Cervical Cancer - Causes and Preventive Measures

Causes

In recent years, scientists have made much progress toward understanding what happens in cells of the cervix when cancer develops. In addition, they have identified several risk factors that increase the odds that a woman might develop cervical cancer.

The development of normal human cells mostly depends on the information contained in the cells’ chromosomes. Chromosomes are large molecules of DNA. DNA is the chemical that carries the instructions for nearly everything our cells do. We usually resemble our parents because they are the source of our DNA. However, DNA affects more than our outward appearance.

Some genes (packets of our DNA) have instructions for controlling when our cells grow and divide. Certain genes that promote cell division are called oncogenes. Others that slow down cell division or cause cells to die at the right time are called tumor suppressor genes. Cancers can be caused by DNA mutations (gene defects) that turn on oncogenes or turn off tumor suppressor genes. Scientists now think that HPV causes the production of 2 proteins known as E6 and E7. When these proteins are produced, they turn off some tumor suppressor genes. This may allow the cervical lining cells to grow uncontrollably, which in some cases will lead to cancer.

But HPV does not completely explain what causes cervical cancer. Most women with HPV don’t get cervical cancer, and certain other risk factors, like smoking and HIV infection, influence which women exposed to HPV are more likely to develop cervical cancer

Prevention

Since the most common form of cervical cancer starts with pre-cancerous changes, there are 2 ways to stop this disease from developing. The first way is to prevent the pre-cancers, and the second is to find and treat pre-cancers before they become cancerous.

Things to do to prevent pre-cancers

Avoid being exposed to HPV:You can prevent most pre-cancers of the cervix by avoiding exposure to HPV. Certain types of sexual behavior increase a woman's risk of getting HPV infection, such as:

having sex at an early age
having many sexual partners
having a partner who has had many sex partners
having sex with uncircumcised males

Delay sex: Waiting to have sex until you are older can help you avoid HPV. It also helps to limit your number of sexual partners and to avoid having sex with someone who has had many other sexual partners. Remember that someone can have HPV for years yet have no symptoms - it does not always cause warts or any other symptoms. Someone can have the virus and pass it on without knowing it.

Use condoms: Condoms provide some protection against HPV. One study found that when condoms are used correctly they can lower the HPV infection rate by about 70% - if they are used every time sex occurs. Condoms cannot protect completely because they don't cover every possible HPV-infected area of the body, such as skin of the genital or anal area. Still, condoms provide some protection against HPV, and they also protect against HIV and some other sexually transmitted diseases.

Don’t smoke: Not smoking is another important way to reduce the risk of cervical precancer and cancer.

Get vaccinated: Vaccines have been developed that can protect women from HPV infections. So far, a vaccine that protects against HPV types 6, 11, 16 and 18 (Gardasil®) and one that protects against types 16 and 18 (Cervarix®) have been studied.

Gardasil® has been approved for use in this country by the FDA. It requires a series of 3 injections over a 6-month period. The second injection is given 2 months after the first one, and the third is given 4 months after the second. Side effects are said to be mild. The most common one is short-term redness, swelling, and soreness at the injection site. In clinical trials, Gardasil prevented genital warts caused by HPV types 6 and 11 and prevented pre-cancers and cancers of the cervix caused by HPV types 16 and 18. This vaccine only works to prevent HPV infection -- it will not treat an infection that is already there.

To be most effective, the HPV vaccine should be given before a person starts having sex. The Federal Advisory Committee on Immunization Practices (ACIP) has recommended that the vaccine be given routinely to females aged 11 to 12. It can be given to younger females (as young as age 9) at the discretion of doctors. ACIP also recommended women ages 13 to 26 who have not yet been vaccinated get "catch-up" vaccinations.

The American Cancer Society also recommends that the vaccine be routinely given to females aged 11 to 12 and as early as age 9 years at the discretion of doctors. The Society also agrees that “catch-up” vaccinations should be given to females aged 13 to 18. The independent panel making the Society recommendations found that there was not enough proof of benefit to recommend catch-up vaccination for every woman aged 19 to 26 years. As a result, the American Cancer Society recommends that women aged 19 to 26 talk with their health care provider about the risk of previous HPV exposure and potential benefit from vaccination before deciding to get vaccinated. Research is now being done on using Gardasil in older women and in males. The American Cancer Society guideline focuses on Gardasil at this time. As new information on Cervarix®, Gardasil®, and other new products becomes available, these guidelines will be updated.

Gardasil is expensive - the vaccine series costs around $360 (not including any doctor’s fee or the cost of giving the injections). It should be covered by most medical insurance plans (if given according to ACIP guidelines). It should also be covered by government programs that pay for vaccinations in children under 18. Because this vaccine costs so much, you may want to check your coverage with your insurance company first.

It is important to realize that the vaccine doesn’t protect against all cancer-causing types of HPV, so routine Pap tests are still necessary. One other benefit of the vaccine is that it protects against the 2 viruses that cause 90% of genital warts.

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Cervical Cancer - Risk Factor

A risk factor is anything that changes your chance of getting a disease such as cancer. Different cancers have different risk factors. For example, exposing skin to strong sunlight is a risk factor for skin cancer. Smoking is a risk factor for many cancers. But having a risk factor, or even several, does not mean that you will get the disease.

Several risk factors increase your chance of developing cervical cancer. Women without any of these risk factors rarely develop cervical cancer. Although these risk factors increase the odds of developing cervical cancer, many women with these risks do not develop this disease. When a woman develops cervical cancer or pre-cancerous changes, it may not be possible to say with certainty that a particular risk factor was the cause.

In thinking about risk factors, it helps to focus on those that you can change or avoid (like smoking or human papilloma virus infection), rather than those that you cannot (such as your age and family history). However, it is still important to know about risk factors that cannot be changed, because it's even more important for women who have these factors to get regular Pap tests to detect cervical cancer early.

Cervical cancer risk factors include:


Human papilloma virus infection: The most important risk factor for cervical cancer is infection by the human papilloma virus (HPV). HPV is a group of more than 100 related viruses. They are called papilloma viruses because some of them cause a type of growth called a papilloma. Papillomas are not cancers, and are more commonly called warts. HPV is passed from one person to another during skin-to-skin contact. HPV can be spread during sex - including vaginal intercourse, anal intercourse, and even during oral sex.

Doctors believe that women must have been infected by HPV before they develop cervical cancer. Certain types of HPV are called "high-risk" types because they are often the cause of cancer of the cervix. These types include HPV 16, HPV 18, HPV 31, HPV 33, and HPV 45, as well as some others. About two-thirds of all cervical cancers are caused by HPV 16 and 18.

Different types of HPVs cause warts on different parts of the body. Some types cause common warts on the hands and feet. Other types tend to cause warts on the lips or tongue.

Still other types of HPV may cause warts on or around the female and male genital organs and in the anal area. These warts may barely be visible or they may be several inches across. The medical term for genital warts is condyloma acuminatum. Two types of HPV, HPV 6 and HPV 11, cause most cases of genital warts. These two types are seldom linked to cervical cancer, and so are called "low-risk" types of HPV. Other sexually transmitted HPVs have been linked with genital or anal cancers in both men and women.

Many women become infected with HPV, but very few will ever develop cervical cancer. In most cases the body's immune system fights off the virus, and the infection goes away without any treatment. For reasons that we don't understand, the infection persists in some women and can cause cervical cancer. Although there is currently no cure for HPV infection, there are ways to treat the warts and abnormal cell growth that HPV causes.

The Pap test looks for changes in cervical cells caused by HPV infection. Newer tests look for HPV infections by finding genes (DNA) from HPV in the cells. Some doctors use the test for HPV to help decide what to do when a woman has a mildly abnormal Pap test result. If the test finds a high-risk type of HPV, it may mean she will need a full evaluation with a colposcopy procedure.

HPV infections occur mainly in young women and are less common in women over 30. The reason for this is not clear. Uncircumcised men are thought to be more likely to have the virus and be able to pass it on to someone else. HPV infection can be present for years without any symptoms. Even when someone doesn't have visible warts (or any other symptom), he (or she) can still be infected with HPV and pass the virus to somebody else.

Condoms ("rubbers") do provide some protection against HPV, but they cannot completely protect against infection. This is because HPV can still be passed from one person to another by skin-to-skin contact with an HPV-infected area of the body that is not covered by a condom - like the skin in the genital or anal area. Still, it is important to use condoms to protect against AIDS and other sexually transmitted illnesses that are passed on through some body fluids.

Vaccines have been developed to help prevent infection with some types of HPV. Right now, there is an HPV vaccine that has been approved for use in the United States by the Food and Drug Administration (FDA). This vaccine is called Gardasil®, and it protects against HPV types 6, 11, 16, and 18. More HPV vaccines are being developed and tested.

