Vaginitis is an inflammation of the vagina. The normal environment of the vagina is acidic which helps to prevent overgrowth of organisms that can cause vaginitis. When disruption of the lining occurs due to extreme stress or antibiotic use, women may develop vaginitis.

There are different types of vaginitis. The most common are:

• Yeast vaginitis caused by Candida albicans (a yeast)
• A bacterial infection called bacterial vaginosis
• Vaginitis related to sexually transmitted diseases such as Trichimonas

Any woman can get vaginitis.

Signs and symptoms vary depending on what type of vaginitis you have but may include:

• Vaginal discharge
• Itching
• Burning
• Foul odor
• Pain/irritation with sexual intercourse
• Inflammation (irritation, redness, and swelling caused by the presence of extra immune cells) of the labia majora, labia minora, or perineal area
• General vaginal irritation

Prevention of yeast infections (candidiasis), the most common type of vaginitis, starts with good hygiene:

• Drying completely after bathing
• Wearing fresh undergarments
• Wiping from front to rear after defecation

Douching is not recommended, as it upsets the normal balance of yeast in the vagina.

Treatment depends on the type of vaginitis. For uncomplicated yeast infections, over-the-counter antifungal creams can be used. In some situations, women may be given a prescription pill called Diflucan to treat a yeast infection. For bacterial vaginosis, either oral or vaginal forms of the medications Flagyl or Clinidamycin can be used. For trichimonas, a single dose of Flagyl is used. Other types of vaginal infections are treated based on specific findings on exam or culture results.

Abnormal uterine bleeding can occur for a number of reasons, including problems with ovulation, a hormonal imbalance or abnormalities of the vagina, cervix or uterus.

Abnormal bleeding includes:

• Bleeding that is prolonged – longer than a woman’s normal menstrual period
• Too frequent – less than 21 days from the first day of one episode of bleeding to the first day of the next
• Heavier than usual or requiring more than a pad every hour during the heaviest time

Common reasons for abnormal uterine bleeding include:

• Anovulation – Lack of normal cyclic bleeding due to problems with hormone secretion by the ovary. This usually can be diagnosed by a history and physical examination. Blood tests for hormone levels are sometimes helpful. Treatment usually involves correcting the hormonal imbalance with medication.
• Abnormalities of the vagina and cervix – Infections or other conditions of the vagina and cervix sometimes can cause bleeding, though usually this is light and may be associated with intercourse. Post-menopausal women sometimes can have thinning of the vaginal walls that can lead to light bleeding. Abnormalities of the cervix, including cervical cancer, also can cause bleeding. These conditions can be diagnosed by physical examination and office tests.
• Uterine Fibroids – Fibroids are non-cancerous (benign) growths that develop within the uterus. Most women with fibroids have no symptoms and don’t need treatment. When symptoms occur, women should seek medical attention.
• Endometrial polyps – These are benign growths in the uterine lining that can lead to irregular uterine bleeding. They can be removed by hysteroscopy, a procedure during which a slender “telescope” is inserted through the vagina and cervix into the uterine cavity to allow examination of the cavity and removal of the polyps.
• Endometrial cancer – In women who have experienced menopause, abnormal bleeding can sometimes be a sign of endometrial cancer, or cancer of the lining of the uterus. This usually can be diagnosed by tests done in the office, including an endometrial biopsy in which some cells are removed from the endometrius. Endometrial cancer can be treated with surgery if diagnosed early.

To determine the cause of abnormal uterine bleeding, patients undergo a pelvic exam, including a Pap smear and lab tests to check for any underlying causes. A pregnancy test may also be done when appropriate. An ultrasound is used to check for any abnormalities, such as fibroids. An endometrial biopsy, hysteroscopy, or D&C may also be performed to further evaluate the condition of your uterus.

Heavy bleeding often can be decreased or stopped by endometrial ablation, a procedure in which the uterine lining is removed or destroyed. Some women choose hysterectomy, or removal of the uterus, as the most definitive way of ending abnormal bleeding once and for all.

Abnormal bleeding may be treated with hormones such as oral contraceptive pills. Sometimes hysteroscopy is required to remove a polyp or small fibroid.

A sexually transmitted disease (STD) is an illness that has a significant probability of transmission between humans by means of sexual behavior.

There are numerous sexually transmitted diseases and the consequences of untreated sexually transmitted diseases can be very serious for women. Untreated STDs can lead to chronic pelvic pain, loss of fertility, or even death. Early identification and treatment results in less chance to spread disease, and for some conditions may improve the outcomes of treatment.

Not all STDs are symptomatic. Symptoms may also not appear immediately after infection. In some instances a disease can be carried with no symptoms, which leaves a greater risk of passing the disease on to others.

Most Common STDs include:

• Chlamydia trachomatis is the most common sexually transmitted disease in North America. Caused by bacteria, it results in a genital infection and must be treated with antibiotics. It can lead to chronic pelvic pain and infertility if not treated with antibiotics because it can spread to other pelvic organs. Your sexual partner will need to be treated also.
• Herpes genitalis is another common STD. It is a viral infection and doesn’t lead to chronic pelvic pain or infertility, but it can cause a very painful and disturbing genital blisters. Often the woman with herpes also will experience flu-like feelings or a headache, or swollen glands. Antiviral medications can be prescribed that will reduce pain and discomfort. There is no cure for the infection itself, although it may be dormant indefinitely.
• Venereal or genital warts (also called condyloma accuminata) are caused by a virus. They also can cause abnormal pap smears. Creams and some other medicines can cause the warty tissue to disappear but the warts may recur.
• Gonorrhea is another common STD. It is caused by bacteria and can be treated with an antibiotic. The woman and her partner both need to be treated. Women often don’t have symptoms but a vaginal discharge or painful urination may occur. Men are more likely to have discharge and painful urination. Untreated, gonorrhea can spread to other parts of the body and cause serious complications.
• Trichomonas may cause a woman to experience foul discharge and extreme itching. It can be treated with antibiotic. Partners need to be treated too.
• Syphilis is not as common as the above diseases but can have very serious consequences for women and their babies. It can cause a painless ulcer, but often there will be no obvious symptoms. Syphilis is caused by bacteria and can be treated by antibiotics. The woman and her partner need to be treated.
• HIV/AIDS are viral infections that can be transmitted sexually, from mother to baby during birth, or through infected blood. There are presently no cures for these diseases, but they can be managed with antivirals and other medications. HIV/AIDS can destroy a person’s natural disease resistance system leaving him or her vulnerable to a number of different conditions.
• Hepatitis B is a viral infection that can be transmitted sexually, from mother to baby during birth, or through infected blood. There is presently no cure for this disease but it can be managed with antivirals and other medicines. Hepatitis B is a serious liver disease. Vaccine is available to prevent contracting Hepatitis B, which can also be transmitted via infected blood.

If you’re concerned that you may have contracted or been exposed to an STD, you will need an examination. The doctor will examine the vagina, cervix and pelvic organs and use swabs to take cell samples to determine if an STD is present. Several tests may be necessary, as many of the STDs can occur at the same time. Results may take several days, but treatment can often be started at the first visit.

After initial infection, there is often a time frame during which an STD test will be negative. During this period the infection may be transmissible. The duration of this period varies depending on the infection and the test.

Treatments include:

• Antibiotic and antiviral medications can be given to treat gonorrhea, chlamydia, herpes, syphilis and trichomonas.
• Genital warts can be treated in the gynecologist’s office or at home.
• HIV/AIDS and Hepatitis B will require referral to specialists for evaluation.

Chronic pelvic pain has many possible causes, and the symptoms may vary with what’s causing the pain. Pain can be caused by a gynecologic condition, or be the result of an intestinal, urinary or muscular problem. Pelvic pain can even be a manifestation of stress or depression.

Common reasons for pelvic pain include:

• Pelvic Adhesions – Adhesions are bands of scar tissue that bind organs together. They are created by previous infections such as appendicitis or pelvic inflammatory disease, by pelvic or abdominal surgery or by endometriosis. Symptoms from adhesions include generalized pelvic discomfort or localized pain. Adhesions can be difficult to diagnose, however in some cases, the uterus and ovaries feel bound together on pelvic examination. A definitive diagnosis of adhesions is usually made during surgical exploration, frequently via laparoscopy. Surgery to cut bands of scar tissue can relieve pain. However, sometimes the adhesions re-form.
• Uterine Fibroids – Fibroids are non-cancerous (benign) growths that develop within the uterus. Most women with fibroids have no symptoms and don’t need treatment. When symptoms occur, women should seek medical attention.
• Ovarian Cysts – Cysts are closed sacs that contain fluid, semifluid or solic material.
• Irritable Bowel Syndrome – This is a very common cause of pelvic pain. It may be associated with diarrhea, constipation or a combination of both. Symptoms of bloating and discomfort may be relieved by a bowel movement. Stress and diet can aggravate the condition. The gynecology provider may make a referral to a gastrointestinal specialist for diagnosis and treatment.
• Bladder Problems – Pelvic pain may be triggered by a bladder condition. Pain associated with the need to urinate frequently or urgently may need to be evaluated by a urologist.
• Myofacial Trigger Points – Chronic pain can be created by spasm of the muscles that line the pelvis. On pelvic examination, there may be tenderness and tightness in particular muscles.
• Depression – Recurring or chronic pain can cause some women to feel depressed. These feelings are normal. In some cases, pelvic pain can be a symptom of depression or anxiety.
• Endometriosis – This is a condition in which the lining of the uterus (endometrium) grows outside the uterus. The lining can attach to the ovaries, fallopian tubes, intestines or other structures in the pelvis. It may cause pelvic pain, especially during menstruation. Hormones of the menstrual cycle cause the endometriosis to bleed each month. This can be painful and result in the formation of pelvic adhesions, also known as scar tissue. Blood trapped in the ovary can build up into a cyst. This is called an endometrioma.
• Vulvodynia – Vulvodynia is pain at the opening to the vagina or the surrounding lips (vulva). The cause is unknown. It’s thought that the nerves, muscles and tissues in the area are inflamed, so treatment is focused on addressing these factors. Women with this condition may find it painful to insert a tampon, have sexual intercourse or even wear tight pants. Symptoms include burning, stinging, stabbing, irritation and rawness. The pain may be constant or intermittent, localized or diffuse.
• Musculoskeletal Causes – The muscles, joints and nerves in the pelvis can be injured just like any other part of your body. For instance, tissues can be overstretched, torn or cut in childbirth or surgery; muscles can weaken or tighten from disuse and injury; and habitual postures and movements can slowly stretch or compress structures in the pelvis, leading to pain and dysfunction. The pelvic muscles, joints and nerves may be the sole cause of pain or just a piece of the problem. A thorough examination of the abdomen and pelvis can uncover these sources of pain, which can be treated with physical therapy and biofeedback.

Treatment for chronic pelvic pain is tailored to each patient, depending on the underlying causes of the pain. Some treatment options include:

• Hormones for conditions such as endometriosis or heavy menstrual bleeding.
• Pain medications such as narcotics, nonsteroidal anti-inflammatories or medicines for nerve pain.
• Surgery for some women with adhesions, adenomyosis or endometriosis.
• Physical therapy and biofeedback for women with myofascial (connective tissue) or muscle pain.
• Mind/body techniques such as meditation, breathwork, guided imagery and yoga.
• Nutrition and supplements — for instance, a diet rich in fruits, vegetables and grains is important. Avoiding foods that can increase inflammation and increasing foods that decrease inflammation can be useful.
• Alternative healing systems such as traditional Chinese medicine, which have been found to help relieve pain.
• Psychological therapy, medication, or both to help you cope with chronic pain. A therapist can offer support and tools to handle living with chronic pain, and can also help you and your partner cope with the relationship and sexual issues that can arise as a result of chronic pain.

An ovarian cyst is a closed sac within the ovary that contains fluid or solid material. The majority of ovarian cysts in pre-menopausal women will be “normal” cysts, related to development of the egg in the ovary and ovulation. These cysts will almost always go away over time.

Many women at some time in their lives will be diagnosed with an ovarian mass or cyst. Ovarian cysts affect women of all ages, however they occur most often during a woman’s childbearing years.

Sometimes cysts are found because a woman is having pain or discomfort, and sometimes they are felt on a routine pelvic examination.

