying to conceive or not), weight loss is encouraged. This can help regulate menstrual cycles, and improve cholesterol and insulin levels. Insulin-sensitizing drugs help the body respond to insulin. This helps to decrease androgen levels and improve ovulation. This may make the menstrual cycles more regular. For women trying to conceive, medication to cause ovulation may be prescribed.

What are the health risks of women with PCOS?

Patients with PCOS, especially those that are obese, have a higher rate of type 2 diabetes, high blood pressure, heart disease, high cholesterol, fatty liver, endometrial cancer, and gestational diabetes and high blood pressure with pregnancy.

Fibroids

A uterine fibroid or leiomyoma is a benign (not cancer) growth in the uterus. Fibroids are the most common type of growth found in a woman’s pelvis. According to ACOG, they occur in about 25-50% of all women. Many women who have fibroids are unaware of them because the growths can remain small and not cause symptoms or problems. However, in some women, fibroids can cause problems because of their size, number, and location.

In women who have symptoms, the most common symptoms of uterine fibroids include: 

  • Heavy menstrual bleeding
  • Prolonged menstrual periods — seven days or more of menstrual bleeding
  • Pelvic pressure or pain
  • Frequent urination
  • Difficulty emptying your bladder
  • Constipation
  • Backache or leg pains

Fibroid location, size and number influence signs and symptoms: 

Uterine Fibroids diagram

 

 

 

 

 

 

 

Submucosal fibroids - Fibroids that grow into the inner cavity of the uterus are more likely to cause prolonged, heavy menstrual bleeding and are sometimes a problem for women attempting pregnancy.

Subserosal fibroids - Fibroids that project to the outside of the uterus can sometimes press on your bladder, causing you to experience urinary symptoms. If fibroids bulge from the back of your uterus, they occasionally can press either on your rectum, causing a pressure sensation, or on your spinal nerves, causing backache. 

Intramural fibroids- Some fibroids grow within the muscular uterine wall. If large enough, they can distort the shape of the uterus and cause prolonged, heavy periods, as well as pain and pressure.

Pedunculated fibroid - A fibroid that hangs by a stalk inside or outside the uterus can trigger pain by twisting on its stalk and cutting off its blood supply.

Diagnosis

Moderate and large-sized uterine fibroids are often felt by a doctor during a bimanual pelvic examination. Imaging tests are often done to confirm the presence of uterine fibroids. The most common test would be an ultrasound. It uses sound waves to get a picture of your uterus to confirm the diagnosis, size and location of fibroids. If a woman is experiencing abnormal vaginal bleeding, her doctor may order other tests to investigate potential causes. These might include a complete blood count (CBC) to determine if a woman has anemia because of chronic blood loss and other blood tests to rule out bleeding disorders or thyroid problems.

Other imaging tests

If traditional ultrasound doesn't provide enough information, your doctor may order other imaging studies, such as: 

  • Magnetic resonance imaging (MRI) - an imaging test can show the size and location of fibroids, identify different types of tumors and help determine appropriate treatment options.
  • Hysterosonography-also called a saline infusion sonogram uses sterile saline to expand the uterine cavity, making it easier to get images of the uterine cavity and endometrium. This test may be useful if a woman has heavy menstrual bleeding despite normal results from traditional ultrasound.
  • Hysterosalpingography- uses a dye to highlight the uterine cavity and fallopian tubes on X-ray images. A doctor may recommend it if infertility is a concern. In addition to revealing fibroids, it can help a doctor determine if a woman’s fallopian tubes are open. 
  • Hysteroscopy- a doctor inserts a small, lighted telescope called a hysteroscope through the cervix into the uterus. The doctor then injects saline into the uterus, expanding the uterine cavity and allowing the doctor to examine the walls of your uterus and the openings of the fallopian tubes.

Treatment of Uterine Fibroids

Most uterine fibroids don’t need any treatment, because they don’t cause symptoms or problems. Uterine fibroids causing problems may be treated with non-surgical or surgical options.

Non-Surgical Treatment Options

Watchful waiting: A minority of fibroids will naturally shrink over time. Most uterine fibroids will either stay the same size or grow, however.

Oral contraceptives (birth control pills): These contain hormones (estrogen, progesterone, or a combination) that can help reduce heavy periods caused by uterine fibroids.

Lupron: This hormone treatment stops menstrual periods and shrinks uterine fibroids. Lupron is usually used as a temporary treatment before surgery.

Intrauterine device (IUD) with levonorgestrel: Mirena is an IUD that releases a hormone that reduces heavy periods.

Pain relievers: Motrin or Aleve can reduce the pain caused by uterine fibroids.

Iron: Heavy periods caused by uterine fibroids can lead to iron-deficiency anemia. Iron tablets can help the body replace the blood lost during menstruation.

Surgical Treatment Options

Myomectomy: Surgery to remove uterine fibroids while leaving the uterus in place. Myomectomy is often done for women wishing to have children. New uterine fibroids may grow, requiring a later procedure in up to a third of women after myomectomy.