Although it is necessary to have had HPV for cervical cancer to develop, most women with this virus do not develop cancer. Doctors believe that other factors must come into play for cancer to develop. Some of the known factors are listed below.

Smoking: Women who smoke are about twice as likely as non-smokers to get cervical cancer. Smoking exposes the body to many cancer-causing chemicals that affect more than the lungs. These harmful substances are absorbed by the lungs and carried in the bloodstream throughout the body. Tobacco by-products have been found in the cervical mucus of women who smoke. Researchers believe that these substances damage the DNA of cervix cells and may contribute to the development of cervical cancer.



Immunosuppression: Human immunodeficiency virus (HIV), the virus that causes AIDS, damages the body's immune system and seems to make women more at risk for HPV infections. This may be what increases the risk of cervical cancer in women with AIDS. Scientists believe that the immune system is important in destroying cancer cells and slowing their growth and spread. In women with HIV, a cervical precancer might develop into an invasive cancer faster than it normally would.



Chlamydia infection: Chlamydia is a relatively common kind of bacteria that can infect the reproductive system. It is spread by sexual contact. Some studies have seen a higher risk of cervical cancer in women whose blood test results show past or current chlamydia infection (compared with women with normal test results). Infection with chlamydia often causes no symptoms in women. A woman may not know that she is infected at all unless she is tested for chlamydia when she gets her pelvic exam. Long-term chlamydia infection can cause pelvic inflammation, leading to infertility.



Diet: Women with diets low in fruits and vegetables may be at increased risk for cervical cancer. Also overweight women are more likely to develop this cancer.



Oral contraceptives (birth control pills): There is evidence that taking oral contraceptives (OCs) for a long time increases the risk of cancer of the cervix. Research suggests that the risk of cervical cancer goes up the longer a woman takes OCs, but the risk goes back down again after the OCs are stopped. In a recent study, the risk of cervical cancer was doubled in women who took birth control pills longer than 5 years, but the risk returned to normal 10 years after they were stopped.



The American Cancer Society believes that a woman and her doctor should discuss whether the benefits of using OCs outweigh the potential risks. A woman with multiple sexual partners should use condoms to lower her risk of sexually transmitted illnesses no matter what other form of contraception she uses.



Multiple pregnancies: Women who have had many full-term pregnancies have an increased risk of developing cervical cancer. No one really knows why this is true. One theory is this may be because some of the women may have been exposed more to HPV through un-protected sexual contact. Also, studies have pointed to hormonal changes during pregnancy as possibly making women more susceptible to HPV infection or cancer growth. Another thought is that the immune system of pregnant women might be weaker, allowing for HPV infection and cancer growth.



Low socioeconomic status: Poverty is also a risk factor for cervical cancer. Many women with low incomes do not have ready access to adequate health care services, including Pap tests. This means they may not get screened or treated for pre-cancerous cervical disease.



Diethylstilbestrol (DES): DES is a hormonal drug that was given to some women to prevent miscarriage between 1940 and 1971. Women whose mothers took DES (when pregnant with them) develop clear-cell adenocarcinoma of the vagina or cervix more often than would normally be expected. There is about 1 case of this type of cancer in every 1,000 women whose mothers took DES during pregnancy. This means that about 99.9% of "DES daughters" do not develop these cancers.
DES-related clear cell adenocarcinoma is more common in the vagina than the cervix. The risk appears to be greatest in women whose mothers took the drug during their first 16 weeks of pregnancy. The average age of women when they are diagnosed with DES-related clear-cell adenocarcinoma is 19 years. Since the use of DES during pregnancy was stopped by the FDA in 1971, even the youngest DES daughters are older than 35 - past the age of highest risk. Still, there is no age cut-off when these women are safe from DES-related cancer - doctors do not know exactly how long women will remain at risk.



DES daughters may also be at increased risk of developing pre-cancerous changes of cervical squamous cells and squamous cell cancer of the cervix. These pre-cancers and cancers seem to be linked to HPV.



Although DES daughters have an increased risk of developing clear cell carcinomas, women don’t have to be exposed to DES for clear cell carcinoma to develop. In fact, women were diagnosed with the disease before DES was developed.



Family history of cervical cancer: Cervical cancer may run in some families. If your mother or sister had cervical cancer, your chances of developing the disease are increased by 2 to 3 times. Some researchers suspect that some instances of this familial tendency are caused by an inherited condition that makes some women less able to fight off HPV infection than others. In other instances, women from the same family as a patient already diagnosed may be more likely to have one or more of the other non-genetic risk factors previously described in this section

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Cervical Cancer - Detailed guide

Introduction

The cervix is the lower part of the uterus (womb). It is sometimes called the uterine cervix. The body (upper part) of the uterus, is where a fetus grows. The cervix connects the body of the uterus to the vagina (birth canal). The part of the cervix closest to the body of the uterus is called the endocervix. The part next to the vagina is the exocervix (or ectocervix). The place where these 2 parts meet is called the transformation zone. Most cervical cancers start in the transformation zone.

Cervical cancers and cervical pre-cancers are classified by how they look under a microscope. There are 2 main types of cervical cancers: squamous cell carcinoma and adenocarcinoma. About 80% to 90% of cervical cancers are squamous cell carcinomas. These cancers are from the squamous cells that cover the surface of the exocervix. Under the microscope, this type of cancer is made up of cells that are like squamous cells. Squamous cell carcinomas most often begin where the exocervix joins the endocervix.

The remaining 10% to 20% of cervical cancers are adenocarcinomas. Adenocarcinomas are becoming more common in women born in the last 20 to 30 years. Cervical adenocarcinoma develops from the mucus-producing gland cells of the endocervix. Less commonly, cervical cancers have features of both squamous cell carcinomas and adenocarcinomas. These are called adenosquamous carcinomas or mixed carcinomas.

Although cervical cancers start from cells with pre-cancerous changes (pre-cancers), only some of the women with precancers of the cervix will develop cancer. The change from precancer to cancer usually takes several years - but it can happen in less than a year. For most women, pre-cancerous cells will go away without any treatment. Still, in some women pre-cancers turn into true (invasive) cancers. Treating all pre-cancers can prevent almost all true cancers.

Pre-cancerous changes are separated into different categories based on how the cells of the cervix look under a microscope.

Although almost all cervical cancers are either squamous cell carcinomas or adenocarcinomas, other types of cancer also can start in the cervix. These other types, such as melanoma, sarcoma, and lymphoma, occur more commonly in other parts of the body. This document discusses the more common cervical cancer types, and will not further discuss these rare types

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Nipple Discharge

Nipple discharge refers to any fluid that seeps out of the nipple in a nonlactating woman. Nonmilk discharge comes out of your breasts through the same nipple openings that carry milk.

One or both breasts may produce a nipple discharge, either spontaneously or when you squeeze your nipples or breasts. A nipple discharge may look milky, or it may be yellow, green, brown or bloody. The consistency of nipple discharge varies from thick and sticky to thin and watery.

Nipple discharge is a symptom that largely affects women. However, nipple discharge in a man under any circumstances is problematic and should be investigated.

Causes

Sometimes, nipple discharge is just a normal (physiological) part of your breast's function. If that's the case, the discharge might resolve on its own.

Most often, nipple discharge stems from a noncancerous (benign) condition. However, breast cancer is a possibility, especially if:

You are over age 40
You have a lump in your breast
The discharge contains blood
Only one breast is affected
Possible causes of nipple discharge include:

Abscess
Breast cancer
Breast infection
Excessive breast stimulation
Fibroadenoma
Fibrocystic breasts
Ductal carcinoma in situ (DCIS)
Galactorrhea
Hormone imbalance
Injury or trauma to the breast
Intraductal papilloma
Mammary duct ectasia
Medication use
Paget's disease of the breast
Pregnancy
Prolactinoma

When to see a doctor

Rarely is nipple discharge a sign of breast cancer. But it might be a sign of an underlying condition that requires treatment. If you're still having periods and your nipple discharge doesn't resolve on its own after your next menstrual cycle, or if it's particularly bothersome, make an appointment with your doctor to have it evaluated. If you're postmenopausal and experience nipple discharge at any time, see your doctor right away.

In the meantime, take care to avoid nipple stimulation — including frequent checks for discharge — because stimulation actually makes the discharge persist.


References

Non-cancerous breast conditions. American Cancer Society. http://www.cancer.org/docroot/CRI/content/CRI_2_6X_Non_Cancerous_Breast_Conditions_59.asp?sitearea. Accessed Jan. 5, 2009.
Golshan M, et al. Nipple discharge. http://www.uptodate.com/home/index.html. Accessed Jan. 6, 2009.
Breast disorders. The Merck Manuals Online Medical Library: The Merck Manual Home Edition. http://www.merck.com/mmhe/sec22/ch251/ch251a.html. Accessed Jan. 6, 2009.

