ABNORMAL UTERINE BLEEDING

What is abnormal uterine bleeding?

Bleeding between periods
Bleeding after sex
Spotting anytime during the menstrual cycle
Bleeding that is heavier or longer than normal

Is abnormal bleeding ever expected?

During the first few years after the start of menses (age 9-16)
When menopause nears (in the late 40s, early 50s)

What causes abnormal uterine bleeding?

Hormone imbalance
Pregnancy
Miscarriage
Ectopic pregnancy
Birth control methods IUD, pills, etc
Infection of uterus or cervix
Fibroids
Problems with blood clotting
Polyps
Certain types of cancer uterine, ovarian, cervical
Chronic medical conditions diabetes, thyroid

How is abnormal uterine bleeding diagnosed?

History and physical exam: including pap smear, pelvic exam
Menstrual history regularity, frequency, flow amount
Lab tests
Blood count to look for anemia
Hormone levels
Pregnancy test
Endometrial biopsy based on age, a small amount of tissue is take from the uterus and sent to the
pathologist, used to rule out cancer
Ultrasound
Sonohysterography fluid is placed into the uterus through a small catheter and ultrasound is used
to take pictures of the uterus and other pelvic organ
Hysteroscopy a small camera is inserted into the uterus to look at the inside of the uterus and
cervix checks for fibroids, polyps, other abnormalities
Dilation & Curettage (D&C) performed in the operating room, the cervix is dilated and tissue is
removed from the uterus and sent to the pathologist for analysis
Hysterosalpingogram (HSG) dye is inserted into the uterus, x-ray pictures are taken of the uterus
and fallopian tubes
Laparoscopy a camera is inserted into the abdomen through a small hole in the belly button and
your physician looks at your uterus, tubes, ovaries and other pelvic organs. This procedure is
performed in the operating room at the hospital
How is abnormal uterine bleeding treated?
Hormones
 Non-steroidal anti-inflammatories (Motrin, Ibuprofen, Naproxen)
Antibiotics if infection is present
Surgery
Removal of polyps or fibroids
Endometrial ablation use of laser, heat, electricity, or freezing to destroy the lining of the uterus.
Permanently stops bleeding. Not for women that desire future pregnancy.
Hysterectomy removal of the uterus. Permanently stops bleeding. Not for women who desire future
pregnancy.
 BIRTH CONTROL
Choosing a Method Right for You
Birth Control Facts:
Abstinence is the ONLY way to guarantee you won't become pregnant
a woman CAN become pregnant while breastfeeding
withdrawal method (pulling out) is NOT an effective form of birth control
Douching after sex will NOT prevent pregnancy
A woman near menopause should continue birth control for 1 full year after her last period

How do I choose the right birth control for me?

Lifestyle Factors:
how often you have sex
if you want children in the future
how you feel about planning for sex or interrupting sex to use birth control
how many sex partners you have and your relationship with each
your health insurance coverage
Health Factors:
protection against sexually transmitted diseases (STDs)
the effects of certain types of birth control on your existing health condition(s)
health risks associated with certain types of birth control

How does birth control work?

Birth control works by preventing conception, however, there are several different ways in which to do
this.
Preventing Ovulation: hormones can be used to prevent an egg from maturing and being released,
these include:
birth control pills
skin patches
contraceptive vaginal rings (i.e. NuvaRing)
Injections (i.e. Depo Provera)
Prevention of fertilization: these methods keep the sperm and egg from joining, including:
Barrier methods condoms, diaphragm, cervical cap
Spermicide
The IUD/IUC (Intrauterine device or intrauterine contraception)
Sterilization (Male vasecotomy, Female tubal sterilization)
Natural Family Planning

When is it unsafe to use hormonal birth control?

It may be unsafe for you to use hormonal birth control in the following circumstances:
you are a smoker and over age 35
you have high blood pressure, gallbladder, liver, or heart problems
you have diabetes, migraines, bleeding, or vein problems
Notify your physician if you have any of these problems so that the best option for you can be used.

