Lincoln Center Obstetrics & Gynecology, P.A.

Choosing the right birth control (contraceptive) method is a very personal decision. There are several options available and only you and your partner can decide which one is right for you. In fact, it’s not uncommon for a woman to change her birth control method several times throughout her reproductive years. The considerations to keep in mind when choosing a contraceptive method are:

How effective the method is.
How likely you are to use it, i.e. will you use it if you have to put it in place every time? Can you remember to take a pill every day?
Safety
Cost
Protection against sexuality transmitted disease
Reversibility

Most contraceptive methods take commitment so make sure you understand the method you have chosen before you begin.

Birth Control Pills

More than 60 million women take the pill worldwide and it is the most popular form of contraception in the United States. Most pills contain estrogen and progestin and work by preventing ovulation. Used correctly (taking it at about the same time every day), it is 99% effective. Pills available today are a much lower dose than the original birth control pill of the 1960's and have fewer side effects.

Side Effects

There are some minor side effects associated with the birth control pill. These include: breakthrough bleeding (bleeding between periods), nausea, headaches, and breast tenderness. Many of these side effects decrease during the first three months of usage.

Advantages

The advantages of the pill are that it does not interrupt sexual activity and allows for spontaneity. It offers protection against ovarian, endometrial, and colo-rectal cancers. The pill decreases menstrual bleeding and cramping. The pill also decreases the risk of PID (pelvic inflammatory disease) and can shrink some benign ovarian cysts. It is an easily reversible method.

Disadvantages

The disadvantages are that it offers no protection against sexually transmitted diseases (STD's). It can be expensive, it must be taken consistently every day and can cause mood changes. It can also cause rare, but dangerous complications.

Not all women are good candidates for the birth control pill. You should not take the pill if you are over 35 and smoke. You should not take the pill if you begin getting SEVERE migraine headaches after starting the birth control pill. Women who have a history of blood clots or stroke, have heart disease, or high blood pressure, have had breast cancer, have liver problems, have kidney problems or have active gallbladder disease should not take the pill.

Diaphragm

A diaphragm is a flexible rubber cup-shaped device that you fill with contraceptive jelly and insert into your vagina up to six hours before sexual intercourse. The diaphragm, when properly inserted, covers the cervix (the opening of the uterus). The diaphragm itself acts as a physical barrier against sperm, while the contraceptive jelly kills any sperm that happens to get past the device. It must be left in place for six hours after intercourse.

The effectiveness of the diaphragm is 84-94% when used with spermicide. Using condoms along with the diaphragm increases the effectiveness to almost 99%. Inserting the diaphragm can be difficult and there is also an increased risk of urinary tract infections with its use. Once the diaphragm is inserted, more contraceptive jelly or cream must be inserted into the vagina with each additional act of intercourse.

The diaphragm must be fitted by your doctor or midwife and its size must be rechecked after the birth of each baby or if you have a significant weight loss or gain.

Intrauterine Device (IUD)

An IUD is a small, T-shaped piece of plastic that is inserted into the uterus by your doctor or midwife. The effectiveness is about 99%. Once the IUD is inserted, it offers protection for 5 to 10 years depending on the IUD used. A mirena IUD is a hormone containing IUD which has the added benefit of less menstrual flow and cramping.

The most common side effect of the IUD is heavier bleeding and cramping with your period unless a Mirena IUD is used. There are several serious complications that can arise from using the IUD’s such as infection, tubal pregnancy (pregnancy located in the fallopian tube), and perforation of the uterine wall.

Not everyone is a good candidate for the IUD. If you and your partner are not monogamous, the IUD is probably not for you. You should not use the IUD if you are having a problem with unexplained, abnormal uterine bleeding, have a history of endocarditis, are allergic to copper, or are anemic.

IUD's are probably one of the easiest contraceptive methods to use. You don't have to think about it every day. Once the IUD is in place, you only need to check the string once a month. In order to reverse the method, have the IUD removed by your health care provider.

Spermicide

Spermicides kill sperm, preventing the fertilization of an egg and can be purchased from a pharmacy without a prescription in cream, jelly, foam, or suppository form. However when used alone, they are only 79% effective. When used with condoms, the effectiveness increases to 99%. Spermicide has to be inserted in the vagina ½ hour or less before intercourse, and it must be reapplied with each additional act. They are convenient, portable, and relatively inexpensive to use.

Condoms

A condom is a thin shield placed directly over the man's erect penis. It catches the sperm released during ejaculation, thereby preventing the sperm from entering the woman's vagina.

Most condoms are made from rubber (latex), but some are made from animal tissue. They may be lubricated or treated with a spermicide. Latex condoms, especially those treated with a spermicide, can protect both partners from most sexually transmitted diseases. They can be purchased without a prescription and are sold in a variety of places.

The condom is convenient, inexpensive, and easy to obtain. They are a good choice if either partner is not monogamous. They can increase the effectiveness of other forms of birth control and reduce the risk of STD's. The disadvantages are a reduction in sexual spontaneity and sensation, along with the possibility of the condom breaking or leaking.

Injections

Depo-Provera injections are given every 90 days or four times a year and are 99% effective. The shots contain progestin, a hormone, which suppresses ovulation. The side effects include bleeding irregularities (although many women stop having periods after a few months), weight gain, headaches, decreased sex drive, and a delay in the return of fertility. Depo-provera injections do not offer protection against sexually transmitted diseases.

Many women prefer the injections because they only have to think about birth control 4 times a year. Women with menstrual cramps or heavy bleeding enjoy the amenorrhea (absence of periods) that often accompanies the injections.

Female Condom

The female condom is a lubricated, plastic sheath with rings on each end. One end is open and remains outside the vagina. The other end is closed and looks like a diaphragm. It is placed inside the vagina so that it covers the cervix, preventing sperm from entering the uterus and fertilizing an egg.