Adapted from: Mayo Foundation for Medical Education and Research

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Mastitis

Mastitis is an infection of the breast tissue that causes pain, swelling and redness of the breast. Mastitis most commonly affects women who are breast-feeding, although in rare circumstances this condition can occur outside of lactation.

Often, mastitis occurs within the first six weeks after birth (postpartum), but it can happen later during breast-feeding. The condition can leave you feeling exhausted and rundown, making it difficult to care for your baby.

Sometimes mastitis leads a mother mistakenly to wean her baby before she intends to. But you can continue breast-feeding while you have mastitis.

Symptoms

With mastitis, signs and symptoms can appear suddenly and may include:

Breast tenderness or warmth to the touch
General malaise or feeling ill
Swelling of the breast
Pain or a burning sensation continuously or while breast-feeding
Skin redness, often in a wedge-shaped pattern
Fever of 101 F (38.3 C) or greater
Although mastitis usually occurs in the first several weeks of nursing, it can happen any time during breast-feeding. Mastitis tends to affect only one breast — not both breasts.

Causes

Mastitis occurs when bacteria enter your breast through a break or crack in the skin of your nipple or through the opening to the milk ducts in your nipple. Bacteria from your skin's surface and baby's mouth enter the milk duct and can multiply — leading to pain, redness and swelling of the breast as infection progresses.

Risk factors

Things that put you at increased risk of mastitis include:

Sore or cracked nipples, although mastitis can develop without broken skin.
A previous bout of mastitis while breast-feeding — if you've experienced mastitis in the past, you're more likely to experience it again.
Using only one position to breast-feed, which may not fully drain your breast.
Wearing a tightfitting bra, which may restrict milk flow.
When to seek medical advice
In most cases, you'll feel ill with flu-like symptoms for several hours before you recognize that there's a sore red area on one of your breasts. As soon as you recognize this combination of signs and symptoms, it's time to contact your doctor.

Your doctor will probably want to see you to confirm the diagnosis. Oral antibiotics are usually very effective in treating this condition. If you've had mastitis before, your doctor may prescribe antibiotics over the phone. If your signs and symptoms don't improve after the first two days of taking antibiotics, see your doctor right away to make sure your condition isn't the result of a more serious problem.

Tests and diagnosis

Your doctor diagnoses mastitis based on a physical examination, taking into account signs and symptoms of fever, chills and a painful area in the breast. Another clear sign is a wedge-shaped area on the breast that points toward the nipple and is tender to the touch. As part of the examination, your doctor will make sure you don't have a breast abscess — a complication that can occur when mastitis isn't treated promptly.

Complications

Complications that may arise from mastitis include:

Recurrence. Once you've had mastitis, you're more likely to get it again, either breast-feeding the same infant or a future child. Delayed or inadequate treatment is usually to blame for mastitis recurrence.
Milk stasis. When the milk isn't completely drained from your breast during breast-feeding, milk stasis can occur. This causes increased pressure on the ducts and leakage of milk into surrounding breast tissue, which can lead to pain and inflammation.
Abscess. When mastitis is inadequately treated, or if it's related to milk stasis, a collection of pus (abscess) can develop in your breast. An abscess usually requires surgical draining. To avoid this complication, talk to your doctor as soon as you develop signs or symptoms of mastitis.

Treatments and drugs

Mastitis treatment usually involves:

Antibiotics. Treating mastitis usually requires a 10- to 14-day course of antibiotics. You may feel well again 24 to 48 hours after starting antibiotics, but it's important to take the entire course of medication to minimize your chance of recurrence.

Self-care remedies. Resting, continuing breast-feeding and drinking extra fluids can help your body overcome the breast infection.

If your mastitis doesn't clear up after taking antibiotics, check back with your doctor. A rare form of breast cancer — inflammatory breast cancer — can also cause redness and swelling that could initially be confused with mastitis. You may need a biopsy to make sure you don't have breast cancer.

Prevention

Minimize your chances of getting mastitis by fully draining the milk from your breasts while breast-feeding. Allow your baby to completely empty one breast before switching to the other breast during feeding. If your baby nurses only for a few minutes on the second breast — or not at all — start breast-feeding on that breast the next time you feed your baby.

Alternate the breast you offer first at each breast-feeding, and change the position you use to breast-feed from one feeding to the next. Make sure your baby latches on properly during feedings. Finally, don't let your baby use your breast as a pacifier. Babies enjoy sucking and often find comfort in suckling at the breast even when they're not hungry.

Lifestyle and home remedies

If you have mastitis, it's safe to continue breast-feeding. Breast-feeding helps your breast clear the infection.

To relieve your discomfort:

Maintain your breast-feeding routine.
Avoid prolonged engorgement before breast-feeding.
Use varied positions to breast-feed.
Drink plenty of fluids.
If you have trouble emptying a portion of your breast, apply warm compresses to the breast or take a warm shower before breast-feeding or pumping milk.
Wear a supportive bra.
While waiting for the antibiotics to take effect, take a mild pain reliever, such as acetaminophen (Tylenol, others) or ibuprofen (Advil, Motrin, others).
If breast-feeding on the infected breast is too painful, try pumping or hand-expressing milk.

Adapted from: Mayo Foundation for Medical Education and Research

Galactorrhea

Galactorrhea (say: "gal-act-tor-ee-ah") is a condition that occurs when a woman's breast makes milk (or a milky discharge) even though she is not breast feeding a baby. The milk may come from one or both breasts. It may leak with no stimulation or it may leak only when the breasts are touched.

Although less common, galactorrhea can occur in men.

What causes galactorrhea?

Galactorrhea has many causes. Here are some of them:
• Tumors (usually benign), especially tumors of the pituitary (say: "pit-too-it-terry") gland, which is located in the brain
• Medicines such as hormones, antidepressants, blood pressure medicines and certain tranquilizers
• Herbal supplements such as nettle, fennel, blessed thistle, anise and fenugreek seed
• Drugs such as marijuana and opiates
• Pregnancy
• Clothing that irritates the breasts (like scratchy wool shirts or bras that don't fit well)
• Doing very frequent breast self-exams (daily exams)
• Stimulation of the breast during sexual activity
• Kidney disease
• Oral contraceptives
• An underactive thyroid (also called hypothyroidism), which is a gland that produces hormones
Sometimes the cause of galactorrhea can't be found.

Galactorrhea produces a white fluid. If the fluid coming from your breast is reddish, your doctor may want to check you for cancer. Blood in the discharge is not galactorrhea.

What are the symptoms of galactorrhea?

The symptoms of galactorrhea can include the following:
• Milky discharge from one of both nipples (discharge may also be yellow or greenish in color)
• An absence of menstrual periods or periods that are not regular
• Headaches
• Vision loss
• Less interest in sex
• Increase in hair growth on your chin or chest
• Acne
• Erectile dysfunction and less interest in sex in men

What tests might my doctor order?

Your doctor might order blood tests to check your hormone levels and to see if you are pregnant. Your doctor might also want you to have an MRI (magnetic resonance imaging) scan of your head to see if you have a tumor or abnormality of the pituitary gland.

Tests are not always needed if you and your doctor can figure out what is causing your galactorrhea.

How is galactorrhea treated?

Most tumors that cause galactorrhea are not cancerous. They can be treated with medicine or surgery, depending on the cause. If a certain medicine you are taking is causing your galactorrhea, your doctor may prescribe a different medicine.

In many cases, no treatment is necessary and the condition goes away on its own with time. Until it goes away, here are some things you can do to help:
• Avoid stimulating your breasts.
• Avoid touching your nipples during sexual activity.
• Don't do breast self-exams more than one time a month.
• Avoid tight-fitting clothing or clothing that causes friction.

Adapted from: American Academy of Family Physicians

Breast Cysts

Breast cysts are fluid-filled sacs within your breast. You can have one or many breast cysts. They're often described as round or oval lumps with distinct edges. In texture, a breast cyst usually feels like a soft grape or a water-filled balloon, but sometimes a breast cyst feels firm.

Breast cysts are common in women in their 30s and 40s. If you have breast cysts, they usually disappear after menopause, unless you're taking hormone therapy.

Breast cysts don't require treatment unless a cyst is large and painful or otherwise uncomfortable. In that case, draining the fluid from a breast cyst can ease your symptoms.

Symptoms

Signs and symptoms of breast cysts include:

A smooth, easily movable round or oval breast lump with distinct edges
Breast pain or tenderness in the area of the lump
Increased lump size and tenderness just before your period
Decreased lump size and resolution of other signs and symptoms after your period
Having one or many simple breast cysts doesn't increase your risk of breast cancer.

Causes
Each of your breasts contains 15 to 20 lobes of glandular tissue, arranged like the petals of a daisy. The lobes are further divided into smaller lobules that produce milk during pregnancy and breast-feeding. Small ducts conduct the milk to a reservoir just beneath your nipple. Supporting this network is a deeper layer of connective tissue called stroma.