What life changes will affect my birth control needs?

If you begin or end a relationship
If you want to become pregnant
If you decide you don't want children in the future or if you don't want any more children
If you have recently given birth and need to resume birth control
If you have changes to your health
If you are concerned about contracting or transmitting an STD.
 ENDOMETRIOSIS
What is endometriosis?
Endometriosis is when tissue similar to the lining of the uterus (endometrium) grows in places
outside of the uterus, such as:
Peritoneum the lining of the wall inside the abdomen
Ovaries
Fallopian tubes
Surface of the uterus
Cul-de-sac (space behind the uterus)
Bowel
Bladder and ureters (tubes that connect the bladder and kidneys)
Rectum
Endometrial tissue outside the uterus responds to hormone changes during your menstrual cycle
each month, causing bleeding and pain, especially before and during your period
Most common in women in their 30s and 40s, however, it can occur in any female that is
menstruating
Occurs more often in women that have never had children
Strong family association among mothers, children, siblings
Found in 75% of women with chronic pelvic pain

What are the symptoms of endometriosis?

Most commonly pain:
During and just before menses
During intercourse (sex)
During urination or bowel movements
More frequent menstruation (more than once a month)
Infertility, in severe cases

How is endometriosis treated?

Treatment depends on your symptoms, extent of disease, desire for future pregnancy
Medical therapy:
Pain relief (non-steriodal anti-inflammatories)
Hormones: oral contraceptives, Depo Lupron, Progestin, Danazol
Surgical therapy: laparoscopy to remove endometriosis; removal of uterus and ovaries in severe
cases (total hysterectomy)

Does endometriosis return?

Symptoms return in 50% of patients within one year of surgical intervention
Utilizing medications and surgery is most beneficial, however, there is NO cure
The more severe your case of endometriosis, the more likely it is to return.
 UTERINE FIBROIDS (LEIOMYOMA)
What are Fibroids?
Fibroids are benign (non-cancerous) growths in the uterus (womb).
They develop from the cells that make up the muscle (myometrium) of the uterus also called leiomyoma
or myoma
The most common type of growth found in the female pelvis
20-25% of all women have fibroids
Size, Shape and Location may vary:
Small, pea-sized to large, melon sized (5-6 cm in diameter)
Can grow inside the uterus, on its outer surface, within the wall of the uterus, or from a stalk
(pedunculated fibroids)
A woman may have just one fibroid, or many fibroids.
They may remain small for a long time, grow rapidly, or grow slowly over a number of years.
As they grow, they can distort the shape of the uterus

What causes fibroids?

Most common in women aged 30-40, however, can affect women of any age
More common in black women, often developing at younger ages and growing rapidly.
The cause is UNKNOWN
Estrogen, the female hormone, seems to increase their growth

What are the symptoms of fibroids?

Most fibroids, even large ones, produce no symptoms. However, possible symptoms are:
Changes is menstruation: heavy bleeding, longer or more frequent periods, menstrual cramps,
vaginal bleeding outside of the menstrual period, anemia
Pain: often dull, heavy, aching, or possibly sharp. Usually in abdomen or low-back, may occur during
intercourse
Pressure: difficulty urinating, frequent urination, constipation, rectal pain, difficult bowel
movements, abdominal cramps
Enlarged uterus or abdomen
Miscarriage or infertility

How are fibroids diagnosed?

Ultrasonography: uses sound waves to create a picture of the uterus and pelvic organs this allows for
your physician to know the size, location, and number of fibroids
Hysteroscopy: a camera is inserted through the vagina and cervix into the uterus and allows you
physician to see the inside of your uterus
Hysterosalpingogram (HSG): a special x-ray test where dye is inserted into the uterus as x-rays are
taken. May detect abnormalities in the size and shape of the uterus and fallopian tubes
Laparoscopy: a camera is inserted into the abdomen through a small cut at the navel, allowing your
physician to see fibroids out the outside of the uterus and changes in the shape of the uterus.
MRI or CT scans: can be used to assess size, shape, growth of fibroids

How are fibroids treated?

