- Premenstrual Syndrome
- Ovarian Cysts
- Uterine Leiomyomas
- Female Infertility
- Pelvic Inflammatory Disease
Premenstrual Syndrome: Also called PMS
-The effects of this disorder ranges from minimal discomfort to severe,
disruptive behavioral and somatic changes. Symptoms usually appear
7 to 14 days before menses and usually subside with its onset.
Cause: Direct cause unknown, PMS may result from a progesterone
deficiency in the luteal phase ot the menstrual cycle or from an increased
estrogen-progesterone ratio. Approximately 10% of patients with PMS
have elevated prolactin levels
Behavioral changes: Mild to severe personality changes
Somatic changes :
Breast tenderness or swelling
Abdominal tenderness or bloating
Diarrhea or constipation
Patient may also experience exacerbations of skin problems such as;
ache – respiratory problems such as asthma, and neurologic problems such
Treated symptomatically: treatment may include;
Antidepressants, NSAID’s (nonsteroidal anti-inflammatory drugs),
Treatment may require; a diet that is low in simple sugars, caffeine,
and salt, with adequate amounts of protein, high amounts of complex carbohydrates,
and possibly, vitamin supplements formulated for PMS
There is also a self – help groups that exist for women with PMS check
in your local area.
Ovarian Cysts: Usually, these cysts are
nonneoplastic sacs that contain fluid or semisolid material. Ovarian
cysts are usually small and produce no symptoms, ovarian cysts should be
thoroughly investigated as possible sites of malignant change. Common
types ;include follicular, cysts, which are usually very small, semitransparent,
and fluid-filled; and lutein cysts, including corpus luteum cysts, which
are functional, nonneoplastic enlargements of the ovaries; and theca-lutein
cysts, which are commonly bilateral and filled with clear, straw-colored
fluid. Polycystic (or sclerocystic) ovary disease is part of the
Ovarian cysts can develop any time between puberty and menopause, including
during pregnancy. Corpus luteum cysts occur infrequently, usually
during early pregnancy.
Cause: Follicular cysts arise from follicles that over
distend instead of going through the atretic stage of the menstrual cycle.
Corpus luteum cysts are caused by excessive accumulation of blood during
the hemorrhagic phase of the menstrual cycle. Theca-lutein cysts
are commonly associated with hydatidiform mole, choriocarcinoma, or hormone
therapy. Polycystic ovary disease results from endocrine abnormalities.
Usually small cysts produces no symptoms, unless torsion or rupture
causes signs of acute abdomen.
Low back pain
Mild pelvic discomfort
Dyspareunia ( difficult and or painful intercourse)
Abnormal uterine bleeding
Acute abdominal pain (similar to that of appendicitis) -in ovarian cysts
In corpus luteum cysts appearing early in pregnancy, the patient may
develop unilateral pelvic discomfort and (with rupture) massive intraperitoneal
In polycystic ovary disease, the patient may develop amenorrhea ( abnormal
absence or stoppage of menses), Oligomenorrhea (abnormally infrequent menstruation),
or infertility secondary to the disorder as well as bilaterally enlarged
Follicular cysts usually don’t require treatment because they tend to
disappear spontaneously within 60 days. If they interfere with daily
activities, Clomiphene citrate P.O. for 5 days or progesterone I.M. for
5 days, reestablishes the ovarian hormonal cycle and induces ovulation.
Oral contraceptives may also accelerate involution of functional cysts
(including both types of lutein cysts and follicular cysts).
Treatment for corpus luteum cysts that occur during pregnancy is symptomatic
because these cysts diminish during the third trimester and rarely require
Theca-lutein cysts disappear spontaneously after elimination of hydatidiform
mole or choriocarcinoma, or discontinuation of HCG or clomiphene citrate
Polycystic ovary disease treatment may include; drugs, such as clomiphene
citrate to induce ovulation or if drug therapy fails to induce ovulation,
surgical wedge resection of one-half to one-third of the ovary.
Surgery may become necessary for both diagnosis and treatment.
For example, a cyst that remains after one menstrual period should be removed.
Pathologic studies confirm the diagnosis.
Endometriosis: Endometrial tissue appears outside
the lining of the uterine cavity. This ectopic tissue usually remains
in the pelvic area, most commonly around the ovaries, uterovesical peritoneum,
uterosacral ligaments, and the cul-de-sac, but it can appear anywhere in
the body. Active endometriosis usually occurs between ages 30 and 40, more
so in women who postpone child-bearing. It is uncommon before age
20. Severe symptoms of endometriosis may occur abruptly ore develop
slowly over many years. Endometriosis usually becomes progressively
severe during the menstrual years, and subsides after menopause.