Breast cysts develop when an overgrowth of glands and connective tissue (fibrocystic changes) block milk ducts, causing them to dilate and fill with fluid.

Microcysts are too small to feel but may be seen during imaging tests, such as mammography or ultrasound.
Macrocysts are large enough to be felt and can grow to about 1 to 2 inches (2.5 to 5 centimeters) in diameter. Large breast cysts can put pressure on nearby breast tissue, causing breast pain or discomfort.
The cause of breast cysts remains unknown. Some evidence suggests that excess estrogen in your body may play a role in breast cyst development.

When to seek medical advice
Normal breast tissue in healthy women often feels lumpy or nodular. If you detect the presence of any new breast lumps, however, or if a previously evaluated breast lump seems to have grown or otherwise changed, make an appointment with your doctor to get it checked out.

Tests and diagnosis
Screening and diagnosis of a breast cyst usually begins after you or your doctor has identified a breast lump. The process may involve the following tests or exams:

Clinical breast exam. Your doctor physically examines the breast lump and checks for any other problem areas in your breasts. Questions to anticipate include when you first noticed the lump, whether its size has changed, if you have any breast pain associated with the breast lump, whether you have nipple discharge and how your menstrual cycle affects the lump. However, your doctor can't tell from a clinical breast exam alone whether a breast lump is a cyst, so you'll need another test, either an ultrasound or fine-needle aspiration — or maybe both.
Breast ultrasound. Breast ultrasound can help your doctor determine whether a breast lump is fluid-filled or solid. The radiologist — a doctor who specializes in imaging methods — performing the ultrasound makes this determination based on certain characteristics seen during the imaging exam. A fluid-filled area usually indicates a breast cyst. A solid-appearing mass most likely is a fibroadenoma, but it could also be breast cancer.

Some doctors skip breast ultrasound and perform fine-needle aspiration instead.

Fine-needle aspiration. During this procedure, your doctor inserts a thin needle into the breast lump and attempts to withdraw (aspirate) fluid. If fluid comes out and the breast lump goes away, your doctor can make a breast cyst diagnosis immediately.

Unless there appears to be blood in the fluid, it requires no further testing or treatment after draining. If the fluid is bloody, a laboratory may need to test it. Lack of fluid or a breast lump that doesn't disappear after aspiration suggests that the breast lump — or at least a portion of it — is solid, and a sample of cells may be collected and sent for analysis to check for the presence of cancer (fine-needle aspiration biopsy).

Mammography usually isn't indicated for a breast cyst. However, you may undergo a mammogram if your doctor suspects, during the course of evaluating your breast lump, that the lump is caused by something other than a breast cyst.

Treatments and drugs
No treatment is necessary for simple breast cysts. Your doctor may recommend nothing more than closely monitoring a breast cyst to see if it resolves on its own.

Fine-needle aspiration
Fine-needle aspiration, the procedure used to diagnose a breast cyst, also may serve as treatment, if your doctor removes all the fluid from the cyst at the time of diagnosis.

First, your doctor feels your breast to locate the cyst and hold it steady. Next, he or she inserts a thin needle into the breast lump and withdraws (aspirates) the cyst fluid. Often, fine-needle aspiration is done using ultrasound to guide accurate placement of the needle.

If the fluid is nonbloody and the breast lump disappears, you need no further treatment. Your doctor will probably recommend a visit in four to six weeks to see if the cyst returns.
If the fluid appears bloody or the breast lump doesn't disappear, your doctor may send a sample of the fluid for laboratory testing and refer you to a breast surgeon or to a radiologist — a doctor who specializes in imaging studies — for follow-up.
If you have breast cysts, you may need to have fluid drained more than once. Recurrent or new cysts are common.

Hormone use
Using oral contraceptives to regulate your menstrual cycles may help reduce the recurrence of breast cysts. Discontinuing hormone replacement therapy during the postmenopausal years may reduce the formation of cysts as well.

Surgery
Surgical removal of a breast cyst is an option only in a few unusual circumstances. If an uncomfortable breast cyst recurs month after month, or if a breast cyst contains blood-tinged fluid and displays other worrisome signs, surgery may be considered.

Lifestyle and home remedies
Wear a supportive bra. If you have breast pain from a breast cyst, good support to surrounding breast tissue may help relieve some discomfort.
Avoid caffeine. There's no scientific proof that caffeine consumption is linked to breast cysts. However, many women find relief from their symptoms after eliminating caffeine from their diets. Consider reducing or eliminating caffeine — in beverages as well as in foods such as chocolate — to see if your symptoms improve.
Reduce salt in your diet. Although studies on salt restriction and cyst formation aren't conclusive, some experts suggest that reducing salt in your diet may help. Consuming less sodium reduces the amount of excess fluid in your body, which in turn may help alleviate symptoms associated with a fluid-filled breast cyst.

Alternative medicine
Evening primrose oil is a fatty acid (linoleic acid) supplement that's available over-the-counter. Some evidence suggests that evening primrose oil may help minimize discomfort associated with breast cysts. Although the exact mechanism isn't clear, some experts believe that women deficient in linoleic acid are more sensitive to hormonal fluctuations during the menstrual cycle, resulting in breast pain associated with breast cysts.

Adapted from:Mayo Foundation for Medical Education and Research

Breast Calcifications

Breast calcifications are calcium deposits within breast tissue. They appear as white spots or flecks on a mammogram and are usually so small that you can't feel them.

Breast calcifications are common in all women and are even more prevalent after menopause. Although breast calcifications are usually noncancerous (benign), certain patterns of calcifications — such as tight clusters with irregular shapes — may indicate breast cancer.

On a mammogram, breast calcifications can appear as large white dots or dashes (macrocalcifications) or fine, white specks, similar to grains of salt (microcalcifications). Macrocalcifications are almost always noncancerous and require no further testing or follow-up. Microcalcifications are usually noncancerous, but certain patterns can be a sign of cancer. If calcifications are suspicious, further testing may be necessary.

Causes
While some calcifications may indicate breast cancer, there are many conditions in the breast that can cause calcifications to form. Causes of breast calcifications include:

Breast cysts
Calcification in a fibroadenoma, a noncancerous growth
Cell secretions or debris
Mammary duct ectasia
Mastitis
Previous injury to the breast
Previous radiation therapy for cancer
Skin (dermal) or blood vessel (vascular) calcification

When to see a doctor
Your doctor may recommend additional testing if the calcification:

Is clustered rather than scattered throughout the breast
Varies in size and shape from other calcifications
Is irregularly shaped
These tests may include additional mammograms with compression or magnification views of the calcification, as well as ultrasound imaging or biopsy. The radiologist also will likely request any prior mammogram images you have had to compare and determine if the calcifications are new or have changed in number or pattern. Some women are instructed to return for another mammogram in six months.

Adapted from: Mayo Foundation for Medical Education and Research

Dysfunctional Uterine Bleeding

Dysfunctional uterine bleeding is abnormal bleeding resulting from changes in the hormonal control of menstruation.

Bleeding occurs frequently or irregularly, lasts longer, or is heavier.

This disorder is diagnosed when the physical examination, ultrasonography, and other tests have ruled out the usual causes of vaginal bleeding.

An endometrial biopsy is usually done.

The bleeding can usually be controlled with estrogen plus a progestin or sometimes with either alone.

If the biopsy detects abnormal cells, treatment involves high doses of a progestin and sometimes removal of the uterus.

Dysfunctional uterine bleeding occurs most commonly at the beginning and end of the reproductive years: 20% of cases occur in adolescent girls, and more than 50% occur in women older than 45. In about 90% of cases, the ovaries do not release an egg (ovulate). Thus, pregnancy is impossible.

Dysfunctional uterine bleeding commonly results when the level of estrogen remains high instead of decreasing as it normally does after the egg is released and not fertilized. The high estrogen level is not balanced by an appropriate level of progesterone. In such cases, no egg is released. As a result, the lining of the uterus (endometrium) continues to thicken (instead of breaking down and being shed normally as a menstrual period). This condition is called endometrial hyperplasia. The lining is then shed incompletely and irregularly, causing bleeding. Bleeding is irregular, prolonged, and sometimes heavy. This type of bleeding is common among women who have polycystic ovary syndrome and occurs in some women with endometriosis. A high estrogen level not balanced by progesterone increases the risk of endometrial cancer, even in young women.

Dysfunctional uterine bleeding may be an early sign of menopause.

Symptoms

Bleeding may differ from typical menstrual periods in the following ways:

Occur more frequently (less than 21 days apart—polymenorrhea)

Last longer or involve more blood loss than menses (more than 7 days or more than about 3 ounces—menorrhagia)

Occur frequently and irregularly between periods (metrorrhagia)

Bleeding during regular menstrual cycles may be abnormal, or bleeding may occur at unpredictable times. Some women have symptoms associated with menstrual periods, such as breast tenderness and bloating.