Small fibroids that do not cause problems or occur in women near menopause may not need to be treated.
However, if the above symptoms are occurring, the following may be used:
Hormones: Depo Lupron, Depo Provera, oral contraceptives
Myomectomy: surgical removal of the fibroids while leaving the uterus in place. This is a great option
for someone that desires future pregnancy.
Uterine Artery Embolization: the blood vessels that supply the uterus are embolized. This results in
decreased blood flow to the uterus and fibroids, thereby decreasing their growth and symptoms. This
option is best for women who have completed child-bearing and do not desire future pregnancy
 Hysterectomy: removal of the uterus. This is the definitive treatment for fibroids.
 HUMAN PAPILLOMAVIRUS (HPV)

What is HPV?
A common virus with many different types that can cause cervical cancer, genital warts, or warts
on the hands or feet.
There are over 100 different types of this virus
most are harmless (the types that cause warts of the hands and feet)
Most people clear the virus with their bodies on natural defense system

Which types of HPV should I worry about?

Genital HPV
Approximately 30 types affect the genital area
High-Risk Types:
associated with abnormal changes in the cells of the cervix (opening to the uterus)
that may lead to cervical cancer
include HPV types 16 and 18
Low-Risk Types:
associated with genital warts and non-cancerous (benign) changes of the cervix
include HPV types 6 and 11
AFFECTS BOTH MEN AND WOMEN
ALL TYPES OF HPV CAN CAUSE ABNORMAL PAP SMEARS

How do I get Genital HPV?

Any sexual activity involving the genital contact can spread HPV, intercourse is not necessary
Most people with HPV do not have any signs or symptoms of the virus and can pass it to others
without knowing it.
The CDC (Centers for Disease Control & Prevention) estimates that 80% of women will have
had HPV by age 50
HPV is easily transmitted and any sexual exposure puts you at risk. Many people get HPV within
the first 2-3 years of becoming sexually active

How do I prevent HPV?

The only way to totally protect yourself from HPV is to AVOID any sexual activity involving
genital contact (Abstinence)
However, you may also be able to decrease your chances of exposure with the following:
limit the number of sexual partners you have
stay in a long-term, exclusive relationship with someone who DOES NOT have HPV
use a condom, although, it is unknown exactly how much protection they offer from HPV
Routine Pap Smears to detect for abnormal changes in the cells of the cervix and yearly
screening for HPV.
Currently there is a vaccine available to help protect you against the most common strains
associated with cervical cancer and genital warts, even if you have been exposed to HPV, it can
help protect you against the types that you have not been exposed to
 HORMONE REPLACEMENT THERAPY (HRT)
What is hormone replacement therapy?
Replacement of estrogen and progestin to help relieve the symptoms of menopause and decrease
bone loss and the risk for osteoporosis

Are there any risks associated with HRT?

The Womens Health Initiative, a study by the National Institutes of Health, found that prolonged
used of estrogens in post-menopausal women may increase the risk for heart attack, stroke, blood
clots, and breast cancer for some women
The current theory regarding breast cancer and estrogen is that estrogen increases the growth rate
of certain types of breast cancer leading to earlier detection and is most women, better survival
rates.
The risk varies from woman to woman depending on how far past menopause she is.
For example, a woman 20 years past menopause may be at greater risk that a woman 3 years
past menopause
It is recommended that women use the lowest dose of hormones that controls her symptoms for
the shortest amount of time possible.
For women whose only symptom is vaginal dryness, local estrogen therapy via creams or rings is
preferable

What types of HRT is available?