Infertility is the primary complication. Spontaneous abortion may
Cause: Direct cause is unknown, but familial susceptibility
or recent surgery that required opening the uterus may predispose a woman
to edometriosis. Researcher shows the possible cause of endometriosis
1.) trasportation—during menstruation, the fallopian tubes expel
endometrial fragments that implant of the ovaries or pelvic peritoneum
2.) formation in situ–inflammation or a hormonal change triggers metaplasia
(differentiation of coelomic epithelium to endometrial epithelium)
3.) induction–this is a combination of transportation and formation
in situ and is the most likely cause. The endometrium chemically
induces undifferentiated mesenchyma to form endometrial epithelium
Dysmenorrhea (painful menstruation)– Pain usually begins 5 to
7 days before menses reaches its peak and last for 2 to 3 days. It
is less cramping and less concentrated in the abdominal midline than primary
Lower abdominal pain and in the vagina —
Pain to posterior pelvis and back
Multiple tender nodules on uterosacral ligaments or in the rectovaginal
system. They enlarge and become more tender during menses.
Ovarian enlargement may also be evident.
Other symptoms depend on the location of the ectopic tissue:
Ovaries and oviducts–infertility and profuse menses
Ovaries or cul-de-sac–deep-thrust dyspareunia (painful intercourse)
Bladder–suprapubic pain, dysuria (painful or difficulty urinating),
hematuria (Presence of blood in the urine)
Rectovaginal septum and colon–painful defecation, rectal bleeding with
menses, pain in the coccyx or sacrum
Small bowel and appendix–nausea and vomiting, which worsen before menses,
and abdominal cramps
Cervix, vagina, and perineum–bleeding from endometrial deposits in
these areas during menses
Diagnostic tests: Laparoscopy may confirm the diagnosis
and determine the stage of the disease. barium enema rules out malignant
or inflammatory bowel disease.
Treatment varies according to the stage of the disease and t he patient’s
age and the desire t have children.
For young women who want to have children includes: androgens,
such as danazol, which produce a temporary remission in Stages I and II.
Oral contraceptives and progestins also relieve symptoms.
Stage III and IV (when ovarian masses are present), they should be removed
to rule out cancer. The patient may undergo conservative surgery,
but the treatment of choice for women who don’t want to bear children or
who have extensive disease (StageIII and IV) is a total abdominal hysterectomy
performed with bilateral salpingo-oophorectomy.
Uterine leiomyomas: Known also as Myomas,
Fibromyomas, and Fibroids, these neoplasms (tumor; any new and abnormal
growth) art the most common benign tumors in women. They usually
occur in the uterine corpus, although they may appear on the cervix or
on the round or broad ligament. Uterine Leiomyomas are usually multiple
and usually occur in women over age 35; they affect blacks three times
more often than whites.
Cause: The cause is unknown, but excessive levels of estrogen
and human growth hormone (HGH) probably influence tumor formation by stimulating
susceptible fibromuscular elements. Large doses of estrogen and the
later stages of pregnancy increase both tumor size and HGH levels.
When estrogen production decreases, uterine leiomyomas usually shrink or
disappear (usually after menopause)
Submucosal hypermenorrhea (excessive menstrual bleeding, but occurring
at regular intervals and being of usual duration)
Possibly other forms of abnormal endometrial bleeding
Dysmenorrhea (abnormally painful menses)
If tumor is large, the patient may develop a feeling of heaviness in
Urinary frequency or urgency
Irregular uterine enlargement
Blood studies/ anemia will support the diagnosis
D&C (dilatation and curettage)
Submucosal hysterosalpingoraphy – detects submucosal leiomyomas
Laparoscopy – visualizes subserous leiomyomas on the uterine surface
Treatment of choice for women who desire to have children – A surgeon
may remove small leiomyomas that have caused problems in the past or that
appear likely to threaten a future pregnancy
Tumors that twist or grow large enough to cause intestinal obstruction
require a hysterectomy, with preservation of the ovaries if possible
Pregnant patient: If a patient uterus no larger than a 6 month
normal uterus by the 16th week of pregnancy, the outcome for the pregnancy
remains favorable, and surgery is usually unnecessary. However if
a pregnant woman has a leiomyomatous uterus the size of a 5 to 6 month
normal uterus by the 9th week of pregnancy, spontaneous abortion will probably
occur, especially with a cervical leiomyoma. If surgery is necessary,
a hysterectomy is usually performed 5 to 6 months after delivery (when
involution is complete), with preservation of the ovaries if possible
Appropriate intervention depends on the severity of symptoms, the size
and location of the tumors, and the patient’s age, parity, pregnancy status,
desire to have children, and general health.