The female condom offers protection against most sexually transmitted diseases, but it is cumbersome to use, more visible, and less comfortable than a male condom. It is not available in all areas of the country.

Natural Family Planning

Natural family planning is based on fertilization occurring just before, during, and after ovulation. By monitoring yourself daily, you may be able to determine when you are ovulating. In practice, it is the most risky form of birth control and is only 30-70% effective. It is more effective for women with regular menstrual cycles who keep good daily records and are dedicated to the method. It is inexpensive and has no health risks involved. However, if you or youR partner are not monogamous this method is probably not for you.

Sterilization

Voluntary sterilization is the most popular birth control method worldwide. Sterilization involves blocking or cutting the woman's fallopian tubes so no eggs can travel to the uterus to be fertilized. It is generally an outpatient procedure and normal activities can be resumed within a few days. Sterilization, a permanent form of birth control, is 99.6% effective.

The risks with sterilization are the risks associated with any type of surgery. On rare occasions women may have complications from the anesthesia, internal bleeding, and injury to the surrounding internal structures, or infection. Because of its permanent nature women should consider this form of birth control when they no longer feel they want to have children or wish to think about birth control. <Back to Top>

What is a Colposcopy?

A colposcopy is the painless viewing of the cervix and the vagina through a high-powered microscope called a colposcope. The colposcope looks like a pair of binoculars attached to a stand. It does not enter the vagina. Direct examination through the colposcope allows the detection of abnormalities on the cervix that can not be seen with the naked eye.

What preparation is there for the Test?

You should make your appointment for a time when you will not be menstruating (on your period). You should also refrain from intercourse and the use of spermicidal jelly, vaginal medications, douches, or tampons for at least 24 hours before the procedure as they can interfere with the accuracy of the test.

If you would like you may take a non-steroidal anti-inflammatory medication such as Ibuprofen or Naproxen Sodium one hour before your appointment to be more comfortable.

What Happens During the Test?

You will lie on the examining table with your feet in the stirrups, just like a regular pelvic exam. The provider will use a speculum to separate the walls of the vagina, just like during a normal Pap test. The speculum will remain in the vagina throughout the procedure, causing you to feel a little pressure. A vinegar solution (called acetic acid) will be applied to the cervix to remove mucous and debris. The colposcope will be placed near the vaginal opening. The provider will be able to see your vagina and cervix under magnification. Any areas showing abnormal cells will be biopsied. In a biopsy, a tiny sample of tissue will be removed from the area with a tweezers-like instrument. An endocervical scraping from the os (the opening in the middle of the cervix) may be taken as this is often where abnormal cells begin. You may feel a pinch or cramping when the tissue samples are taken. The samples will be sent to a pathology lab to be examined.

What Should I Look for After the Procedure?

If a biopsy was taken, you may have slight bleeding or spotting for a few days following the procedure. Additionally, you may notice a coffee ground or mustard-like discharge. This is normal. You may use pads, but no tampons for 48 hours following the procedure. You should also refrain from douching or having sexual intercourse for one week following the procedure. If you have any cramping after the procedure, you may continue the Ibuprofen or Naproxen Sodium for relief. <Back to Top>

What is Endometriosis?

Endometriosis is a common cause of pelvic pain that strikes 10-20% of American women. Normally, during the menstrual cycle tissue builds up and breaks down within the uterus. In endometriosis, endometrial tissue (tissue from the lining of the uterus) is found outside the uterus. During the menstrual cycle this tissue builds up and breaks down in the same way but there is no way for it to leave the body. The implants bleed internally, causing irritation, inflammation, and scarring.

Women with endometriosis have symptoms ranging from mild to severe, although some women have no symptoms at all. Symptoms can include menstrual cramps, pain during sex, low back pain, constipation, pain with bowel movements, and infertility. Some women have chronic pelvic pain. Symptoms are usually at their peak just prior to and with the menstrual period. Symptoms are not indicative of the severity of the endometriosis. A woman with severe pain may have minimal disease, while a woman with severe disease may have no symptoms.

What Causes Endometriosis?

There is no simple explanation for endometriosis. One school of thought is that it is caused by "retrograde menstruation", meaning the flow during the menstrual period backs up into the fallopian tubes. This flow carries endometrial tissue that attaches to the ovaries, uterus, and other organs. This theory though, does not explain why women who have had a tubal ligation continue to develop endometriosis. Only one in ten women with known retrograde menstruation develops endometriosis.

Another idea is that all the tissues where endometriosis is found develop from the same part of the embryo. It is thought that the irritation of wandering menstrual blood causes these tissues to change into functioning endometrial tissue. There is no conclusive evidence, though, that tissues from a common embryonic source can change this way.

Another suggestion is the "immune defect" theory. This theory is based on the high levels of certain antibodies in the blood of endometriosis patients and the fact that women with close relatives with the disease are at greater risk. These women may have an immune reaction against their own tissues. Research into this theory is ongoing.

How is it diagnosed?

A pelvic exam is the first step. The doctor or midwife will examine your cervix and vagina, along with feeling for any lumps or tender points on the uterus, fallopian tubes, and ovaries. Sometimes the endometrial implants can be felt upon examination (but not always).

When your medical history and exam suggest endometriosis as a possibility, a laparoscopy may be offered to diagnose endometriosis. This surgical procedure allows the doctor to see the internal pelvic structures directly.

Laparoscopy is a simple, outpatient procedure. A thin, lighted tube is inserted into a small incision in the navel, allowing the physician to view the organs on a television screen. The physician can note the location, size, and extent of any endometrial implant.

What treatment is available?

Endometriosis is a chronic condition with no real cure. There are many factors to consider when you and the doctor choose a treatment method. One factor is whether to preserve fertility – do you want to become pregnant, either now or in the future? Another factor is the severity of your symptoms. Endometriosis can be treated with medication, surgery, or a combination of both.

What drugs are available?

Hormones may help slow the growth of the endometrial implants. They do not, though, reduce adhesions (scar tissue) that cause pain. The most commonly used hormones are birth control pills, progestins, gonadotropin-releasing hormone (GnRH) agonists and Danazol.

Birth Control Pills - the hormones in birth control pills keep the menstrual flow lighter and shorter, which can help relieve pain.
Progestin - Progestin is used to shrink endometrial implants. It works against the effects of estrogen on the endometriosis. You probably won't have a period while on the medication.
Gonadotropin-releasing hormone (GnRH) agonists - This medication causes a pseudo-menopausal state. It shuts down the ovaries, without surgically removing them. It does this by overloading the pituitary so FSH and LH are not produced. This pseudo-menopausal state stops the growth of endometrial tissue (inside and outside the uterus) and reduces the pain of endometriosis. The side effects, though, are the symptoms of menopause - hot flashes, headaches, and vaginal dryness. There is also an increased risk of osteoporosis. Treatment usually does not last for more than six months without the addition of estrogen or bone density monitoring. The side effects abate when treatment is discontinued.
Danazol - Danazol is a synthetic hormone that also reduces the pituitary's production of the hormones FSH (follicle stimulating hormone) and LH (lutenizing hormone). Like the GnRH agonists, Danazol causes a pseudo menopausal state. The endometrial implants shrink and pain is reduced. Treatment can last from 3 to 9 months. Side effects include hair, skin, mood, voice, and sex drive change. Some women complain of weight gain, bloating, and vaginal dryness.

What about surgery?

Excision is now the recommended method to remove endometriosis implants and the scar tissue associated with it. In most cases this procedure can be successfully completed with a laparoscope.

A laparotomy, which involves opening up the abdominal cavity, is sometimes required for more widespread disease that can't be reached through the tiny incision used in the laparoscopy.

If you plan to have no more children, complete hysterectomy may be the final surgical approach. If the disease is seriously affecting your health and lifestyle, you may wish for a definitive treatment. <Back to Top>

What are Fibroids?

Fibroids are tumors consisting of an overgrowth of muscle and connective tissue. Fibroids may grow into the uterine cavity, from the uterine wall to the outside of the uterus, or may be confined within the uterine wall. Twenty-five to fifty percent of women have fibroids and under most circumstances they are benign. The incidence increases with age (20% in their 20's, 30% in their 30's, 40% in their 40's).

What are the risk factors?

Since Fibroids tend to run in families if another member of your family has fibroids, you are at an increased risk of getting them. The risk increases if you are heavy for your height, but decreases if you smoke or have had a child.

What are the causes?

Fibroid growth seems to be related to estrogen production, but the experts are not clear why some women develop them and other women do not. Fibroids are slow growing during the reproductive years, but may increase in size with pregnancy. In women who don't use estrogen replacement therapy after menopause, many times the fibroids begin to shrink in size. The estrogen only affects the fibroid, though, after it has already developed. What causes the initial fibroid to develop is unknown. There may be a genetic component. Researchers are now investigating chromosome abnormalities that may play a part in the production of fibroids.

What are the symptoms?

The two most common symptoms are abnormal uterine bleeding and pelvic pressure. Menstrual periods with fibroids may be very long and very heavy. There may be pressure in the pelvic region from the enlarged uterine size caused by the fibroids. Symptoms from the pressure are often related to where the fibroid is exerting pressure. Also, there may be urinary frequency, constipation or difficulty with bowel movements. However, many women with fibroids never have any symptoms at all!

The presence of fibroids in the uterus can cause a variety of reproductive problems - recurrent miscarriage, infertility, premature labor or complications of labor.

How are they diagnosed?

A pelvic exam by the healthcare provider is usually the first step towards diagnosing fibroids. The uterus will feel enlarged or irregular. He or she may describe the uterus as being "12 weeks" or "14 weeks" meaning it is the size of a twelve week pregnancy.

Once your uterus has been identified as being enlarged or irregularly shaped, the presence of fibroids can be seen by ultrasound. An ultrasound can specify the number and size of the tumors. A hysteroscopy may be recommended - with this procedure the physician can see inside the uterine cavity by inserting a small telescope-like instrument (hysteroscope) through the cervix into the uterus.

What are the treatment options?

The only cure for fibroids is a hysterectomy. If you are still considering having children this may not be an option for you. Hysterectomies are performed either abdominally (through an incision in the abdomen), vaginally (through an incision in the vagina), or through a laparoscope abdominally. The method used depends on your situation and will be based on the size of your uterus and your medical history.

One of the first treatments usually tried for the abnormal uterine bleeding associated with fibroids is the use of oral contraceptives or progestin. Also, GnRH agonists (gonadotropin-releasing hormone) have been shown to temporarily shrink fibroids by blocking estrogen production. This class of hormone causes menstrual symptoms, such as hot flashes, vaginal dryness, and bone loss. Using a low dose of estrogen and progesterone along with the GnRH agonist may prolong the length of time the medication can be used.

Another procedure, called a myomectomy, removes only the fibroids, leaving the uterus intact. This procedure can be performed by laparoscopy or through an open incision in the abdomen (laparotomy). The type performed depends on whether the fibroids are superficial or deep. Because a myomectomy is major surgery and may be more complicated than a hysterectomy consideration as to whether or not you plan to bear children has to be given when evaluating whether it is the right option for you.

It may take as long as or longer than a hysterectomy and can cause more blood loss with a greater risk or need for a transfusion. Scarring of the uterus following a myomectomy may cause fertility problems. And, the procedure does not prevent the growth of new fibroids and the need for future surgery.

The final two newly emerging options for fibroid treatment are uterine artery embolization and ultrasound guided cryotherapy. If you are interested in more information about these options, contact your provider for the latest updates. <Back to Top>

What are Fibrocystic Breast Changes?

Important: This information is provided to answer questions concerning fibrocystic breast changes. If you discover a lump in your breast or have a discharge from you nipple you should contact you doctor immediately!

Fibrocystic breast disease is a benign breast condition affecting about 60% of women during their childbearing years, especially ages 30 to 50 that is characterized by your breast becoming lumpy and painful, especially the week before you period.

What causes it?

The breasts are made up of milk producing glands, fat and fibrous tissue. The glands are linked by thin tubes called ducts. Each month in response to estrogen and progesterone released by the ovaries, the milk glands and ducts enlarge and the breasts retain water which causes the breasts to feel swollen, lumpy and tender. After menstruation the breasts feel less tender and lumpy.

As this hormonal stimulation continues repeatedly, pockets of fluid called cysts may form and there is an increase in the firmness of the breast tissue. The tissue may feel "ropey" on exam. These are fibrocystic changes.

What are the symptoms?

Dense, irregular and bumpy feeling breasts, especially in the outer quadrants.
Breast pain that may come and go, or be persistent.
Breasts feel heavy, full.
Premenstrual pain and swelling.
Pain improves after menstrual cycle.
Change in nipple sensation, itching.

What can be done to relieve the symptoms?

Avoid caffeine (coffee, tea, cola, chocolate) for a few months.
Take over the counter NSAIDS (Advil, Motrin, Aleve, etc.)
400 IU of Vitamin E daily in divided doses.
Decrease salt intake, especially the week before menstruation.
In severe cases, oral contraceptives can help.

What are the signs of problems?

New lump
Existing lump increases in size or doesn't go away with menstruation.
A distinct lump, rather than a lumpy area.
A change in breast size.

How important are self breast exams?

Performing breast self exams monthly are very important because they will help you become aware of how your breasts normally feel so you can identify a change. Any new lump should be checked by your physician.

The best time to perform the breast self exam is in the first 7 to 10 days after the beginning of your period before the breasts are swelling. <Back to Top>

What is Menorrhagia?

Menorrhagia is excessive menstrual bleeding commonly referred to as heavy bleeding and about 1 in 5 women suffer from this condition. If your bleeding lasts seven or more days per cycle, or is so excessive that you need to change protection nearly every hour, you may have menorrhagia. Only your doctor can tell you for sure.

Women suffering from menorrhagia can experience fatigue, anemia, embarrassing accidents, and restricted activity. And there are now more treatment options available to you.

What Are The Treatment Options?

Drug Therapy is typically the first treatment option, consisting of oral contraceptives or other hormones that treat hormonal imbalances. This therapy is effective only about 50% of the time, and usually must be continued in order to remain effective. Some women have undesirable side effects, including headaches, weight change, and nausea.

Dilation and curettage (D & C) is frequently the second option if drug therapy is ineffective. It is a common surgical procedure that involves scraping of the inside of the uterus. However, for the majority of women with menorrhagia, it's only a temporary solution that reduces bleeding for a few cycles.

Endometrial ablation. If you do not plan to have any more children, your doctor may suggest minimally invasive surgical treatment options. Several methods are currently available:

Conventional endometrial ablation removes the lining of the uterus with an electrosurgical tool or laser. This method effectively reduces bleeding in approximately 85% of patients, and most women return to work within 3 days. Risks include perforation of the uterus, bleeding, infection, or even heart failure due to fluids used to open up or distend the uterus.
A new generation of endometrial ablation devices is now available. These devices vary in the way they abolish the lining of the uterus. Some use heated fluid, others radiofrequency, and still others freezing. Your provider can discuss the best option available for your specific condition.

What Can I Expect After Having An Endometrial Ablation Procedure?

The following are some of the post-operative discomforts associated with any endometrial ablation procedure.

You may experience some post-operative uterine cramping and discomfort shortly after the procedure, which can generally be treated with mild pain medication such as Ibuprofen (e.g. Advil® or Motrin®.)

Some patients may experience nausea and vomiting as a result of the anesthesia. Watery and/or bloody discharge after an endometrial ablation is also common for several weeks after the procedure.

Most women can return to normal activities within a day or two of their treatment. Sexual activity can be resumed in 7 to 10 days.

Are There Any Post-Procedure Complications?

You should call your physician if you develop a fever higher than 100.4ºF, worsening pelvic pain that is not relieved by ibuprofen or other medication prescribed by your physician, nausea, vomiting, shortness of breath, dizziness, bowel or bladder problems, and/or a greenish vaginal discharge.

Can I Still Become Pregnant After Endometrial Ablation?

It is important to know that although the chances for pregnancy are reduced following an endometrial ablation procedure, it is still possible to become pregnant.

However, pregnancy following endormetrial ablation is very dangerous for both the mother and the fetus and you should use some form of birth control if you decide to have endometrial ablation. Please discuss these options with your physician.

Hysterectomy or surgical removal of the uterus is the only definitive treatment for menorrhagia. Hysterectomy is a major procedure, performed in the hospital most often under general anesthesia, and is accompanied by surgical risks, hospitalization, and, depending on the technique used, a recovery period of up to 6 weeks. <Back to Top>

What is Hormone Replacement Therapy?

Hormone Replacement Therapy is the use of two hormones – estrogen and progesterone - to help relieve the symptoms of menopause. Because there are both risks and benefits to HRT choosing whether or not to take hormone replacement therapy (HRT) can be a difficult decision to make and there has been much made of HRT, both pro and con, in the popular press. Your decision should be based on a number of factors including:

The severity of your menopausal symptoms and how they are affecting your life.
Your individual risk for blood clots, heart disease, bone loss, breast and reproductive tract cancer.

If you have had your uterus surgically removed, then you will only need to take estrogen. Progesterone is added for those with a uterus to cut the risk of uterine cancer that exists with unopposed estrogen (estrogen without progesterone).

What are the benefits?

The benefits of HRT are that it:

Provides relief from menopausal symptoms including hot flashes, insomnia, vaginal dryness and atrophy.
Helps to prevent osteoporosis.

What are the risks?

Unopposed estrogen (taking estrogen without progesterone if you have a uterus) increases the risk of endometrial cancer.

There appears to be the possibility of a slightly increased risk of developing breast cancer with prolonged use of estrogen. Many studies have shown no increase in risk but for long-term use, the incidence of breast cancer may raise to 8 per 10,0000 women.

Whatever you decide concerning HRT you should remember that menopause is a naturally occurring event in the lives of all women and that one third of your life will probably happen after menopause. The symptoms and physical changes that occur with menopause should not prevent you from enjoying this phase of your life. If you have any questions or concerns you should discuss them with your doctor or midwife. <Back to Top>

What is Human Papilloma Virus (HPV)?

Human Papilloma Virus (HPV) is a group of viruses that can cause warts anywhere on the human body. The HPV types that attack the genital tract are 99.4% sexually transmitted. HPV is currently the most common sexually transmitted virus in the USA with a 1,000 percent increase in HPV patients since 1987. Because it is a non-reportable disease, the actual number of patients infected with HPV is unknown although more than 50 million Americans are believed to be currently infected with the virus. The number is estimated to be growing by almost a million every year.

Venereal warts (also known as genital warts or condylomata) are the "clinical" form of this infection because they can be easily seen and diagnosed. Venereal warts look like a fleshy bump of tissue on the labia, clitoris, or around the anus. The "sub-clinical" version is more common. The infection resides under the skin and cannot be seen. The sub-clinical varieties have been linked to cancers of the genital tract so it is important for sexually active women to have yearly Pap tests to detect pre-cancerous changes.

Risk Factors

If you have sex with more than one partner or had a partner who has had sex with more than one partner you are at risk for HPV

Symptoms

Whether there are symptoms depends on the strain of HPV present. If there are warts, you will notice a raised, fleshy area. If left untreated, the wart may disappear or it may grow and merge with other warts to take on a cauliflower-like appearance. Some people complain of burning or itching and occasionally a wart may bleed if irritated. You may see warts from one to eight months from exposure, or they may appear many months or years later. It may be difficult or impossible for you to determine when you were exposed.

Evidence of a sub-clinical infection may first show up on a Pap test. Your test may show HPV changes or dysplasia (pre-cancerous cells). HPV infection on the cervix usually has no symptoms at all.

Diagnosis

Diagnosis of warts is usually made by sight. If a suspected wart is flat and difficult to see, your doctor may look at the area with a Colposcope (a binocular-like instrument). Warts or HPV infection on the cervix is suggested on a Pap test. Definitive diagnosis is usually made with a colposcopic exam and biopsies.

There is a test available that can identify HPV DNA and may be ordered by your physician. This test will only tell if you are shedding the HPV virus when the test is performed. A negative result does not necessarily mean you have not come into contact with the virus.

Treatment for Venereal Warts

Like with other viruses, there is no cure for HPV. Over time though, the warts usually stop developing on their own. However, the warts can be treated as they appear so you should consult your doctor or midwife for treatment. Some possible treatments are:

Trichloroacetic Acid (TCA) - This is a strong chemical painted on the warts to destroy them. The application may cause some burning and should be applied by an experienced practitioner.
Podophyllin – perhaps the oldest drug used to treat venereal warts it cannot be used in pregnancy, has to be painted on the warts to destroy them and has to be carefully washed off. Podophyllin is rarely used anymore.
Interferon - This is a new drug that can be injected directly into the wart itself.
Prescription Drugs for Home Use - There are two medications (Condylox and Aldara) your doctor can prescribe for home use as treatment for venereal warts. Your doctor will show you how to apply them. They can cause burning and inflammation. <Back to Top>

What is a Laparoscopy?

A laparoscopy is a procedure that allows your physician to look directly at your reproductive organs using an instrument called a laparoscope. This procedure is diagnostic, in that it allows the doctor to see problems that could not be seen with a pelvic exam, X-Rays, or Ultrasound. Often, the problem can also be treated during the procedure. Normally, you can go home the same day the procedure is performed.

What is a Laparoscope?

A laparoscope is a long, narrow tube with a fiber optic light at one end. It is inserted into the abdomen through an incision in or under the navel. It can be maneuvered in any direction to allow views of the internal organs. Generally two to three other small incisions will be made below the bikini line to allow surgical instruments or a laser to be inserted into the lower abdomen.

When is the Laparoscope Used?

There are many conditions that are diagnosed and treated with the use of a Laparoscope:

Adhesions

When tissues in the abdomen stick together, and this forms scar tissue, called adhesions, the laparoscope may be used. Adhesions can result from infection, previous pelvic surgery, or endometriosis. They can be a cause of pelvic pain. The tissues can be separated during a laparoscopy.

Endometriosis

When uterine tissue (endometrium) is found outside the uterus the condition is called endometriosis. This tissue bleeds each month with the menstrual cycle but these products cannot escape the body. This can result in pelvic pain and adhesions. Endometriosis is diagnosed by laparoscopy and many times can be treated through the laparoscope.

Infertility

If a woman is having trouble conceiving, the physician may perform a laparoscopy to look for endometriosis and to look at the fallopian tubes. If the tubes are blocked, the egg and the sperm cannot meet.

Ectopic Pregnancy

An ectopic pregnancy is a pregnancy that has implanted outside of the uterus. Most of the time, it has implanted in a fallopian tube. A laparoscopy can be used to diagnose, and many times treat this problem.

Ovarian Cysts

An ovarian cyst is a pouch containing fluid or solid material attached to or around the ovary which may be painful. Often the cyst will resolve on its own. If it doesn’t then it can often be treated through the laparoscope.

Fibroids

Fibroids are tumors made up of fibrous tissue that can grow inside, outside, or within the walls of the uterus. Sometimes a laparoscope is used to diagnose fibroids.