Orally, vaginally (ring, cream, pill) or transdermally (through the skin)
Cyclic therapy: estrogen for 25 days, with progestin added on certain days bleeding may occur
during period without progestin
Combined therapy: estrogen and progestin is taken together daily in one pill may have irregular
bleeding during the first few months of therapy, should resolve after one year of use
Estrogen only therapy: estrogen taken daily 25 days per month some bleeding may occur
Other products:
Anti-depressants SSRIs (selective serotonin reuptake inhibitors) may help relieve mood
symptoms and hot flashes
Herbal products
Bioidentical hormones hormones derived from plants that are compounded by the pharmacist
according to the physicians instructions
 HYSTEROSALPINGOGRAM (HSG)
What is a HSG?

an x-ray of the inside of the uterus and fallopian tubes

it is performed to help find out why you are not becoming pregnant
it is performed by a radiologist (medical doctor trained in the use of x-rays)
it is done shortly after your menstrual period ends

What happens during an HSG?

You will be asked to lie on an x-ray table with your knees bent, like you would during a pap
smear
A small metal tube (speculum) will be inserted into the vagina to hold it open
Your cervix, the opening to the uterus, may or may not be numbed with an anesthetic
A thin tube is inserted into the uterus through the cervix and dye is put into the uterus through
this tube
X-rays are taken as the dye progress through the uterus and tubes. The images may be visible on
a monitor and you may be able to watch the progress of the dye.
The procedure lasts 10-20 minutes usually, however, more x-rays may be taken 30-60 minutes
later if there appears to be a problem

What are the risks and complications with an HSG?

Pain or discomfort you may be given medication to take prior to the procedure if necessary
Infection you may be treated with an antibiotic a few days before and after the procedure
Bleeding should be minimal and resolve several days after the procedure
Allergic reaction to the dye used in the procedure notify your physician and the hospital staff of
any allergies you may have
Rarely, damage to uterine wall or fallopian tubes
Notify your physician and go to the ER immediately for heavy bleeding ( greater than 1 pad
soaked per hour), severe abdominal pain, or fever greater than 100 F

What happens after the HSG?

You should be able to return to work the same or next day

You may have cramping or thick discharge for several hours, may last a day or two
Avoid tampons, douche, intercourse for 24-48 hours after the procedure

What do the results mean?

If a blockage of the uterus or fallopian tubes is found, you may need further lab tests or
procedures to accurately diagnose and treat the problem found. This will be determined by your
physician
 URINARY INCONTINENCE
What is urinary incontinence?
Leakage of urine that interferes with daily life
There are several different types of urinary incontinence

What are the types of urinary incontinence?

Stress Incontinence:
Most common type
Occurs when pressure in the bladder is greater than pressure in the urethra due to:
Coughing, sneezing, laughing, running, walking, aerobics
Caused by weakening of the support structures of the bladder and urethra
Urge Incontinence:
Also known as overactive bladder
There is a sudden, strong urge to urinate and leaking occurs before reaching the bathroom
Occurs if the muscles of the bladder contract too much, leading to leaking
May be caused by the nerves that send signals to the bladder
Mixed Incontinence: when symptoms of both stress and urge incontinence are present
Overflow Incontinence:
When the bladder is not completely emptied during urination.
Occurs when the bladder muscle is not active enough or the urethra is blocked allowing for
steady leaking of small amounts of urine
Functional Incontinence:
Leakage occurs due to other medical conditions that prevent getting to the restroom in time:
Arthritis, stroke, nervous system disorders, mobility problems (difficulty walking)

Are there any other associated symptoms of urinary incontinence?

Urgency: strong urge to urinate even if the bladder is not full
Frequency: voiding more than you feel is normal
Nocturia: the need to void during sleep
Dysuria: painful urination
Enuresis: bed-wetting or leakage during sleep

What are the causes of urinary incontinence?

Urinary tract infection
Pelvic support problems or pelvic organ prolapse
Urinary tract abnormalities
Fistula abnormal opening between the urinary tract and the vagina allowing urine to leak
through the vagina. Caused by pelvic surgery, childbirth, radiation treatment, advanced cancer of
the pelvic organs
Neuromuscular disorders: disorders that affect muscle control; associated with diabetes, stroke
or multiple sclerosis
Medications: most commonly, diuretics

How is urinary incontinence diagnosed?