If bleeding continues, women may develop an iron deficiency and sometimes anemia.

Diagnosis

Dysfunctional uterine bleeding is suspected when bleeding occurs at irregular times or in excessive amounts. It is diagnosed when all other possible causes of vaginal bleeding have been excluded. These causes include abnormalities of the genital organs (including polycystic ovary syndrome), inflammation, blood clotting disorders, pregnancy, complications of pregnancy, and use of contraceptives or certain drugs.

To establish that bleeding is abnormal, doctors ask questions about the pattern of bleeding. To exclude other possible causes, they ask about other symptoms and possible causes (such as use of drugs, the presence of other disorders, fibroids, and complications during pregnancies). A physical examination is also done. A complete blood cell count can help doctors estimate how much blood has been lost and whether anemia is present.

Tests to check for possible causes may be done based on the findings during the interview and physical examination. For example, blood tests to determine how fast blood clots or to measure hormone levels may be done.

Transvaginal ultrasonography (using a thin probe inserted through the vagina and into the uterus) is often used to check for growths in the uterus and to determine whether the uterine lining is thickened.

If the risk of cancer of the uterine lining (endometrial cancer) is high, an endometrial biopsy is done before drug treatment is started. Risk is increased in women with the following:

.Age 35 or older
.Obesity
.Polycystic ovary syndrome
.High blood pressure
.Diabetes
.Bleeding that is persistent, irregular, or heavy despite treatment
.Thickening of the uterine lining (detected by ultrasonography)
.Inconclusive findings during ultrasonography

Most women with dysfunctional uterine bleeding have one or more of these conditions and thus require a biopsy.

Treatment

Treatment depends on how old the woman is, how heavy the bleeding is, whether the uterine lining is thickened, and whether the woman wishes to become pregnant. It focuses on controlling the bleeding and, if needed, preventing endometrial cancer.

When the uterine lining is thickened but its cells are normal, hormones may be used to control bleeding.

For heavy bleeding, a combination oral contraceptive (a birth control pill with estrogen and a progestin) may be used.

For very heavy bleeding, estrogen may be given intravenously until the bleeding stops. Sometimes a progestin is given by mouth at the same time or started 2 or 3 days later. Occasionally, bleeding is so heavy that fluids are given intravenously and a blood transfusion is needed. Very rarely, a catheter needs to be inserted into the uterus and inflated to put pressure on the bleeding vessels and thus stop the bleeding.

Bleeding usually stops in 12 to 24 hours. After bleeding stops, low doses of the oral contraceptive may then be prescribed for at least 3 months to prevent the bleeding from recurring.

Some women should not be treated with a combination oral contraceptive or estrogen. They include postmenopausal women and women with significant risk factors for a heart or blood vessel disorder. For these women, an intrauterine device (IUD) that contains a progestin may be used, or a progestin may be given alone by injection or by mouth. These treatments may also be used when those that include estrogen are ineffective.

If women wish to become pregnant and bleeding is not too heavy, they may be given clomiphene (a fertility drug) by mouth instead of hormones. It stimulates ovulation.

If the uterine lining remains thickened or the bleeding persists despite treatment with hormones, dilation and curettage (D and C) is usually needed. In this procedure, tissue from the uterine lining is removed by scraping. This procedure may reduce bleeding, but in some women, it causes scarring of the endometrium (Asherman's syndrome), which can cause menstrual bleeding to stop (amenorrhea).

If the uterine lining contains abnormal cells (particularly in women who are older than 35 and who do not want to become pregnant), treatment begins with a high dose of a progestin. A biopsy is done after 3 to 6 months of treatment. If it detects abnormal cells, a hysterectomy is done because the abnormal cells may become cancerous. If women are postmenopausal, a progestin is not used. Hysterectomy is done.

Adapted from: Merck & Co., Inc.

Vaginal Bleeding

Normal vaginal bleeding, or menstruation, occurs every 21 to 35 days when the uterus sheds its lining, marking the start of a new reproductive cycle. Your menstrual period may last for just a few days or several days and be heavy or light, but still be considered normal.

Abnormal vaginal bleeding is any vaginal bleeding unrelated to normal menstruation. This type of bleeding may include spotting of small amounts of blood between periods — often seen on toilet tissue after wiping — or heavy periods in which you soak a pad an hour for several hours. Bleeding that lasts for weeks at a time is also considered abnormal.

Abnormal vaginal bleeding can signal gynecologic conditions and other medical problems. If you have gone through the menopausal transition — 12 consecutive months without a menstrual period — vaginal bleeding is a particular cause for concern.

Causes

Possible causes of abnormal vaginal bleeding:

Cervical cancer
Cervicitis
Chlamydia
Ectopic pregnancy
Endometrial cancer
Endometrial hyperplasia
Endometritis
Fluctuating hormone levels
Gonorrhea
Hypothyroidism (underactive thyroid)
Menorrhagia (heavy menstrual bleeding)
Miscarriage
Ovarian cancer
Ovarian cysts
Pelvic inflammatory disease (PID)
Perimenopause
Polycystic ovary syndrome
Sexual intercourse
Stopping birth control pills or hormone replacement therapy (withdrawal bleeding)
Tamoxifen side effect
Uterine fibroids
Uterine polyps
Uterine sarcoma
Vaginal cancer
Vaginal or cervical trauma
Vaginitis
Von Willebrand disease

When to see a doctor

If you're pregnant, contact your doctor immediately if you notice vaginal bleeding.

In general, anytime you experience unexpected vaginal bleeding, consult your doctor. Whether or not vaginal bleeding might be normal depends on your age and the circumstances:

Newborn girls may experience some vaginal bleeding during the first few days of life — any vaginal bleeding beyond that should be checked out.

In girls who haven't gone through puberty and their first menses, any vaginal bleeding should be investigated.

Adolescents who have just begun having periods may have irregular cycles during the first few years. Many women have light spotting for a few days before menstruating.

Women starting birth control pills may experience occasional spotting the first few months.

Perimenopausal women nearing menopause may experience increasingly heavy or irregular periods. Ask your doctor about possible treatments to minimize your symptoms.

Postmenopausal women not taking hormone therapy should see a doctor if they experience vaginal bleeding.

Postmenopausal women taking cyclic hormone therapy may experience some vaginal bleeding. A cyclic hormone therapy regimen — oral estrogen daily plus oral progestin for 10 to 12 days a month — can lead to bleeding that resembles a period (withdrawal bleeding) for a few days out of the month. If you have bleeding other than expected withdrawal bleeding, contact your doctor.

Postmenopausal women taking continuous hormone therapy — taking a low-dose combination of estrogen and progestin daily — may experience light, irregular bleeding for the first six months. If bleeding persists longer or heavy bleeding begins, see your doctor.

Postmenopausal women not on hormone therapy should see a doctor if they experience vaginal bleeding.

Adapted from: Mayo Foundation for Medical Education and Research

Douching - A prevention?

The word "douche" means to wash or soak in French. Douching is washing or cleaning out the vagina (also called the birth canal) with water or other mixtures of fluids. Usually douches are prepackaged mixes of water and vinegar, baking soda, or iodine. Women can buy these products at drug and grocery stores. The mixtures usually come in a bottle and can be squirted into the vagina through a tube or nozzle.

Why do women douche?
Women douche because they mistakenly believe it gives many benefits. In reality, douching may do more harm than good. Common reasons women give for using douches include:

to clean the vagina
to rinse away blood after monthly periods
to get rid of odors from the vagina
to avoid sexually transmitted diseases (STDs)
to prevent pregnancy

How common is douching?
Douching is common among women in the United States. It is estimated that 20 to 40 percent of American women aged 15 to 44 years douche regularly. About half of these women douche every week.

Is douching safe?
Most doctors and the American College of Obstetricians and Gynecologists (ACOG) suggest that women steer clear of douching. All healthy vaginas contain some bacteria and other organisms called the vaginal flora. The normal acidity of the vagina keeps the amount of bacteria down. But douching can change this delicate balance. This may make a woman more prone to vaginal infections. Plus, douching can spread existing vaginal infections up into the uterus, fallopian tubes, and ovaries.

What are the dangers linked to douching?
Research shows that women who douche regularly have more health problems than women who do not. Doctors are still unsure whether douching causes these problems. Douching may simply be more common in groups of women who tend to have these issues. Health problems linked to douching include:

vaginal irritation,
vaginal infections called bacterial vaginosis or BV,
sexually transmitted diseases (STDs), and
pelvic inflammatory disease (PID)
Pelvic inflammatory disease (PID) is an infection of a woman's uterus, fallopian tubes and/or ovaries. It is caused by bacteria that travel from a woman's vagina and cervix up into her reproductive organs. If left untreated, PID can cause fertility problems (difficulties getting pregnant). PID also boosts a woman's chances of ectopic pregnancy (pregnancy in the fallopian tube instead of the uterus). Some STDs, BV, and PID can all lead to serious problems during pregnancy. These include infection in the baby, problems with labor, and early delivery.