Uterine artery embolization (UAE): A procedure that cuts off blood flow to a uterine fibroid, causing it to shrink. UAE is not a surgical procedure. It is a minimally invasive procedure during which a thin catheter is inserted into an artery in the groin and guided using X-ray cameras to arteries that feed the uterus. Once it's there, the doctor injects very small particles through the tube. The particles clog the blood vessels that feed the fibroid tumor. That causes them to shrink over time and brings about an improvement in the woman's symptoms. A specially trained radiologist performs this procedure.

Hysterectomy: Surgery to remove the entire uterus and all uterine fibroids. Hysterectomy cures uterine fibroids and prevents them from ever returning. A hysterectomy may be needed if pain or abnormal bleeding persists, fibroids are very large, or other treatments are not possible. Women with symptoms from uterine fibroids who don’t want a future pregnancy often undergo hysterectomy.

Prolapse

Uterine prolapse occurs when pelvic floor muscles and ligaments stretch and weaken, providing inadequate support for the uterus. The uterus then slips down into or protrudes out of the vagina. Uterine prolapse can happen to women of any age, but it often affects postmenopausal women who have had one or more vaginal deliveries. Damage to supportive tissues during pregnancy and childbirth, effects of gravity, loss of estrogen, and repeated straining over the years all can weaken your pelvic floor and lead to uterine prolapse.

If you have mild uterine prolapse, treatment usually is not needed. But if uterine prolapse is uncomfortable or disrupts your normal life, you should contact your health provider. Possible treatments options include vaginal pessaries or surgery.

Uterine prolapse varies in severity. You may have mild uterine prolapse and experience no signs and symptoms.

If you have moderate to severe uterine prolapse, you may experience the following symptoms:

  • Sensation of heaviness or pulling into your pelvis
  • Tissue protruding from your vagina
  • Urinary problems, such as urine leakage or retention
  • Trouble having a bowel movement
  • Low back pain
  • Feeling as if you’re sitting on a small ball or as if something is falling out of your vagina
  • Sexual concerns, such as sensing looseness in the tone of your vaginal tissues
  • Symptoms that are less bothersome in the morning and worsen as the day goes on

Factors that may increase your risk of uterine prolapse:

  • One or more pregnancies and vaginal births
  • Giving birth to a large baby
  • Increasing age
  • Frequent heavy lifting
  • Chronic coughing
  • Prior pelvic surgery
  • Frequent straining during bowel movements
  • Obesity

Possible complications of uterine prolapse:

  • Vaginal or cervical ulcers-In severe uterine prolapse , part of the vaginal lining may be displaced by the fallen uterus and protrudes outside the body, rubbing on underwear. The friction may lead to vaginal sores (ulcers).
  • Prolapse of other pelvic organs. If you experience uterine prolapse, you might also have prolapse of other pelvic organs, including your bladder and rectum. A prolapsed bladder (cystocele) bulges into the front part of the vagina, which can lead to difficulty in urinating and increased risk of urinary tract infections. Weakness of connective tissue overlying the rectum may result in a prolapsed rectum (rectocele) which may lead to difficulty having bowel movements. 

Additional Information:

Incontinence

What is urinary incontinence?

Urinary incontinence is the involuntary leakage of urine. The severity of urinary incontinence ranges from occasionally leaking urine when you cough or sneeze or having an urge to urinate that is so sudden and strong you do not get to the bathroom in time.

Types of urinary incontinence:

  • Stress incontinence-loss of urine when you exert pressure (stress) on your bladder by coughing, sneezing, laughing, exercising or lifting heavy objects.
  • Urge incontinence-a sudden, intense urge to urinate, followed by an involuntary loss of urine. With urge incontinence, you may need to urinate often, including throughout the night.
  • Overflow incontinence-inability to empty your bladder resulting in frequent or constant dribbling of urine. Feeling of never completely emptying your bladder. When you try to urinate you may only experience a weak stream.
  • Mixed incontinence-experiencing more than one type of urinary incontinence.
  • Functional incontinence-Many older adults, especially people in nursing homes, experience incontinence simply because a physical or mental impairment keeps them from making it to the toilet in time.
  • Total incontinence-continuous leaking of urine, day and night, or the periodic uncontrollable leaking of large volumes of urine

Causes of incontinence:

  • Alcohol
  • Overhydration
  • Caffeine
  • Medications-Heart medicines, blood pressure drugs, sedatives, muscle relaxants and other meds.
  • Urinary tract infections
  • Constipation
  • Obesity
  • Smoking

Causes of persistent incontinence:

  • Pregnancy and childbirth
  • Changes with aging
  • Hysterectomy
  • Painful bladder syndrome (interstitial cystitis)
  • Bladder cancer or bladder stones
  • Neurological disorders
  • Obstruction

If urinary incontinence affects your day-to-day activities, call your physician for an appointment. In most cases, simple lifestyle changes or medical treatment can ease your discomfort or stop urinary incontinence. Surgery can also improve certain types of incontinence. 

Additional Information: