Section 22. Women's Health Issues

Chapter 242. Symptoms and Diagnosis of Gynecologic Disorders

Topics: Introduction | Symptoms | Gynecologic Evaluation

Symptoms

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

Vaginal Itching

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

Vaginal itching may result from irritation by chemicals, such as those in laundry detergents, bleaches, fabric softeners, synthetic fibers, bubble baths, soaps, feminine hygiene sprays, perfumes, menstrual pads, fabric dyes, toilet tissue, vaginal creams, douches, and contraceptive foams. Vaginal itching may result from an infection (see Section 22, Chapter 247), such as bacterial vaginosis, candidiasis (a yeast infection), or trichomoniasis (a protozoan infection). Vaginal itching may also result from vaginal dryness due to hormonal changes at menopause. Other causes include skin disorders such as psoriasis or lichen sclerosus. Lichen sclerosus is characterized by thin white patches that develop around the opening of the vagina. If untreated, lichen sclerosus can cause scarring and may increase the risk of cancer. Treatment consists of a cream or an ointment containing a high dose of a corticosteroid (such as clobetasol).

Itching may be accompanied by a discharge. If itching persists or is accompanied by a vaginal discharge that looks or smells abnormal, a woman should see her doctor.

Abnormal Vaginal Discharge

A small amount of vaginal discharge is usually normal. The discharge consists of secretions (mucus) produced mainly by the cervix but also in the vagina. The discharge is usually thin and clear, milky white, or yellowish. Its amount and appearance vary with age. Typically, the discharge has no odor. It is not accompanied by itching or burning.

Newborn girls normally have a vaginal discharge of mucus, often mixed with a small amount of blood. This discharge is due to estrogen absorbed from the mother before birth. It usually stops within 2 weeks, as the level of estrogen in the blood decreases. Normally, older infants and girls, except those near puberty, do not have any significant vaginal discharge.

During a woman's reproductive years, the amount and appearance of the normal vaginal discharge vary with the menstrual cycle. For example, at the middle of the cycle (at ovulation), more mucus is usually produced and the mucus is thinner. Pregnancy, use of oral contraceptives, and sexual arousal also affect the amount and appearance of the discharge. After menopause, the estrogen level decreases, often reducing the amount of normal discharge.

A vaginal discharge is considered abnormal if it is

• heavier than usual
• thicker than usual
• puslike
• white and clumpy (like cottage cheese)
• grayish, greenish, yellowish, or blood-tinged
• foul-smelling (fishy)
• accompanied by itching, burning, a rash, or soreness.

A discharge may indicate inflammation of the vagina (vaginitis), which may be due to a chemical irritant (as for vaginal itching) or to an infection (see Section 22, Chapter 247). In some women, spermicides, vaginal lubricants or creams, or diaphragms can irritate the vagina or vulva, causing inflammation. For women who are allergic to latex, contact with latex condoms can irritate the area. In young girls, a foreign object in the vagina can cause inflammation of the vagina, with a vaginal discharge that may contain blood. Most commonly, the foreign object is a piece of toilet paper that has worked its way into the vagina. Sometimes it is a toy.

A white, gray, or yellowish cloudy discharge with a foul or fishy odor is typically caused by bacterial vaginosis. A thick, white, and clumpy discharge (which looks like cottage cheese) is typically caused by candidiasis, a yeast infection. A heavy, greenish yellow, frothy discharge that may have a bad odor is typically caused by trichomoniasis, a protozoan infection.

A watery, blood-tinged discharge may be caused by cancer of the vagina, cervix, or lining of the uterus (endometrium). Radiation therapy to the pelvis may also cause an abnormal discharge.

Doctors may identify the cause of the abnormal discharge based on the appearance of the discharge, the woman's age, and other symptoms. A sample of the discharge is examined under a microscope to check for an infection and to identify it. Treatment depends on the cause. If a product (such as a cream, powder, soap, feminine hygiene spray, or brand of condom) causes persistent irritation, it should not be used.

Abnormal Vaginal Bleeding

Bleeding from the vagina may originate in the vagina or another reproductive organ, particularly the uterus. Abnormal vaginal bleeding includes menstrual bleeding that is excessively heavy or light, occurs too frequently, or is irregular. Any vaginal bleeding that is not associated with a menstrual period or that occurs before puberty or after menopause is also considered abnormal (see Section 22, Chapter 244).

Abnormal vaginal bleeding may result from a disorder (such as an injury, infection, or cancer) or from changes in the normal hormonal control of menstruation. Such hormonal changes are more likely to occur when menstrual periods are just starting (in teenagers) or nearing an end (in women in their 40s (see Section 22, Chapter 244)).

Excessive Hairiness

Excessive body hair, particularly on the face and trunk (in a male pattern) and on the limbs, is called hirsutism. Excessive hairiness may not seem like a gynecologic disorder, but it is considered one. It usually results from abnormal levels of female and male hormones.

Hirsutism is more common among postmenopausal women, because levels of female hormones have decreased. Hirsutism may be due to a disorder of the pituitary gland or adrenal glands that results in overproduction of male hormones (such as testosterone). Sometimes exaggerated masculine characteristics (virilization) result. Hirsutism may also be due to polycystic ovary syndrome (see Section 22, Chapter 244). Rare causes include tumors in the ovaries, porphyria cutanea tarda (a form of porphyria that affects the skin), and use of drugs such as anabolic steroids, corticosteroids, and minoxidil.

Blood tests may be performed to measure male and female hormone levels. Drugs that may be the cause are discontinued. Temporary solutions include shaving, plucking, waxing, and using depilatories. Eflornithine, a topical cream available by prescription, may be used. It can slow the growth of hair, causing a gradual reduction of unwanted facial hair. This drug may temporarily irritate the skin, causing redness, burning, stinging, or a rash. Bleaching may be effective if the hair is fine. Laser phototherapy is temporarily effective. The only safe permanent treatment is electrolysis, which destroys the hair follicles. The disorder causing hirsutism is treated when possible.

Pelvic Pain

Many women experience pelvic pain--pain that occurs in the lowest part of the trunk, below the abdomen and between the hipbones. Pelvic pain may be caused by problems related to any of the organs in the pelvis: the reproductive organs (the uterus, fallopian tubes, ovaries, and vagina), bladder, rectum, or appendix. However, pelvic pain sometimes originates in organs outside the pelvis, such as the intestine, ureters, and gallbladder. Psychologic factors, especially stress and depression, may contribute to pelvic pain.

The pain may be sharp, intermittent, or crampy (like menstrual cramps). It may be sudden and excruciating, or it may be dull and constant. The pain may gradually increase in intensity. The area may feel tender to the touch. The pain may be accompanied by fever, nausea, and vomiting.

When a woman suddenly develops very severe pain in the lower abdomen or pelvis, doctors must quickly decide whether the cause requires emergency surgery. Examples of emergencies are appendicitis, a perforated ulcer, an aortic aneurysm, a twisted ovarian cyst, pelvic infections due to sexually transmitted diseases, and a pregnancy that develops outside of the uterus (ectopic pregnancy), usually in a fallopian tube.

To identify the cause, doctors may ask the woman to describe the pain, including its duration and location, and other symptoms. Doctors also ask about previous episodes of similar pain. Information about the timing of the pain in relation to eating, sleeping, sexual intercourse, activity, urination, and defecation may also be useful, as is information about any other factors that worsen or ease the pain.

Doctors gently feel the entire abdomen, checking for tenderness and abnormal growths. A pelvic examination helps doctors determine which organs are affected and whether an infection is present. Other procedures may include a complete blood cell count, urine tests, a pregnancy test, ultrasonography, computed tomography (CT), magnetic resonance imaging (MRI), and cultures to check for infections. Sometimes surgery or laparoscopy (use of a viewing tube to examine the abdominal and pelvic cavities) is needed to identify the cause of the pain.

Treating the disorder causing the pain, if identified, may relieve the pain. If a psychologic disorder is contributing to the pain, counseling or other therapy may help.

See the sidebar What Causes Pelvic Pain?

Breast Symptoms

Symptoms related to the breast are common. They include breast pain, lumps (including solid masses and cysts), pitting or dimpling in the skin of the breast, and a discharge from the nipple (see Section 22, Chapter 251). Breast symptoms may or may not indicate a serious disorder. For example, diffuse breast pain that is related to hormonal changes before a menstrual period does not indicate a serious disorder. However, because breast cancer is a concern and because early detection is essential to the successful treatment of breast cancer, any change in the breast should be evaluated by a doctor. In addition, women should examine their breasts themselves once a month (see Section 22, Chapter 251).