Should I douche to clean inside my vagina?
No. Doctors and the ACOG suggest women avoid douching completely. Most experts believe that douching increases a woman's chances of infection. The only time a woman should douche is when her doctor recommends it.

What is the best way to clean my vagina?
Most doctors say that it is best to let your vagina clean itself. The vagina cleans itself naturally by producing mucous. Women do not need to douche to wash away blood, semen, or vaginal discharge. The vagina gets rid of it alone. Also, it is important to note that even healthy, clean vaginas may have a mild odor.

Regular washing with warm water and mild soap during baths and showers will keep the outside of the vagina clean and healthy. Doctors suggest women avoid scented tampons, pad, powders and sprays. These products may increase a woman's chances of getting vaginal infections.

My vagina has a terrible odor, can douching help?
No. Douching will only cover up the smell. It will not make it go away. If your vagina has a bad odor, you should call your doctor right away. It could be a sign of a bacterial infection, urinary tract infection, STD or a more serious problem.

Should I douche to get rid of vaginal discharge, pain, itching, or burning?
No. Douching may even make these problems worse. It is very important to call your doctor right away if you have:

vaginal discharge with a bad smell
thick, white or yellowish-green discharge with or without a smell
burning, redness, and swelling of the vagina or the area around it
pain when urinating
pain or discomfort during sex

These may be signs of a bacterial infection, yeast infection, urinary tract infection, or STD. Do not douche before seeing your doctor. This can make it hard for the doctor to figure out what is wrong.

Can douching after sex prevent sexually transmitted diseases (STDs)?
No. This is a myth. The only way to completely prevent STDs is to not have sex. But practicing safer sex will dramatically decrease your risk of getting these diseases. You can greatly reduce your chances of getting an STD in the following ways:

using latex condoms or female condoms every time you have sex
avoiding contact with sores on the penis or vagina
preventing the exchange of semen, blood, and vaginal secretions

Can douching after sex stop me from getting pregnant?
No. Douching does not prevent pregnancy and should never be used as a means of birth control. Actually, douching may make it easier to get pregnant by pushing the sperm further up into the vagina and cervix.

Can douching hurt my chances of having a healthy pregnancy?
It may. Limited research shows that douching may make it more difficult for a woman to get pregnant. In women trying to get pregnant, those who douched more than once a week took the longest to get pregnant.

Studies also show that douching may boost a woman's chance of ectopic pregnancy. Ectopic pregnancy is when the fertilized egg attaches to the inside of the fallopian tube instead of the uterus. If left untreated, ectopic pregnancy can be life-threatening. It can also make it difficult for a woman to get pregnant in the future.

Adapted from:National Women's Health Information Center

Vaginitis

Vaginitis is an inflammation of the vagina. It is often caused by infections, some of which are associated with serious diseases. The most common vaginal infections are
Some vaginal infections are transmitted through sexual contact, but others, such as yeast infections, probably are not.

Other causes of vaginitis
Although most vaginal infections in women are due to bacterial vaginosis, trichomoniasis, or yeast, there may be other causes as well. These causes include other sexually transmitted infections, allergic reactions, and irritations.
Allergic symptoms can be caused by spermicides, vaginal hygiene products, detergents, and fabric softeners. Inflammation of the cervix (opening to the womb) from these products often is associated with abnormal vaginal discharge, but health care providers can tell them apart from true vaginal infections by doing lab tests.

Cause
This infection is caused by an overgrowth of a fungus called Candida albicans in the vagina. Candida is yeast, which is a type of fungus.

Yeast are always present in the vagina in small numbers, and symptoms only appear with overgrowth. Health experts estimate that approximately 75 percent of women will have at least one yeast infection with symptoms during their lifetimes; 40 to 45 percent will experience two or more episodes.

Transmission
Several factors are associated with increased yeast infection in women, including
Pregnancy
Uncontrolled diabetes mellitu
Oral contraceptives or antibiotics
Douches
Feminine hygiene sprays
Topical antibiotics and steroid medicines
Weakened or compromised immune systems

Wearing tight, poorly ventilated clothing and underwear also can contribute to vaginitis. Women with chronic (recurring) yeast infections should work with their health care providers to find out possible underlying causes.

Health experts do not know whether yeast can be transmitted sexually. Because almost all women have the fungus in their vaginas, it has been difficult for researchers to study this.

Symptoms
The most frequent symptoms of yeast infection in women are itching, burning, and irritation of the vagina. Painful urination and painful intercourse also are common.
Vaginal discharge is not always present and may only be present in small amounts. The thick, whitish-gray discharge is typically described as cottage-cheese-like, although it can vary from watery to thick.

Most male partners of women with yeast infections do not have any symptoms of the infection. Some men, however, have reported temporary rashes and burning sensations of the penis after intercourse if they did not use condoms.

Diagnosis
Because few specific signs and symptoms of yeast infections are usually present, health care providers cannot diagnose this condition by a person’s medical history and physical examination. They usually diagnose yeast infection by examining vaginal secretions under a microscope for evidence of yeast.

Treatment
Various antifungal vaginal medicines are available to treat yeast infections. Women can buy antifungal creams to be applied directly to the area, tablets to be taken orally, or suppositories (butoconazole, miconazole, clotrimazole, and tioconazole) for use in the vagina.

Because bacterial vaginosis, trichomoniasis, and yeast infections are difficult to tell apart on the basis of symptoms alone, a woman with vaginal symptoms should see her health care provider for an accurate diagnosis before using these products.
Women who have chronic or recurring yeast infections may need to be treated with vaginal creams or oral medicines for long periods of time. HIV-infected women can develop severe yeast infections that often do not respond to treatment.

Adapted from: National Institute of Allergy and Infectious Diseases (niaid.nih.gov)

Vaginal Yeast Infection

Vaginal yeast infection, or Vulvovaginal Candidiasis, is a common cause of vaginal irritation. In addition, 12 to 15 percent of men develop symptoms after sexual contact with an infected partner

Cause
This infection is caused by an overgrowth of a fungus called Candida albicans in the vagina. Candida is yeast, which is a type of fungus.
Yeast are always present in the vagina in small numbers, and symptoms only appear with overgrowth. Health experts estimate that approximately 75 percent of women will have at least one yeast infection with symptoms during their lifetimes; 40 to 45 percent will experience two or more episodes.

Transmission
Several factors are associated with increased yeast infection in women, including
Pregnancy
Uncontrolled diabetes mellitus
Oral contraceptives or antibiotics
Douches
Feminine hygiene sprays
Topical antibiotics and steroid medicines
Weakened or compromised immune systems

Wearing tight, poorly ventilated clothing and underwear also can contribute to vaginitis. Women with chronic (recurring) yeast infections should work with their health care providers to find out possible underlying causes.

Health experts do not know whether yeast can be transmitted sexually. Because almost all women have the fungus in their vaginas, it has been difficult for researchers to study this.

Symptoms
The most frequent symptoms of yeast infection in women are itching, burning, and irritation of the vagina. Painful urination and painful intercourse also are common.
Vaginal discharge is not always present and may only be present in small amounts. The thick, whitish-gray discharge is typically described as cottage-cheese-like, although it can vary from watery to thick.

Most male partners of women with yeast infections do not have any symptoms of the infection. Some men, however, have reported temporary rashes and burning sensations of the penis after intercourse if they did not use condoms.

Diagnosis
Because few specific signs and symptoms of yeast infections are usually present, health care providers cannot diagnose this condition by a person’s medical history and physical examination. They usually diagnose yeast infection by examining vaginal secretions under a microscope for evidence of yeast.

Treatment
Various antifungal vaginal medicines are available to treat yeast infections. Women can buy antifungal creams to be applied directly to the area, tablets to be taken orally, or suppositories (butoconazole, miconazole, clotrimazole, and tioconazole) for use in the vagina.

Because bacterial vaginosis, trichomoniasis, and yeast infections are difficult to tell apart on the basis of symptoms alone, a woman with vaginal symptoms should see her health care provider for an accurate diagnosis before using these products.
Women who have chronic or recurring yeast infections may need to be treated with vaginal creams or oral medicines for long periods of time. HIV-infected women can develop severe yeast infections that often do not respond to treatment.

Adapted from: National Institute of Allergy and Infectious Diseases (niaid.nih.gov)

Vaginal Atrophy (Atrophic Vaginitis)

Vaginal atrophy (atrophic vaginitis) is thinning and inflammation of the vaginal walls due to a decline in estrogen. Vaginal atrophy occurs most often after menopause, but it can also develop during breast-feeding or at any other time your body's estrogen production declines.

For many women, vaginal atrophy makes intercourse painful — and if intercourse hurts, your interest in sex will naturally wane. What's more, healthy genital function is closely intertwined with healthy urinary system function.