What takes place during a laparoscopy?

A laparoscopy is usually an outpatient procedure meaning you will go home the same day. Usually, the procedure is performed under general anesthesia, so you will be asked not to eat or drink anything for at least 8 hours before the surgery. Sometimes a regional anesthesia can be used.

The surgeon will make a one inch incision just below or inside the navel, and then will insert a needle and inject carbon dioxide gas into the abdomen. This harmless gas inflates the inside of your abdominal cavity and lifts the abdominal wall away from the internal organs, creating a space to allow the surgeon to see the organs. The needle will be removed and the laparoscope will be inserted into the incision. Other incisions may be made above the pubic area to allow other instruments or a laser to be inserted. Usually, the laparoscope projects the images onto a television screen. This makes the images larger and easier for the surgeon to see. Sometime, pictures are taken during the surgery or a video is made.

After the procedure is over, the instruments will be removed and the gas released. The incisions are usually closed with a few dissolvable stitches or skin glue. You will be sent to the Recovery Room until you are awake and alert.

Following the surgery, it is not unusual to have some abdominal cramping or shoulder discomfort due to the carbon dioxide gas. This will gradually go away over the next few days. <Back to Top>

What is a Loop Electrosurgical Excision Procedure (LEEP)?

Cells on your cervix are constantly growing and changing. Unfortunately, these cells sometimes grow and change abnormally. These abnormal cells are usually first noticed on a Pap test. If you’ve had a Pap test or cervical biopsies come back showing dysplasia, a LEEP may be recommended as treatment for these cells. Dysplasia is not cancer, but can lead to cervical cancer if not treated. During a LEEP, your doctor can remove the affected tissue, including the transformation zone (where many problems begin). It is sent to the pathologist to be sure that:

There is no cancer, and
That the margins are clear - which means all the affected tissue was excised.

About 95% of patients are cured of their problem following a LEEP.

The LEEP will be scheduled during the first half of the menstrual cycle, after you have stopped bleeding. The procedure begins like a Pap test in that you will put your feet in stirrups and a speculum will be inserted into your vagina and opened. Your cervix will be numbed with a local anesthetic and a mild vinegar solution (called acetic acid) will be applied. This solution turns the affected cells white. The doctor will use a colposcope (it looks like binoculars on a stand) placed outside your vagina to look at your cervix microscopically. This will help them decide the size and shape of the loop used to excise the abnormal tissue.

A fine wire loop with a high frequency current (hence the name - loop electrosurgical excision procedure) is used to remove the abnormal tissue from your cervix. The loop will seal blood vessels as it cuts, decreasing bleeding. To further decrease bleeding, a medicated paste or solution may be applied to your cervix. This solution often causes a dark coffee-ground like vaginal discharge for a few days after the procedure. The tissue removed will be sent to a pathologist for diagnosis.

Following the procedure, you may feel a few mild cramps for a few days and you will have a vaginal discharge sometimes for up to 4 weeks. You should not put anything in your vagina (including tampons or sexual intercourse) for three to four weeks after your procedure. You should also avoid heavy lifting and vigorous exercise for three to four weeks.

Your doctor or midwife will want to monitor your Pap test for at least two years following your LEEP. To catch any problems early, it is very important that you see your doctor or midwife as directed.

You must call your doctor if you:

Suffer from heavy bleeding or bleeding with clots (a "coffee ground" discharge is normal)
Experience severe abdominal pain
Have a fever
Have a severely foul-smelling discharge

What is Menopause?

Menopause technically means the "end of menstruation". What is readily apparent to any woman entering this phase of life - the symptoms can begin as many as ten years before the period ends. This transition time is known as peri-menopause. Many symptoms we associate with menopause actually begin during the peri-menopause as the estrogen levels are decreasing. Most women reach menopause between the ages of 45 and 55.

What is Menopause?

When a female is born her ovaries contain hundreds of thousands of eggs. This number of eggs decreases through the years during ovulation. Throughout the childbearing years, not all of a woman’s eggs reach maturity and are released. Each month the eggs that did not reach maturity were reabsorbed by the body. As a woman approaches menopause, only a few thousand eggs are left

Beginning in the early 30's, the levels of estrogen and progesterone produced by a woman’s ovaries starts to decline. This decline escalates when they enter peri-menopause - usually three to five years up to menopause. When the supply of eggs is finally exhausted, ovulation stops. The levels of estrogen and progesterone eventually drop so low that menstruation stops. A woman knows she has passed menopause when she has no periods for 12 months.

When Can I Expect to Enter Menopause?

The average age of menopause is 51, although the normal age is from 45 to 55. One way you can predict what age you will be is to ask your mother or sisters how old they were. Often women begin and end their menstrual life about the same age as their mother did.

What Can I Expect with Menopause?

The diminishing amount of estrogen produced by the ovaries produces changes in the body. These changes occur slowly over time and are different for everyone. Some women notice very little change while other women find it difficult to cope with the dramatic symptoms caused by these changes.

