The Nutshell: Gynecology

Sexually Transmitted Diseases

Sexually transmitted diseases (STDs) are infections that are acquired when having sex with an infected partner, usually caused by bacteria, parasites or virus. Many are passed through oral, vaginal and anal sex. Using a condom will decrease the risk of getting sexual infections: Here are some of the more common ones:

Chlamydia and gonorrhea are both caused by bacteria. There may be no symptoms, or some experience burning on urination, pelvic pain or an abnormal discharge from the vagina. If untreated this infection can progress into the pelvic organs (womb and tubes) and lead to pelvic inflammatory disease. This may cause infertility, chronic pelvic pain or the need for a hysterectomy. Treated early these infections may be cured with antibiotics. It is recommend for women 25 and younger to get tested for Chlamydia and Gonorrhea every year. Both of these infections can be passed from mother to baby during pregnancy and if untreated cause harm to the newborn.

Herpes Simplex (HSV) is caused by a virus, so there is no cure. This infection can cause cold sores on the mouth and lips (HSV1) or genital infections (HSV2) where there are fluid filled painful blisters in the vaginal area. They can also appear on the buttocks, back or anal area. These viruses don’t go away and those infected can have recurrent symptoms. Anti-viral medications are used to reduce the severity of symptoms or number of outbreaks. Mothers can pass this infection to their newborns during childbirth, and it can be extremely dangerous. Medication is suggested after 36 weeks pregnancy in women who have had history of previous outbreaks to reduce the risk of transmission.

HPV(Human papillomaviruses) is caused by a virus and again no cure. Certain types can increase your at risk for cancer especially in the cervix, mouth, throat, vaginal area and anus. It is very important to have your Pap smear done as recommended, and have proper follow-up for all abnormal Pap smears. This virus can also cause venereal warts that can be treated with medications, surgery or laser. A vaccine is available to protect against several types of HPV, especially those that cause cancer, but does not help if already infected.

Syphilis is caused by bacteria and can be cured if treated early with antibiotics. Initially it causes a single, small, painless sore in the genital area that goes away over several weeks. It can then progress to a skin rash on the hands and feet that does not itch. If left untreated it can progress to the internal organs including the heart and brain. This infection can also be passed from mother to newborn causing harmful and often life-long debilitating illnesses.

HIV/AIDS(human immunodeficiency virus) infection can progress to severely damage the body’s immune system cells that are needed to fight infections. Initial symptoms include flu-like symptoms and swollen glands that progress months or even years later to life threatening illnesses like pneumocystis carini (lung infection) and Kaposi’s sarcoma (cancer). This virus is spread through unprotected sex but also sharing IV needles and rarely blood transfusions. Multiple medications are used to treat symptoms and reduce the progression of the disease but there is no cure. Women can pass it to their newborns in pregnancy but proper medication and follow-up can greatly reduce this risk.

Birth Control

Comprises several techniques, some temporary and reversible while others permanent, that is used to prevent pregnancy

Reversible:
The birth control pill is an oral pill taken daily. There are various kinds that contain synthetic combinations of the female hormones estrogen and progesterone in different strengths that prevent ovulation (release of an egg). For most pills women have a period once a month and the pills taken during the cycle time have no hormones. Other types of birth control pills, like Yaz, Estrostep, and Ortho Tri-Cyclen increase the amount of a molecule called sex-hormone-binding globulin that binds to the male hormone testosterone and reduces acne.
Yaz, Yasmin and Beyaz use a new kind of progestin called drospirenone that reduces water retention and swelling, and claims to improve premenstrual symptoms like irritability, moodiness, headaches, anxiety and muscle aches. Seasonale and Seasonique reduce the number of periods to four times each year and Lybrel to no cycle at all. Several new pills are on the market. Beyaz contains folic acid, found to reduce the risk of neural tube birth defects. Natazia that is the first four-phase oral contraceptive where women will take four different combinations and doses of hormones throughout each 28-day treatment cycle. Similar hormones in the pill have been used in other delivery symptoms too and include chewable, patches, injectables, vaginal rings and implants.
Common side effects of birth control pills are nausea, headaches, breast tenderness, bloating and weight gain and acne. More serious concerns are high blood pressure, gall bladder disease, strokes, heart attacks and blood clots. Women over 35 who smoke should not take the pill because there is an increased risk of serious side effects. Also some research suggests the newer birth control have a greater risk of side effects, especially blood clots.
Barrier methods block sperm from entering the womb and include the condom (male and female), diaphragm and cervical cap. These are used sometimes with a lubricant or spermicidal.
Intrauterine device (IUD) is a device placed in the womb that prevents the implantation of the fertilized egg, therefore preventing pregnancy. Two types are available, those containing copper and those containing the hormone, progesterone. There may be an increased risk of infection, bleeding or ectopic pregnancy (pregnancy stuck in Fallopian tube).
Emergency contraceptive pills (ECPs) or the “morning-after pill” are high levels of the hormone estrogen used to interrupt ovulation or implantation of the fertilized egg. Usually accompanied by nausea and may need additional anti-nausea medication.

Permanent:
Tubal sterilization: (also known as having one’s “tubes tied”) is a surgical procedure where a woman’s fallopian tubes are clamped, blocked, cut or burned to prevent the eggs and sperm from meeting in the fallopian tube where fertilization occurs. A tubal ligation should cut and remove a portion of the tube with a suture used to tie off the cut ends. Clips and silicone rings are used to provide a mechanical blockage. Electrocoagulation is used to burn the tubes. Although it can be reversed with some success, this is considered a permanent method.
Essure is an in office procedure where small tubes are used to block the area where the fallopian tube opens into the womb. This is done through a scope placed through the vagina, inserts soft, flexible inserts through the body’s natural pathways (vagina, cervix, and uterus) and into your fallopian tubes. The very tip of the device remains outside the fallopian tube, pass the a permanent transcervical sterilization procedure for women, which creates fibrous growths in the fallopian tubes in order to block the passage of eggs and sperm.

Infertility

Considered when a woman is unable to get pregnant after trying for one year without using contraception or only six months, if she is over 35. This affects over 6 million women in the United States and can have a significant emotional toil on a couple that are trying to conceive. Three common factors are needed for a successful pregnancy, A woman must ovulate, the fallopian tubes must be open and the male partner needs an adequate sperm count. For regular ovulation, an egg is released from a woman’s ovary once a month and this is normally accompanied by a regular menstrual cycle. If no egg is released, a pregnancy cannot occur. Irregular menstrual cycles may indicate a problem with ovulation.

After an egg is released, it is picked up by the end of the fallopian tube (tubes at each upper corner of the womb), travels a short distance and this is where it meets the male sperm. If they join properly a pregnancy occurs (fertilization) and the early pregnancy travels down the tube into the womb where it will bury into its lining. Multiple reasons can cause a blockage or damage to the fallopian tube and prevent either the meeting of egg and sperm or the passage of the early pregnancy into the womb. These may include pelvic inflammatory disease (infection of a woman’s internal reproductive organs), endometriosis (abnormal implants in the woman’s lower abdomen or pelvis) or an ectopic pregnancy (early pregnancy that is stuck in the Fallopian tubes).

The male partner must also have not only an adequate sperm count or numbers but a certain percentage must have adequate shape and movement. Sometimes men are found to have a Varicocele, an enlargement of the veins on a man’s testicle(s) affects the sperm count and can be surgically corrected. Other factors affecting the sperm count are alcohol, medications/drug use and illnesses. Current treatments include infertility can be treated with medicine, surgery, artificial insemination or assisted reproductive techniques.

Depression

Depression is a debilitating disorder. It can interfere with your daily life and negatively affect relationships with family and friends. Many women give-up because they just can’t cope. It’s difficult to understand what causes depression or how to get successful relief. One in eight women will suffer from depression at some point in their life. It is usually diagnosed when a person complains of daily symptoms that have lasted two weeks or more.

These symptoms can include: Sadness, Crying spells, Irritable, Inability to concentrate, Loss of interest in things you use to enjoy doing, Feeling of guilt or worthlessness, Thoughts of suicide,Sleeping disorders, No appetite, Feeling tired all the time, No energy, Trouble concentrating, Forgetfulness.