When a cyst or mass is found in a woman who is still having normal periods, it is important to monitor it to see if it gets smaller or resolves over the course of four to six weeks. An ultrasound, an imaging test that uses sound waves to create a picture of the inside of the body, is an accurate and painless way to monitor an ovarian cyst. Cysts that get smaller between two different ultrasounds usually require no further treatment.

Pain caused by ovarian cysts may be treated with:

• Pain relievers
• A warm bath
• A heating pad or hot water bottle applied to the lower abdomen near the ovaries can relax tense muscles and relieve cramping, lessen discomfort, and stimulate circulation and healing in the ovaries
• Bags of ice covered with towels can be used alternatively to the heading pad to increase local circulation
• Combined oral contraceptive pill to regulate the menstrual cycle, prevent the formation of follicles that can turn into cysts, and possibly shrink an existing cyst
• Limiting strenuous activity may reduce the risk of cyst rupture or torsion

Ovarian cysts that don’t get significantly smaller or disappear over the course of a month or two are more likely to be tumors. These tumors are generally benign, or non-cancerous, especially in younger women. Sometimes ultrasound or other imaging tests, such as an MRI, can determine that the cysts are non-cancerous. If they are also small and don’t cause any symptoms, they can often just be monitored periodically. If a cyst is larger, or if it is difficult to accurately determine the kind of cyst, it will most likely need to be removed surgically.

Ovarian cysts or masses can often be removed via laparoscopy, a surgical technique that uses several tiny incisions in the abdomen. Sometimes, if the cyst is quite large or if a woman is older, it is better to do the operation through a larger abdominal incision.

Often just the cyst or mass can be removed, leaving the ovary in place, but sometimes it is necessary to remove the entire ovary. If an ovary is removed, the other remaining ovary will take over the function for both ovaries, so menstrual periods and fertility generally aren’t affected.

Menopause is defined as the period in time when the ovaries cease functioning and menstrual periods stop. Several years before the onset of menopause, the production of hormones in a woman’s body begins to decline. This is called perimenopause or climacteric, meaning the time from when menstrual periods start to diminish up to a year after the final menstrual period.

Menopause is a phase of a normal woman’s life, one that more than 4,000 women enter each day. In North America the average age of menopause is 51.

Common symptoms of menopause include:

• Reduced fertility
• Changes in menstrual periods
• Hot flashes
• Vaginal dryness
• Insomnia
• Emotional changes
• Libido changes

Most of these symptoms will stop after menopause is completed.

However, menopause also increases the risk of contracting heart disease or osteoporosis, which continue after menopause is completed. Although not associated with menopause, cancer is associated with advancing age in women.

Perimenopause is a natural stage of life, therefore it does not automatically require any kind of medical treatment at all. However, in cases where the physical, mental, and emotional effects of perimenopause are strong enough that they significantly disrupt the everyday life of the woman experiencing them, treatment aimed at alleviating symptoms rather than altering menopause may be appropriate.

• Lifestyle changes
• Nonprescription medications
• Prescription therapies, including hormone replacement therapy
• Lubricants for vaginal dryness
• Antidepressants for emotional changes
• Preventive medications or supplements for chronic post-menopausal conditions such as osteoporosis and heart disease

Fibroids are non-cancerous or benign growths that develop in the uterus.

Fibroids are the most common benign tumors in females and typically found during the middle and later reproductive years. As many as 30 percent of women have one or more of these tumors, which range in size from as small as a pea to as large as a melon. The condition is about twice as common in African American women as Caucasian women.

Most women with fibroids have no symptoms and don’t need treatment. But if symptoms occur, you should seek medical attention.