Hot Flashes - Hot flashes are the most common symptom of menopause. They are probably the symptom most associated with menopause, with as many as 75% of women experiencing them. A hot flash is a sudden rush of heat that spreads over the upper body and face. Some women experience a simple warming; others have acute flashes with sweating. Hot flashes can occur any time of the day or night. They usually last from thirty seconds to several minutes. Some women have hot flashes for a few months, other women complain about them for years. Other women do not have hot flashes at all.
Sleep Difficulties - Many women complain of problems with sleep as they enter menopause. Some women are awoken from a deep sleep by hot flashes. Others have a harder time getting to sleep or staying asleep.
Vaginal and Urinary Tract Changes - The loss of estrogen causes changes in the walls of the vagina. Some women experience vaginal problems during peri-menopause, others don't have symptoms until they are well past menopause. The vaginal lining becomes thinner, dryer, and less elastic as you age. You may have burning or itching. Some women have bleeding or burning with intercourse. The bladder and urethra can lose muscle tone with lower levels of estrogen. This can lead to a loss of bladder control. You may notice leakage when you sneeze, cough, laugh, or exercise.
Bone and Body Changes - Lower estrogen levels can result in osteoporosis. The bones lose density and become fragile. Older women are more likely to break bones. The hip, wrist, and spine are the bones most likely to break.
Emotional Changes - Minor emotional distress can occur with the changes associated with menopause, along with the social changes that can occur in a woman's life. Contrary to prior belief, studies show there is no increase in serious psychiatric disorders in women entering menopause. The emotional distress felt by most women comes from sleep disturbances or other nuisance symptoms. This is also the time of life when many women's lives may be in an upheaval due to their children leaving home or they may become caretaker for an aging parent. Menopausal symptoms make the stress you are normally under harder to cope with.

Sexuality

Many women find sex to be more rewarding after menopause. They no longer have to worry about birth control and may now have more time to spend with their partners. Some women though, find the changes with menopause do have an impact on their sexuality. They may have vaginal dryness or may lose interest in sex.

Hormone Replacement Therapy and vaginal lubricants can help return moisture and elasticity to the vagina and make intercourse more comfortable. There are many vaginal lubricants or moisturizers that can be bought over the counter. If you have been having sexual intercourse on a regular basis, you may not notice vaginal changes with menopause. Regular sex may help the vagina retain its natural elasticity.

A decrease in libido, or sexual drive, can occur with menopause. Lower hormone levels may decrease your sex drive or may affect your ability to have orgasm. Hormone replacement therapy can help some of these changes. Be sure to talk to your doctor or midwife about your concerns. Trying different positions and engaging in longer foreplay may also help.

Birth Control

You will need to use birth control until you have not had a period for one year. Despite having menopausal symptoms, you can still get pregnant.

You can choose from the following birth control methods:

Birth control pills - A low dose birth control pill is safe for many women over 40 who do not smoke. Since the pills contain estrogen, they can alleviate the menopausal symptoms you may be having in the peri-menopausal period.
Barrier Methods - condoms, diaphragm, and spermicides are easily attainable at the pharmacy. Lubricated condoms may help with vaginal dryness, as can spermicides in jelly or cream form.
Intrauterine device (IUD)
Hormonal injections (Depo-Provera)
Sterilization - male or female

Diet and Exercise

As you enter menopause, you should pay close attention to the amount of calcium you are receiving in your diet. Women over the age of 50 should be getting 1,000 mg of calcium each day if they are on hormone replacement therapy, 1,500 mg each day if they are not. The calcium is important to help build strong bones. Ask your pharmacist which calcium supplements contain calcium carbonate, as these brands are best at slowing bone loss.

Eating a balanced diet will help you stay healthy before, during, and after menopause. It is important to eat a variety of foods to make sure you get all the essential nutrients. Exercise is very important as you get older. Regular exercise slows bone loss and improves your overall health. Walking and aerobics are good weight-bearing exercises. <Back to Top>

Why should I perform a monthly breast exam?

Every year more than 200,000 women in the United States are diagnosed with breast cancer. That’s why it is vitally important for a woman to regularly examine her breast. In fact, nearly 90% of breast lumps are found by the woman herself. Unfortunately, many women appear to be hesitant about performing this exam because they are not sure how to do it or what to look for.

However, if you perform a self-exam each month, you will become an expert on your own breasts and you will be able to notice a potential problem before your doctor or midwife. Only by doing this task every month will you become familiar with your breasts and make it more likely to notice any changes. And, changes are what you are looking for. If you find any lump, hard knot or thickening you should contact your doctor or midwife immediately. Don’t worry that it may be nothing. It is much better to be safe than sorry.

When Should I Examine My Breasts?

If you are still having periods, you should do the exam seven days after your period begins. Your breasts are least likely to be tender and swollen at this time. If you no longer have periods, choose a day each month for the exam, such as the first of the month.

How Do I Examine My Breasts?

In Front of a Mirror

Inspect both breasts with your arms at your sides. Next, raise your arms over your head. Look for any changes in the shape of each breast - swelling, puckering, dimpling, or scaling of the skin. Gently squeeze your nipple and look for a discharge. Report any discharge to your doctor or midwife. Next, put your hands on your hips and press firmly to flex your chest muscles. The left and right breasts will not exactly match - this is normal.

In the Shower

Examine your breasts during a bath or shower. Your hands will glide easily over the wet skin. Press the sensitive pads of your fingers flat against the outer part of the breast, moving gently over every part of each breast. Start at the nipple and go around in a circular motion, enlarging the circle each time you reach the point where you began. Completely examine the breast and chest area from your collarbone to the base of a properly-fitting bra, and from your breastbone to your underarm.

Lying Down

Repeat this procedure lying flat on your back. Place your left arm over your head and a pillow or folded towel under your left shoulder. This position flattens the breast and makes it easier to examine. Repeat on the other side. <Back to Top>

What is Osteoporosis?

Osteoporosis is a disease in which the bones lose mass, becoming thin and weak. Some bone loss is to be expected as part of the aging process, but with osteoporosis the bone loss is so severe that it causes the bones to become porous, brittle, and likely to break. The disease affects 25 million Americans, mostly women after menopause.

Risk Factors

A number of factors determine the risk of developing osteoporosis:

Sex - women have lighter, thinner bones than men.
Age - with the decrease in estrogen with menopause, bone mass is decreased.
Race - Caucasian and Asian women have 5 to 10% lower bone density than African-American women. The lighter the complexion, the higher the risk for osteoporosis. Women with very fair skin, freckles, and blond or reddish hair are at the highest risk for osteoporosis.
Build - a smaller frame, or weaker bones, increases the risk for bone fracture. Overall muscle tone can play a role in the likelihood of experiencing a bone fracture.
Age at menopause - early menopause causes reduced levels of estrogen over a longer period of time than when menopause occurs later.
Heredity - having a mother, grandmother, or sister with osteoporosis increases your risk.
Medication use - steroids, diuretics, anti-convulsants.
Alcohol use and smoking
Medical conditions - anorexia, Celiac disease, diabetes, kidney or liver disease, or chronic diarrhea.