Complete history and physical exam including pelvic exam
Stress test recording any loss of urine that occurs during coughing with a full bladder
 Dye test injecting a non-toxic dye into the bladder and noting any loss of urine that may occur
on a pad
Urodynamics measuring the pressure and volume of the bladder as it is filled and the flow rate
as it is emptied
Cystoscopy looking into the bladder with a small, thin camera to detect any growths or
abnormalities

What are the treatment options available for urinary incontinence?

Behavioral treatments: weight loss, avoiding constipation, avoiding heavy lifting, avoiding
alcohol or caffeine, treat lung diseases that cause coughing, stop smoking, bladder training
Physical therapy: kegel exercises, biofeedback
Devices: pessary or weighted devices to increase muscle strength
Medications: to relax the bladder, control muscle spasms, strengthen the muscles of the urethra,
antibiotics to treat infection
Surgery: for stress urinary incontinence, returns the bladder and urethra to their correct position
 MENOPAUSE
What is menopause?
The point in a womans life when she stops having periods
The average age is 51
When the ovaries stop producing enough estrogen to cause thickening of the lining of the uterus,
causing menstruation to stop
Perimenopause are the years leading up to menopause and can occur as early as the late 30s.
Menopause can also occur after surgical removal of the ovaries (oophorectomy), however, it
does not occur after hysterectomy (removal of the uterus) even though menses stops at this time

What are the signs and symptoms of menopause?

Hot flashes
Insomnia (difficulty sleeping)
Vaginal atrophy thinning and dryness of the vagina
Increased bone loss leading to osteoporosis
Increased risk for heart attack and stroke
Irritability, nervousness, fatigue, anxiety, stress, or depression
Decreased sex drive or desire

What to expect at your annual exam?

Complete history and physical exam
Pap smear, breast exam, rectal exam
Mammography beginning at age 40
Colorectal cancer screening yearl rectal exam and occult blood testing beginning at age 40,
colonoscopy every 10 years beginning at age 50
Cholesterol screening, thyroid function studies, fasting glucose, hemoglobin (blood count)
testing

How is menopause managed?

Hormone Replacement therapy: estrogen and progestin is used to treat the symptoms of
menopause
Local hormone therapy: vaginal rings or creams to promote healthy vaginal tissue
Herbal therapies: black cohosh, St. Johns Wort, evening primrose oil, valerian root, ginseng
Bone loss inhibitors: calcium supplements, bisphosphonates, selective estrogen receptor
modulators (SERMs)
Good nutrition: balanced diet, calcium and vitamin D supplements
Exercise: regular exercise slows bone loss and improves overall health, should include weight-
bearing exercises (walking, aerobics, etc.)
 OVARIAN CYSTS
What are the ovaries and what do they do?
The ovaries are small, walnut sized organs that are attached to the uterus and fallopian tubes
They contain thousands of immature eggs, which is enclosed in a capsule, or follicle.
Each month, several of the follicles enlarge. One follicle grows more rapidly than the others to produce a
mature egg.
During ovulation, the egg is released. It travels through the fallopian tube to the uterus.
If the egg is not fertilized (does not connect with sperm and result in pregnancy), the follicle shrinks in 2-
3 weeks and the process starts again
The ovaries also produce hormones that are associated with menstruation: estrogen, progesterone, and
testosterone.

What are ovarian cysts?

A fluid-filled sac on the ovary that can be as small as a pea or as large as a grapefruit.
Many women have cysts on their ovaries during their childbearing years, most go away on their own
without causing any problems or symptoms
Cysts are rarely cancerous in women under age 50.

What are the types of ovarian cysts?