Call your doctor immediately if there is any abnormal bleeding or pelvic
Menopause: The mechanisms of menstruation
cease to function. Menopause results from a complex, long term syndrome
of physiologic changes, the climacteric-cause by declining ovarian function.
Cause: Physiologic menopause, the normal decline
in ovarian function caused by aging, begins in most women between ages
40 and 50 and results in infrequent ovulation, decreased menstruation,
and eventually, cessation of menstruation ( usually ages 45 – 55)
Pathologic menopause (premature menopause), the gradual or abrupt
cessation of menstruation before age 40, cause unknown, however certain
disorders, especially severe infections and reproductive tract tumors,
may cause pathologic menopause by seriously impairing ovarian function.
Other factors that may incur pathologic menopause include malnutrition,
debilitation, extreme emotional stress, excessive radiation exposure, and
surgical procedures that impair ovarian blood supply.
Artificial menopause is the cessation of ovarian function following
radiation therapy or surgical procedures.
Declining ovarian function and decreased estrogen levels accompanying
all forms of menopause produce various menstrual irregularities;
Decrease in the amount and duration of menstrual flow
Episodes of amenorrhea (absence or abnormal stoppage of menses) and
polymenorrhea (abnormal frequent menstruation) (possible with hypermenorrhea)-excessive
These irregularities may last only a few months or may persist for several
years before menstruation ceases permanently.
Changes in the body’s systems usually don’t occur until after the permanent
cessation of menstruation
Reproductive system: changes may include; shrinkage
of vulval structures and loss of subcutaneous fat, possible leading to
atrophic vulvitis; atrophy of vaginal mucosa and flattening of vaginal
rugae, possibly causing bleeding after coitus or douching; vaginal itching
and discharge from bacterial invasion; and loss of capillaries in the atrophying
vaginal wall, causing the pink, rugose lining to become smooth and white.
Menopause may also produce excessive vaginal dryness and dyspareunia due
to decreased lubrication from the vaginal walls, and decreased secretion
from Bartholin’s glands; a reduction in the size of the ovaries and oviducts;
and progressive pelvic relaxation as the supporting structures of the reproductive
tract lose their tone from the absence of estrogen
Urinary system: Atrophic cystitis, resulting from
the effects of decreased estrogen levels on bladder mucosa and related
structures, may produce pus in the urine (pyuria), painful or difficulty
urinating (dysuria), and urgency, and incontinence. May have on occasion
have blood in the urine (hematuria)
Breasts: Menopause may cause reduced breast size
Integumentary system: Estrogen deprivation may lead
to loss of skin elasticity and turgor. The patient may have slight
alopecia (balding), and may experience loss of pubic and axillary hair.
Autonomic nervous system: Hot flashes and night
sweats. Patient may experience vertigo, syncope, tachycardia, dyspnea,
tinnitus, emotional disturbances such as irritability, nervousness, crying
spells, and fits of anger. Patients may also experience and exacerbation
of preexisting neurotic disorders such as; depression, anxiety, and compulsive,
manic, or schizoid behavior
Vascular and musculoskeletal systems: Menopause
may also induce atherosclerosis and osteoporosis.
Artificial menopause, without estrogen replacement, produces symptoms
within 2 to 5 years in 96% of women. Since menstruation in both pathologic
and artificial menopause often ceases abruptly, severe vasomotor and emotional
disturbances may result.