It is unclear what causes depression. Some researchers believe it may be related to a chemical imbalance in the brain, so it can’t function properly. Depression can also come from or become worse with stress, medications, (for birth control, high blood pressure, seizures, hormone replacement, pain relief, shingles) or medical problems (thyroid disorders, infertility and Alzheimer’s disease). Life’s stresses can cause depression as seen with physical/mental abuse and financial strains. Also hormonal changes like those associated with menstrual cycle, pregnancy and menopause can lead to depression.

Puberty and adolescence has become a concerning time for depression, especially with the increasing incidence of associated youth suicides. At this age, there is not the maturity needed to overcome what can be overwhelming feelings. Acceptance becomes an important part of teen living during this delicate period and lack of it leads to desperation, dejection and despair. With the Internet access and uncontrolled mobile technology, it has become easy to embarrass someone locally and globally. Know your child, keep lines of communication open and take any concerns seriously. If needed, seek immediate professional assistance. Also, hold your school administrators responsible and if they don’t respond, move!

Successful treatment of depression involves a commitment to want to get better, and it starts with you. It is important to have good nutrition, exercise and reduce stress. Find the things that make you happy like a good movie, massage, finding positive ways to let out frustration or just some personal treats. Next, find a good soundboard to vent, which may be a spouse, good friend or clergy. Your partner can help by assisting with the housework or the kids. It’s important not to isolate yourself or use alcohol or illicit drugs to feel better. They often worsen the situation and deepen the despair.

Professional help is available if needed and can include counseling and/or medication. Anti-depressant medications have been helpful in some women, but everyone responds differently. Sometimes several medications have to be tried to find the one that works for you. One commonly prescribed group of medications are called Serotonin reuptake inhibitors (SSRIs) such as Prozac, Zoloft, and Paxil. They work by increasing the amount of serotonin available, a chemical in the brain that may be imbalanced. Side effects may include bleeding, increased bone loss in those over 50, sexual dysfunction and there is also a risk of suicide. Don’t abruptly stop taking medications you are on for depression because they may need to be tapered slowly. Always calls your health provider if you are having problems with your medication.

Whether you are under a doctor’s care or have found your own coping mechanisms, it is good to laugh. This will uplift your spirit and perhaps give you a positive outlook, if only for a moment. After all, laughter is the best medicine.

Uterine Leiomyomas (Uterine Fibroids)

Many women have uterine leiomyomas, some unaware because they don’t experience symptoms. It is estimated to occur in over half of women over forty. These smooth muscle tumors grow in different parts of the uterus (womb) and cause it to enlarge. Submucosal ones lie just below the lining of the womb, intramural inside the walls of the womb, subserosal beneath the serosa or covering of the womb or pedunculated hang off the inner or outer lining of the womb but are attached by a stalk. Those women with symptoms complain of irregular and/or heavy bleeding, pelvic pain or pressure, urinary problems and sometimes infertility. These uterine leiomyomas rarely lead to cancer themselves and are not associated with cervical or uterine cancers.

The presence and size of uterine leiomyomas can be first recognized on a pelvic exam and later confirmed with an ultrasound. If they are not causing any symptoms they can be followed with yearly exams. Birth control pills will not shrink fibroids, but may temporarily control symptoms, especially bleeding. Uterine leiomyomas do tend to shrink after the menopause. In certain situations where there are high doses of the female hormone estrogen, the uterine fibroids can become larger like pregnancy and after using certain birth control pills.

A non-surgical approach is a procedure called embolization. The interventional radiology department usually at a hospital does this. A catheter or small tube is placed into the uterine arteries that supply blood to the uterus (womb). Tiny plastic pellets are injected to clog up the smaller branches of the uterine arteries and reduce the blood going to the uterine leiomyomas. This leads to death of its tissue.

Sometimes surgery may be required. This may involve only removing the uterine leiomyomas (fibroid) or the entire womb (hysterectomy). Very large uterine leiomyomas can be shrunken with medication before surgery to make it a safer procedure. If they cause severe bleeding, significant anemia (low blood count) or a sudden, sharp pelvic pain, emergency treatment may be necessary.