The good news is that simple, effective treatments for vaginal atrophy are available. Reduced estrogen levels do result in changes to your body, but it doesn't mean you have to live with the discomfort and urinary problems associated with vaginal atrophy.

Symptoms
With moderate to severe vaginal atrophy, you may experience the following vaginal and urinary signs and symptoms:

Vaginal dryness
Vaginal burning
Watery vaginal discharge
Burning with urination
Urgency with urination
More urinary tract infections
Urinary incontinence
Light bleeding after intercourse
Discomfort with intercourse
Shortening and tightening of the vaginal canal

When to see a doctor
By some estimates, more than half of menopausal women experience vaginal atrophy, although very few seek treatment. The rest may resign themselves to the symptoms or be embarrassed to broach the topic with their doctors.

Make an appointment to see your doctor if you experience painful intercourse that's not resolved by using a vaginal moisturizer (Replens, others) or water-based lubricant (Astroglide, K-Y, others), or if you have vaginal symptoms, such as unusual bleeding, vaginal discharge, burning or soreness.

Causes

Vaginal atrophy is caused by a loss of estrogen. Less circulating estrogen makes your vaginal tissues thinner, drier, less elastic and more fragile.

A drop in estrogen levels and vaginal atrophy may occur:

After menopause
During the years leading up to menopause (perimenopause)
During breast-feeding
After surgical removal of both ovaries (surgical menopause)
After pelvic radiation therapy for cancer
After chemotherapy for cancer
As a side effect of breast cancer hormonal treatment
Vaginal atrophy due to menopause may begin to bother you during the years leading up to menopause (perimenopause), or it may not become a problem until several years into menopause. Although the condition is common, not all menopausal women develop vaginal atrophy. Regular sexual activity helps you maintain healthy vaginal tissues.

Risk factors

Certain factors may contribute to vaginal atrophy. Among these are:

Smoking. Cigarette smoking impairs blood circulation, depriving the vagina and other tissues of oxygen. Decreased blood flow to your vagina contributes to atrophic changes. Smoking also reduces the effects of naturally occurring estrogens in the body. In addition, women who smoke have an earlier menopause and are less responsive to estrogen therapy in pill form.

Never giving birth vaginally. Researchers have observed that women who have never given birth vaginally are more prone to vaginal atrophy than are women who have had vaginal deliveries.

Complications
With vaginal atrophy, your risk of vaginal infections (vaginitis) increases. Atrophy leads to a change in the acidic environment of your vagina, making you more susceptible to infection with bacteria, yeast or other organisms.

As the lining gets thinner, you're at risk of developing open sores or cracks in the walls of your vagina. Such sores can develop from friction or injury to the vaginal walls or from recurrent vaginal infections.

Atrophic vaginal changes are also associated with changes in your urinary system and function (genitourinary atrophy), which can contribute to urinary problems. You might experience increased frequency or urgency of urination or burning with urination. Some women experience more urinary tract infections or incontinence.

Preparing for your appointment
Your primary care provider may refer you to a specialist (gynecologist) to evaluate your condition.

Questions your doctor may ask
Your doctor will ask questions about the symptoms you're experiencing and assess your hormonal status. Questions your doctor may ask include:

What vaginal symptoms are you experiencing?
How long have you experienced these symptoms?
Do you continue to have menstrual periods?
How much distress do your symptoms cause you?
Are you sexually active?
Does the condition limit your sexual activity?
Have you been treated for cancer?
Do you use scented soap or bubble bath?
Do you douche or use feminine hygiene spray?
What medications or vitamin supplements do you take?
Have you tried any over-the-counter moisturizers or lubricants?

Tests and diagnosis
Diagnosis of vaginal atrophy may involve:

A pelvic exam, during which your doctor feels (palpates) your pelvic organs and visually examines your external genitalia, vagina and cervix. During the pelvic exam, your doctor also checks for signs of pelvic organ prolapse, indicated by bulges in your vaginal walls from pelvic organs such as your uterus or bladder.

A Pap test, which involves collecting a sample of cervical cells for microscopic examination. Your doctor may also take a sample of vaginal secretions or place a paper indicator strip in your vagina to tests its acidity.

A urine test, which involves collecting and analyzing your urine, if you have associated urinary symptoms.

Treatments and drugs
If you don't have vaginal discomfort, you might not need treatment for vaginal atrophy. Mild symptoms may be relieved by use of an over-the-counter lubricant or moisturizer. However, if you have vaginal atrophy and you're bothered by vaginal dryness, vaginal irritation, discomfort with intercourse, urinary frequency or urinary urgency, effective treatments are available.

In general, treating vaginal dryness is more effective with topical (vaginal) estrogen rather than oral estrogen. Estrogen applied to the vagina can still result in estrogen reaching your bloodstream, but the amount is minimal. Vaginal estrogen also doesn't decrease testosterone levels — important for healthy sexual function — the same way oral estrogen can.

Vaginal estrogen therapy comes in several forms:

Vaginal estrogen cream (Estrace, Premarin, others). You insert this cream directly into your vagina with an applicator, usually at bedtime. Your doctor will let you know how much cream to use and how often to insert it, usually a daily application for the first few weeks and then two or three times a week thereafter.

Vaginal estrogen ring (Estring). A soft, flexible ring is inserted into the upper part of the vagina by you or your doctor. The ring releases a consistent dose of estrogen while in place and needs to be replaced about every three months.

Vaginal estrogen tablet (Vagifem). You use a disposable applicator to place a vaginal estrogen tablet in your vagina. Your doctor will let you know how often to insert the tablet; you might, for instance, use it daily for the first two weeks and then twice a week thereafter.

If vaginal dryness is associated with other symptoms of menopause, such as moderate or severe hot flashes, your doctor may suggest estrogen pills, patches, gel or a higher dose estrogen ring along with a progestin. Progestin is usually given as a pill, but combination estrogen-progestin patches also are available. Talk to your doctor to decide if hormone treatment is an option and, if so, which type is best for you.

You should experience noticeable improvements after a few weeks of estrogen therapy. Some symptoms of severe atrophy may take longer to resolve.

If you have a history of breast cancer, estrogen therapy — vaginal or otherwise — generally isn't recommended, especially if your breast cancer was hormonally sensitive.

Lifestyle and home remedies

If you're experiencing vaginal dryness or irritation, the following measures may provide some relief:

Try a vaginal moisturizer, such as Replens or K-Y Silk-E, to restore some moisture to your vaginal area. You may have to apply the moisturizer every two to three days.
Use a water-based lubricant, such as Astroglide or K-Y, to reduce discomfort during intercourse. Avoid petroleum jelly or other petroleum-based products for lubrication if you're also using condoms. Petroleum can break down latex condoms on contact.
Allow time to become aroused during intercourse, and avoid intercourse if you have any vaginal irritation.

Prevention
Regular sexual activity, either with or without a partner, can decrease problems with vaginal atrophy. Sexual activity enhances blood flow to your vagina, which helps keep vaginal tissues healthy.

Adapted from:Mayo Foundation for Medical Education and Research

Vaginal dryness

Vaginal dryness is a common problem for women during and after menopause, although inadequate vaginal lubrication can occur at any age. Symptoms of vaginal dryness include itching and stinging around the vaginal opening and in the lower third of the vagina. Vaginal dryness also makes intercourse uncomfortable.

A thin layer of moisture always coats your vaginal walls. Hormonal changes during your menstrual cycle and as you age affect the amount and consistency of this moisture.

Most vaginal lubrication consists of clear fluid that seeps through the walls of the blood vessels encircling the vagina. When you're sexually aroused, more blood flows to your pelvic organs, creating more lubricating vaginal fluid. But the hormonal changes of menopause, childbirth and breast-feeding may disrupt this process.

Symptoms
Signs and symptoms of vaginal dryness include:
Dryness
Itching
Burning
Pain or light bleeding with sex
Urinary frequency or urgency

As many as four in 10 women who have reached menopause experience signs and symptoms related to vaginal dryness.

When to see a doctor
Make an appointment with your doctor if you have vaginal burning, itching or soreness or painful sexual intercourse that doesn't improve with self-care measures, such as using a vaginal moisturizer or water-based lubricant.

Causes
A variety of conditions can cause vaginal dryness. Determining the cause is key to helping you find an appropriate solution. Potential causes include:

Decreased estrogen levels
Reduced estrogen levels are the main cause of vaginal dryness. Estrogen, a female hormone, helps keep vaginal tissue healthy by maintaining normal vaginal lubrication, tissue elasticity and acidity. These factors create a natural defense against vaginal and urinary tract infections. But when your estrogen levels decrease, so does this natural defense, leading to a thinner, less elastic and more fragile vaginal lining.