Menstrual bleeding after 1 year of amenorrhea may indicate organic disease
Since physiologic menopause is a normal process, it may not require
Atypical or adenomatous hyperplasia requires drug therapy
Cystic endometrial hyperplasia doesn’t require treatment
If osteoporosis occurs, calcium is given
Women who take estrogen must be monitored regularly to detect possible
cancer early. If the uterus remains progestin is recommended in addition
Female Infertility: Infertility may be
caused by any defect or malfunction of the hypothalamic – pituitary – ovarian
axis, such as certain neurologic diseases. Other possible cause include:
Cervical factors, such as infection and possibly cervical
antibodies that immobilize sperm
Tubal and peritoneal factors, such as tubal loss or impairment
secondary to ectopic pregnancy
Uterine abnormalities, such as; congenitally absent, double
uterus; leiomyomas or Asherman’s syndrome, in which the anterior and posterior
uterine walls adhere because of scar tissue formation
Approximately 15% of all couples in the US cannot conceive after regular
intercourse for at least 1 year without contraception. 45 to 50%
of all infertility is attributed to the female.
Diagnosis requires a complete examination and health history.
Questions includes patient’s reproductive and sexual function, past diseases,
mental state, previous surgery, types of contraception used in the past,
and family history
Intervention aims to correct the underlying abnormality or dysfunction
within the hypothalamic-pituitary-ovarian complex.
Hormone therapy may be necessary in hyperactivity ;or hypoactivity of
the adrenal or thyroid gland
Progesterone replacement for progesterone deficiency
Anovulation requires treatment with clomiphene citrate
If mucus production decreases (an adverse effect of clomiphene citrate),
small doses of estrogen may be given concomitantly to improve the quality
of cervical mucus
Surgical restoration may correct certain anatomic causes of infertility,
such as fallopian tube obstruction
Artificial insemination has proven to be an effective alternative strategy
for dealing with infertility problems
In vitro (test tube) fertilization has also been successful
Pelvic Inflammatory Disease: Or PID
– recurrent, acute, subacute, or chronic infection of the oviducts
and ovaries, with adjacent tissue involvement. PID may refer to inflammation
of the cervix, uterus, fallopian tubes, and ovaries, which can extend to
the connective tissue lying between the broad ligaments (parmetritis).
Early diagnosis and treatment prevent damage to the reproductive system.
Complications of PID may include potentially fatal septicemia, pulmonary
emboli, shock and infertility. Untreated PID may be fatal.
Clinical features vary with the affected area.
They may include profuse, purulent vaginal discharge
Lower abdominal pain
Three types of PID:
Salpingo-oophoritis (fallopian tubes, and ovaries):
Acute: sudden onset of lower abdominal and pelvic pain, usually after
menses, increased vaginal discharge; fever; malaise; lower abdominal pressure
and tenderness; tachycardia; pelvic peritonitis
Chronic: recurring acute episodes
Cervicitis (inflammation of the cervix): Acute-
purulent, foul-smelling vaginal discharge; vulvovaginitis, with itching
or burning; red, edematous cervix; pelvic discomfort; sexual dysfunction;
metrorrhagia; infertility; spontaneous abortion
Chronic- cervical dystocia, laceration or eversion of the cervix, ulcerative
vesicular lesion (when cervicitis results from herpes simplex virus type
Endometritis (inflammation of the uterus): Acute-
mucoopurulent or purulent vaginal discharge oozing from cervix; edematous,
hyperemic endometrium, possible leading to ulceration and necrosis; lower
abdominal pain and tenderness; fever; rebound pain; abdominal muscle spasm;
thrombophlebitis of uterine and pelvic vessels
Chronic- recurring acute episodes (more common from multiple sexual
partners and sexually transmitted infections)
Cause: PID can result from infection with aerobic or anaerobic
Risk factors: Any sexually transmitted infection
More than one sex partner
Conditions or procedures, such as cauterization of the cervix, that alter
or destroy cervical mucus, allowing bacteria to ascend into the uterine
Any procedure that risks transfer of contaminated cervical mucus into the
endometrial cavity by instrumentation such as use of a biopsy curet
Infection during or after pregnancy
Infectious foci within the body, such as drainage from a chronically infected
Effective management eradicates the infection, relieves symptoms, and
avoids damaging the reproductive system.
Aggressive therapy with multiple antibiotics begins immediately after
culture specimens are obtained.
Infection may become chronic if treated inadequately
Supplemental treatment of PID may include bed rest, analgesics, and
Narcotics may be needed, NSAID’s are preferred for pain relief.
Development of a pelvic abscess requires adequate drainage. A
ruptured pelvic abscess is a life-threatening condition. If this
complication develops, the patient may need a total abdominal hysterectomy,
with bilateral salpingo-oophorectomy
See Vaginal problems for more information
Vaginismus: Painful spasm of the vagina.