Functional Cysts: the most common type of ovarian cyst
forms when the follicle does not release a mature egg or the follicle continues to grown after releasing
the egg
usually occur only on 1 ovary and shrink on their own in 1-3 months
rarely, the cyst may twist (undergo torsion) or rupture, causing pain
Dermoid Cysts: occurs when an unfertilized egg starts to grow into different kinds of tissue, such as fat,
hair, and teeth.
Can form on one or both ovaries
usually cause no symptoms, however, if they leak fluid or become twisted, this can cause severe pain
Endometrioma (Chocolate Cyst): occurs when tissue similar to the lining of the uterus
(endometrium) grows and attaches to the outside of the ovary.
This cyst contains old, dark brown blood, giving it the name chocolate cyst
Can grow on one or both ovaries
Often causes pain, especially during menstruation or during intercourse
Benign Cystadenoma (Non-cancerous): occurs when the capsule that surrounds the ovary grows larger
than it should
Can occur on one or both ovaries
Usually it causes no symptoms, however, if it becomes large, it can press on the organs near the
ovaries causing pain
If the cyst presses on the bladder, you can have urinary frequency
These cysts may also rupture and bleed, causing pain

How are ovarian cysts diagnosed?

Pelvic Exam: often this is the first sign of a cyst.
Your health care provider gently feels of your ovaries with two fingers of one hand inside the vagina
and the other hand pressing against the outside of your abdomen (stomach).
This helps to determine the size and kind of cyst you have and if it is on only one or on both ovaries
On occasion, one finger may need to be inserted into the rectum (rectal exam) to better feel the cyst
Medical History: your doctor may ask many questions regarding any symptoms you may be having, how
long you have been having them, if your periods are regular, if you have a history having ovarian cysts
before, or if you have a family history (mother, sisters) of ovarian cysts
Ultrasound: this a simple, painless, non-surgical procedure done in the office or at the hospital. Sound
 waves are passed through the abdomen or vagina and a picture is taken of your uterus and ovaries. This
will help determine the size and type of cyst you have, whether it is fluid filled or cystic.
Other tests: pregnancy test, CA-125 to assess the possibility of cancer, an MRI or CT scan

How are ovarian cysts treated?

Monitoring: most functional cysts go away after 1-3 menstrual cycles. You will be re-evaluated with
ultrasound 4-6 weeks after diagnosis to make sure the cyst has resolved. If it has, no further treatment is
indicated. However, the cyst may return.
Birth Control Pills: these stop the follicles from developing and producing eggs, gives the functional
cyst time to shrink, and prevents new cysts from forming.
Surgical Intervention: some cysts (dermoid, endometrioma, and cystadenoma) must be removed
surgically. Often this is done without removal of the ovary, although, sometimes the ovary must also be
removed.
 POLYCYSTIC OVARY SYNDROME (PCO/PCOS)
What is PCO?
Occurs when levels of certain hormones are abnormal.
Leads to irregularities of menstruation, absence of menstruation, infertility, excess hair growth,
infertility

What causes PCO?

A production of too much androgens (male sex hormones that promote male characteristics
including hair growth and voice deepening) leading to anovulation (no egg is produced)

What are the signs and symptoms of PCO?

Irregular menstrual bleeding
Amenorrhea absence of menstrual bleeding
Infertility difficulty becoming pregnant
Hirsutism unwanted excess hair growth on the face, chest, back, inner thighs, lower abdomen
In severe cases, balding, lowering of the voice, or bigger muscles may occur
Insulin resistance increased insulin levels, insulin that doesnt work properly

How is PCO diagnosed?

History and physical exam, including pelvic exam
Lab Tests: fasting insulin, 2 hour glucose tolerance test, hormone studies
Ultrasound: to look for multiple small cysts on the ovaries

How is PCO treated?

Lifestyle changes: diet and exercise, weight loss
Medications: hormones (birth control pills), medications to lower insulin levels, treat diabetes,
hypertension, thyroid problems, and high cholesterol
Hair removal methods: such as electrolysis, shaving, waxing to remove unwanted hair
 PELVIC ORGAN PROLAPSE
What is Pelvic Organ Prolapse?
Occurs when the pelvic support structures (ligaments and muscles) are weakened and allow for
the pelvic organs to drop down and press against the wall of the vagina, causing a bulge.
Sometimes, the organs press so much against the vagina that the bulge may come out through the
opening of the vagina

What causes Pelvic Organ Prolapse?