Symptoms of fibroids may include:

• Heavy Vaginal Bleeding — Some women experience excessive menstrual bleeding. Some women describe soaking through sanitary protection in less than an hour, passing blood clots and being unable to leave the house during the heaviest day of flow. If this blood loss occurs, you may develop anemia, or a low blood count, that can cause fatigue or lightheadedness.
• Pelvic Pressure or Discomfort — Women with large fibroids may have a sense of heaviness or pressure in the lower abdomen or pelvis. This discomfort is similar to pregnancy when the enlarging uterus presses against surrounding structures.
• Bladder Changes — The most frequent bladder symptom is the need to urinate more frequently. You may awaken several times during the night to urinate or you may be unable to urinate despite the sensation of a full bladder. Bladder symptoms are caused by fibroids pressing against the bladder, reducing its capacity to hold urine or blocking the urine from flowing.
• Pelvic Pain — A less common symptom is severe pain. This occurs when a fibroid goes through a process called degeneration, usually because it outgrows its blood supply. The pain is usually localized and subsides within two to four weeks.
• Low Back Pain — Fibroids that press against the muscles and nerves of the lower back can cause back pain.
• Rectal Pressure — Fibroids also can press against the rectum and cause a sense of rectal fullness, difficulty having a bowel movement or pain with bowel movements. Occasionally, fibroids can lead to the development of a hemorrhoid.

Treatment for fibroids can range from no treatment at all to surgery. Unless fibroids are causing excessive bleeding, discomfort or bladder problems, treatment usually isn’t necessary. Treatments depend on the size and location of the fibroid.

Symptomatic uterine fibroids can be treated by:

• Medication to control symptoms
• Contraceptive pills to reduce bleeding and regulate the menstrual cycle
• Medication aimed at shrinking tumours
• Intrauterine devices (IUD) to decrease bleeding caused by fibroids
• Ultrasound fibroid destruction
• Various surgically aided methods to reduce blood supply of fibroids
• Myomectomy or radio frequency ablation
• Hysterectomy

After menopause fibroids shrink and it is unusual for fibroids to cause problems.

Endometriosis is a condition in which tissue from the membrane normally lining the uterus — the endometrium — grows outside the uterus, typically on the ovaries, fallopian tubes, intestines or other areas in the pelvis. This tissue acts just like the endometrium in accumulating blood in the monthly menses period, but it has no place to shed the blood at the end of the cycle. The accumulation of tissue and blood can cause inflammation and scarring, which can lead to other conditions, particularly pelvic pain and infertility. Blood trapped in the ovaries also can develop into benign cysts called endometrioma.

Endometriosis affects more than one million women in North America and at this time, the exact cause of condition is unknown. Endometriosis is typically seen during the reproductive years. It occurs in roughly 5-10% of women. Between 25 and 50 percent of infertile women are estimated to have endometriosis.

Symptoms of endometriosis typically worsen over time. The severity of symptoms may vary and some women with the condition may not experience any symptoms at all. Symptoms may stop after menopause or during pregnancy, though will begin in women after they have a baby and begin menstruating again.

Common symptoms may include:

• Pelvic pain and cramping before and during periods
• Lower back and stomach pain during periods
• Excessive bleeding during periods
• Pelvic pain during intercourse
• Fatigue
• Diarrhea
• Constipation
• Nausea
• Infertility

It is important to note that these symptoms can occur with other conditions. If you’re experiencing any of these symptoms, see your doctor to determine the cause.

There is currently no cure for endometriosis. In many cases, menopause will stop the process. In patients in the reproductive years, the goal of endometriosis treatment is to provide pain relief, to restrict progression of the process, and to restore or preserve fertility where needed.

Treatment may depend on the severity of your condition, your age and whether or not you are planning to have children, and whether you have any other associated conditions. Treatments include:

• Hormonal therapies to slow the growth of endometriosis. These include birth control pills, progestins, Danazol and the newer drugs known as aromatase inhibitors, which act by interrupting local estrogen formation within the endometrial growths.
• Over-the-counter pain relievers to manage pelvic pain and menstrual cramping.
• Surgery for some women who are trying to get pregnant and for those who suffer from severe pelvic pain. With the use of cystectomy and ablative surgery, pregnancy rates are approximately 40%.
  • Conservative surgery removes endometrial growths, scar tissue and adhesions without removing reproductive organs.
  • In the most severe cases, a hysterectomy — with or without the removal of the ovaries — is performed. This is typically a last resort, particularly for women who are still in their reproductive years.

While surgery can be very effective in treating endometriosis, the recurrence rate of the condition after surgery is an estimated 40 percent.

Women who are experiencing infertility due to endometriosis may also benefit from treatment from an infertility specialist.