Estrogen levels can fall for a number of reasons:
Menopause or perimenopause
Childbirth
Breast-feeding
Effects on your ovaries from cancer therapy, including radiation therapy, hormone therapy and chemotherapy
Surgical removal of your ovaries
Immune disorders
Cigarette smoking

Medications
Allergy and cold medications, as well as some antidepressants, can decrease the moisture in many parts of your body, including your vagina. Anti-estrogen medications, such as those used to treat breast cancer, also can result in vaginal dryness.

Sjogren's syndrome
In this autoimmune disease, your immune system attacks healthy tissue. In addition to causing symptoms of dry eyes and dry mouth, Sjogren's syndrome can also cause vaginal dryness.

Douching
The process of cleansing your vagina with a liquid preparation (douching) disrupts the normal chemical balance in your vagina and can cause inflammation (vaginitis). This may cause your vagina to feel dry or irritated.

Preparing for your appointment
If your usual doctor is a family doctor or general practitioner, he or she may refer you to a specialist (gynecologist) to evaluate your condition.

Questions your doctor may ask
What vaginal symptoms are you experiencing?
How long have you experienced these symptoms?
How much distress do your symptoms cause you?
Are you sexually active?
Does the condition limit your sexual activity?
Do you use scented soap or bubble bath?
Do you douche or use feminine hygiene spray?
What medications or vitamin supplements do you take?
Have you tried any over-the-counter moisturizers or lubricants?

Tests and diagnosis
Diagnosis of vaginal dryness may involve:
A pelvic exam, during which your doctor feels (palpates) your pelvic organs and visually examines your external genitalia, vagina and cervix.

A Pap test, which involves collecting a sample of cervical cells for microscopic examination. Your doctor may also take a sample of vaginal secretions to check for signs of vaginal inflammation (vaginitis) or to confirm vaginal changes related to estrogen deficiency.

A urine test, which involves collecting and analyzing your urine, if you have associated urinary symptoms.

Treatments and drugs
Vaginal estrogen therapy
In general, treating vaginal dryness is more effective with topical (vaginal) estrogen rather than oral estrogen. Estrogen applied to the vagina can still result in estrogen reaching your bloodstream, but the amount is minimal. Vaginal estrogen also doesn't decrease testosterone levels — important for healthy sexual function — the same way oral estrogen can.
Vaginal estrogen therapy comes in several forms:
Vaginal estrogen cream (Estrace, Premarin, others). You insert this cream directly into your vagina with an applicator, usually at bedtime. Your doctor will let you know how much cream to use and how often to insert it, usually a daily regimen for the first few weeks and then two or three times a week thereafter.

Vaginal estrogen ring (Estring). A soft, flexible ring is inserted into the upper part of the vagina by you or your doctor. The ring releases a consistent dose of estrogen while in place and needs to be replaced about every three months.

Vaginal estrogen tablet (Vagifem). You use a disposable applicator to place a vaginal estrogen tablet in your vagina. Your doctor will let you know how often to insert the tablet, for instance daily for the first two weeks and then twice a week thereafter.

If vaginal dryness is associated with other symptoms of menopause, such as moderate or severe hot flashes, your doctor may suggest estrogen pills, patches, gel or a higher dose estrogen ring along with a progestin. Talk to your doctor to decide if hormone treatment is an option and, if so, which type is best for you.

Lifestyle and home remedies
Use a lubricant or moisturizer
If vaginal dryness makes sexual intercourse uncomfortable, try over-the-counter products such as:

Lubricants (Astroglide, K-Y). Water-based lubricants like these lubricate your vagina for several hours. Apply the lubricant to your vaginal opening or to your partner's penis before intercourse.

Moisturizers (Replens, Lubrin). These products imitate normal vaginal moisture and relieve dryness for up to three days with a single application.

Pay attention to sexual needs
Occasional vaginal dryness during intercourse may mean that you aren't sufficiently aroused. Make time to be intimate with your partner and allow your body to become adequately aroused and lubricated. It may help to talk with your partner about what feels good. Having intercourse regularly also may help promote better vaginal lubrication.

Avoid certain products
Though you may be willing to try just about anything to relieve your discomfort, avoid using the following products to treat vaginal dryness, because they may irritate your vagina:
Vinegar, yogurt or other douches
Hand lotions
Soaps
Bubble baths

Adapted from: Mayo Foundation for Medical Education and Research

Vaginal Agenesis

Vaginal agenesis is a congenital disorder of the reproductive system affecting one in 5,000 females. It occurs when the vagina, the muscular canal connecting the cervix of the uterus to the vulva, stops developing because the vaginal plate fails to form the channel.

Some patients may have a shorter vagina, a remnant of one or lack of one all together (Mayer-von Rokitansky-Kuster-Hauser's syndrome). With vaginal agenesis, it is not uncommon to have other malformations in the reproductive tract, such as an absent or small uterus.

In addition, 30 percent of patients with vaginal agenesis will have kidney abnormalities, the most common of which is the absence of one kidney or the dislocation of one or both organs. The two kidneys may also be fused together, forming a horseshoe-like shape. Approximately 12 percent of patients also have skeletal abnormalities, with two-thirds of this group experiencing problems affecting the spine, ribs or limbs.

How is vaginal agenesis diagnosed?

Because external genitalia appear normal, vaginal agenesis is typically not diagnosed until puberty (around age 15), when a young girl notices that she has not had her menstrual period and seeks medical attention. The diagnosis is made by physical examination and a series of X-ray tests. They may include an ultrasound to check if the uterus and ovaries are both present and entirely intact. The patient may even be asked to undergo a MRI that will show a more detailed picture of her reproductive tract.

While most vaginal agenesis sufferers are not aware of their condition until their teen years, a subgroup of these patients will be diagnosed during infancy. In this case, the abnormality is usually detected during an examination or test for unrelated problems.

How is vaginal agenesis treated?

Self-dilation: Some women can have their vagina reconstructed without having an operation. Pressure is applied over the area where the vagina should be with a very small tube, called a dilator. The dilator is held against the skin and pressure is applied for about 15 to 20 minutes a day. Usually, this is more comfortable after the patient has taken a bath because the skin is soft and stretches more easily.

Vaginoplasty: Most young women, however, will require surgical reconstruction. Techniques vary widely, but sufferers usually undergo either a skin graft or bowel operation. In the first procedure, the surgeon creates a vagina by cutting a thin piece of skin from the patient's buttocks and placing it over a mold to create a vagina. He or she then makes a small incision where a normal vagina would be located and inserts the mold so the graft will attach naturally to make the inside of a vagina. After the surgery, the patient is usually on bed rest for a week, during which time a catheter is placed into the bladder for drainage. The mold is removed after seven days. With a bowel vaginoplasty, a portion of the lower colon is removed through an abdominal incision. One end of the bowel is then closed, while the other remains open, functioning as a vaginal opening. The colon is sewn into the vaginal remnant. The night before surgery, patients undergoing this vaginoplasty must empty their bowels to remove stool and bacteria. Following the surgery, a mold will be inserted into the new vagina for three days. During this period a catheter is placed into the bladder through the urethra so that urine can drain.

What can be expected after treatment for vaginal agenesis?
Patients undergoing a skin graft usually wear a vaginal dilator for three months after surgery. It is removed for urination, bowel movements, showering and sexual intercourse. After three months, the patient usually wears the dilator only at night for approximately six months. Vaginal stenosis, or a tightening of the vagina, is the major complication of this procedure.

Only one operation is needed with bowel vaginoplasty. The patient will be seen three weeks after the surgery and again in three months. Some women will experience a tightening of the vagina. If this occurs, dilation will be performed under anesthesia. Home dilation is not necessary.

Frequently asked questions:

At what age should my daughter consider having a vagina created?

When she starts is up to her. Most girls begin the process in their teens, but she may want to wait until some time in the future when she is ready to become sexually active.

After surgery, when can she begin to have sexual intercourse?

Although patients should consult their physician before having sexual intercourse, it is usually acceptable to begin four to six weeks after the procedure. The patient will probably need lubrication since the skin will not produce the same substances as normal vaginal tissue. Lubrication after a bowel vaginoplasty is less of a problem.

Will she be able to lead a normal sex life?

Since much of sexual pleasure comes from stimulation of the clitoris, the female erectile structure, and not the vagina, she should enjoy normal sensations and a good sex life. Since reconstruction is internal, no one will be able to tell that a patient has undergone the procedure.

Will my daughter be able to have children?

Your daughter's individual anatomy will be the biggest factor in whether or not she will be able to have children. It is very likely she will be able to become pregnant if her uterus, ovaries and fallopian tubes are normal. It is unlikely that she will be capable of going through pregnancy by herself if her uterus is tiny or absent. However, since the ovaries usually remain normal, fertility specialists will be able to harvest an egg, fertilize it with her partner's sperm, and implant it into a surrogate mother who would carry it to term. Adoption is another option.

Do doctors know the cause of vaginal agenesis?

There are no known risk factors for vaginal agenesis.

Adapted from:American Urological Association