The main cause is pregnancy and childbirth, however, prolapse may occur in women that have
never been pregnant or given birth

What are the symptoms of Pelvic Organ Prolapse?

Pelvic heaviness or fullness, as if something is falling out of the vagina
Pulling or aching sensation in lower abdomen or pelvis
Leaking of urine or problems having bowel movements

What are the types of Pelvic Organ Prolapse?

Cystocele: also called anterior wall prolapse, occurs when the bladder drops from its normal
place into the vagina. This may cause leakage of urine with coughing, sneezing, lifting objects,
or walking
Vaginal Vault Prolapse with Enterocele: occurs after hysterectomy (removal of uterus) when
the top of the vagina loses its support and drops. An enterocele occurs when the small intestine
bulges through the supporting tissue into the vagina.
Rectocele: when the rectum bulges into or out of the vagina. Also called posterior wall prolapse.
Caused by weakness of the back wall of the vagina. May cause difficulty with bowel movements.
Uterine Prolapse: occurs when the uterus drops into the vagina. Mild uterine prolapse may not
cause problems. Severe uterine prolapse may cause a feeling of pelvic pressure, pulling in the
lower abdomen or back, or cause problems with intercourse. In severe cases, the cervix (opening
to the uterus) may stick out through the vaginal opening and become irritated or infected.

How is Pelvic Organ Prolapse diagnosed?

Complete history and physical exam, including vaginal and rectal exam
Bladder testing or cystometrics may be performed

How is Pelvic Organ Prolapse treated?

Kegels exercises: exercises specific to the pelvic muscles, used to strengthen the muscles that
surround the urethra, rectum, and vagina
Diet and Weight Control: avoid caffeine (soda, tea, coffee) as it can increase urination. Add
fiber to diet to help prevent constipation.
Medication: to help control bladder symptoms, to bulk or soften stool. Hormones can be used to
strengthen the vaginal tissues
Vaginal Pessaries: a plastic device that is inserted into the vagina that supports the pelvic
organs.
Surgical Repair: mesh is used to put the fallen organs back into their place, in the case of
cystocele, rectocele, or enterocele. Hysterectomy is utilized in the event of uterine prolapse.
 PELVIC PAIN
What is pelvic pain?
Pain that occurs in the pelvic or lower abdominal region of the body
It can come and go for brief periods of time or it can be constant
It can occur regularly after intercourse (sex), before or after eating, during urination, during
menstruation, or it can occur daily is severe cases
Can disrupt a womans life work, family, movement, sex, sleep, family duties, mental and
physical health
Pain that is present for 6 months or longer and does not improve with treatment is chronic pelvic
pain

What causes pelvic pain?

Acute Pelvic Pain:
Infection Pelvic Inflammatory Disease, urinary tract infections, vaginal infections
Ovarian Cysts
Ectopic pregnancy
Chronic Pelvic Pain:
Dysmenorrhea severe pain during menstruation
Ovulation Pain pain that occurs at the time of ovulation, Mittleschmerz
Endometriosis when tissue similar to the lining of the uterus is found outside the uterus
Adenomyosis when the lining of the uterus extends into the muscle wall of the uterus
Fibroids
Gastrointestinal problems diverticulitis, irritable bowel syndrome, inflammatory bowel
disease, constipation or cancer
Urologic problems kidney stones, infection, incontinence, bladder cancer, interstitial
cystitis
Muscular & Skeletal problems low back pain, herniated disks, pelvic floor muscle
spasms, fibromyalgia
Psychological problems depression, history of sexual abuse

How is pelvic pain diagnosed?

History and physical exam, including pap smear, sexually transmitted disease testing, pelvic
exam, possible rectal exam
Imaging Studies
Ultrasound using sound waves to take pictures of the uterus, ovaries, fallopian tubes
Cystoscopy using a small camera to look inside the bladder
Laparoscopy using a small camera to look inside the abdomen at the internal organs
Colonoscopy using a small camera to look inside the colon for cancer, polyps, diverticula
(small out-pouches of the sides of the colon or bowel)
Sigmoidoscopy using a small camera to look inside the sigmoid colon and rectum, or the
end of the bowels assess for cancer and polyps
CT or MRI scans highly specialized pictures of the organs of the pelvis
Intravenous Pyelography inserting dye into a vein and taking x-rays of it moving through
the kidneys, ureters, and bladder
Barium Enema a special solution is placed inside the rectum and x-ray pictures are taken
How is pelvic pain treated?
Medications antibiotics, anti-inflammatories, prescription pain relievers, hormones (birth
control pills), anti-depressants
Surgery dependent on the cause of pelvic pain, can be minor outpatient surgery or major
surgery (i.e. hysterectomy)
Counseling in the case of depression, history of sexual abuse or rape
Other treatments heat therapy, muscle relaxants, nerve blocks, mental exercises, physical
therapy, regular exercise, trigger point injections, nutrition therapy, acupuncture, biofeedback
 PREMENSTRUAL SYNDROME (PMS)

What is PMS?
Premenstrual Syndrome (PMS) is a medical condition with multiple emotional and physical
symptoms that can disrupt your health, career, personal life
Symptoms vary in type, timing, and severity from woman to woman, but they usually begin
during the two weeks before your menstrual period and end soon after your period begins.
As many as 80% of Amercian women have one or more symptoms of PMS

What are the symptoms of PMS?

EMOTIONAL SYMPTOMS
Irritability, easily angered or upset, increased tiredness or fatigue, decreased amount of sleep,
feelings of sadness or depression, confusion, forgetfullness, feeling as if you are out of
control for no reason
PHYSICAL SYMPTOMS
breast swelling and tenderness, bloating, temporary weight gain, change in bowel habits
(constipation or diarrhea), craving sweets such as ice cream, cake, candy.

What causes PMS?

Many theories exist, however, it's possible that low levels of serotonin (a chemical produced by
the brain) is the underlying cause of all symptoms of PMS
Serotonin helps to regulate your sleep cycle, menstrual cycle, and carbohydrate metabolism.
PMS symptoms are due to a disruption in these processes, women with PMS tend to have lower
levels of serotonin, making it the likely cause of the emotional and physical symptoms of PMS.

How is PMS diagnosed?

The symptoms associated with PMS may also be caused by other medical conditions, therefore,
it is important to keep a menstrual diary for two to three months to discuss with your physician.
A medical history will be obtained by your physician regarding your symptoms (when they start,
what they are, how they are affecting your life, are they getting worse as you get older, etc.)
A thorough physical exam will be performed including a breast and pelvic exam to make sure
there are no other possible causes of your symptoms.
Lab tests may be obtained, including a Pap Smear (cells obtained from the cervix), urinalysis, or
blood tests, which may include thyroid function and hormone levels.

How is PMS treated?

A healthy diet low in salt, fat and sugar; moderate intake of protein (poultry, beef, fish); and
mostly complex carbohydrates (whole grains, vegetables, fruits).
Avoid alcohol, nicotine, caffeine, artificial sweeteners as they may interfere with your normal
sleep cycle
Vitamin and mineral supplementation Vitamins B6, E, calcium, magnesium, and evening
primrose oil
Sleep Hygeine you should get at least 8 hours of uninterrupted sleep each night, sleep
consistent hours (go to bed and wake up at the same time each day), limit bed activity to sleeping
and sex (do not watch t.v. or read in bed), keep the room dark and quiet, have the room at a
comfortable temperature, sleep in a comfortable bed, keep pets out of the bedroom
Relaxation techniques deep breathing, visualization.
 Exercise walking, biking, swimming, stair climbing. Start slowly and gradually increase to 20-
30 minute sessions 3-4 times per week
Medical therapy diuretics (decrease bloating and water retention), antidepressants, hormones