Prevention

Exercise - increases bone mass before menopause, decreases bone loss after menopause.
Diet - calcium intake is most important from childhood through the mid-20's when bones are growing at their fastest rate; in women following menopause - when rapid bone loss can occur, and in the elderly.
Hormone Replacement Therapy (HRT) - replacing the estrogen after menopause improves calcium absorption and has been shown to prevent osteoporosis in 70 to 80% of women.

What is a PAP Test?

The Pap test, or Pap smear, is a screening test for cervical cancer. It was invented 50 years ago and since then deaths from cervical cancer have declined more than 70%. The test can detect changes in the cells on the cervix (the opening to the uterus, or womb, at the top of the vagina). These changes may be cancerous, pre-cancerous, or caused by inflammation. Unfortunately, though cervical cancer is almost 100% curable when diagnosed and treated in the early stages, nearly 5,000 women die of it each year.

Who Should Get a Pap Test?

Every woman should have regular pelvic exams and Pap tests beginning at age 21, or three years following the onset of sexual intercourse (whichever comes first).

Preparations for a Pap Test

You should not douche 24 to 48 hours before a Pap test. The solution may wash away cells shed from the cervix. You should not use any vaginal creams or gels (including medicinal creams) or have vaginal intercourse 24 to 48 hours before a Pap test. The creams, gels, or seminal fluids may hide cervical cells.

How is a Pap Test Done?

The Pap test is a very simple and quick test. During the pelvic exam, the doctor or midwife will insert a speculum (it looks like a duck's bill) into your vagina and gently open it so the cervix can be seen. A thin brush and a wooden or plastic spatula (similar to a tongue depressor) are used to collect a sample of cells from the cervix. These cells are sent to the lab to be viewed (or "read") by a cytotechnologist.

Will it Hurt?

Usually the test does not hurt. You may feel the scraper or brush being wiped across your cervix, which sometimes causes a slight twinge. Many women report the most uncomfortable part of the exam is the pressure caused by the opening of the speculum. You can help make the exam more comfortable by breathing deeply and trying to relax the muscles at the opening of your vagina.

How are the Results Reported?

The laboratory will contact our office with the results of your Pap smear. Most results come back "negative", which means the cells sampled were normal. Abnormal results are reported following a system that describes the level of change in the cells. These changes range from very minor to severe.

Infection

The Pap test may report the presence of Candida (yeast), Trichomonas, Garnerella (the most commonly found bacteria in the vagina), or other bacteria. You can have these infections without symptoms. Your doctor or midwife may offer treatment or further testing. Rarely, the Pap test will show cells invaded by the Herpes virus. A Pap test is not a reliable test for Herpes. If this happens, your physician or midwife will take a culture specifically for Herpes.

Reactive or Repair-related Changes

These changes are benign and are most commonly seen in women who are menopausal (lack of estrogen can cause the cervical and vaginal linings to thin and become inflamed), who have had a recent vaginal infection or biopsy, and women who use an IUD or diaphragm for birth control. Women who have had radiation to the pelvis may also show reactive changes on their Pap test.

Squamous Cell Abnormalities

Atypical Cells of Undetermined Significance - This means the cytologist has seen cells that are abnormal, but the cause of the abnormality is not clear. Your doctor or midwife will recommend a repeat Pap test after a short period of time.
Low-grade Squamous Intraepithelial Lesion (LGSIL) - These cells are undergoing a transformation with distinct characteristics. These changes may also be called dysplasia. If the cells are low-grade, the changes are mild. These changes have been linked to the Human Papilloma Virus (HPV). HPV causes genital warts and some types have been linked to cervical cancer. In about half of the cases of LGSIL, the cells will spontaneously return to normal. Further evaluation of a LGSIL is recommended though, because 25% of the lesions will progress to a high-grade lesion, and 25% will persist as LGSIL.
High-grade Squamous Intraepithelial Lesion (HGSIL) - These cervical changes are moderate to severe. If left untreated, 50 to 75% will progress to cervical cancer. If your report shows HGSIL, your doctor or midwife will recommend a biopsy.
Cancer - If the cells appear to be cancer, your doctor or midwife will want to do a biopsy to confirm the diagnosis.

What's Next?

Repeat Pap Smear - A repeat Pap smear may be recommended within a certain time frame, depending on your medical history. (Generally 3 months to 6 months).
HPV testing - This is a test that can be added to a pap smear when the result suggest an abnormality in the ASCUS category. Many but not all insurances cover this test. It is, however, extremely helpful in deciding if the abnormality on your pap smear is of concern enough to warrant a colposcopy or whether it can just be followed over time.
Colposcopy - During this procedure, the doctor inserts a speculum into the vagina so the cervix can be seen. A colposcope is used to view the cervix under magnification. The colposcope looks like binoculars on wheels and acts as a microscope. A vinegar-like solution called acetic acid is applied to the cervix with a cotton swab. This may feel a little cold. This solution turns abnormal cells white. A small pinch of tissue may be taken from this area and sent to a pathologist for definitive diagnosis. This pinch may feel like a menstrual cramp. An ECC may be taken to sample the cells in the endocervical canal. This is an area of the cervix which cannot be viewed through a colposcope.

Who is at Increased Risk for Cervical Cancer?

You have had more than one sexual partner, or are with a person who has had more than one sexual partner.
You have a history of genital warts (condyloma) or Human Papilloma Virus (HPV)
You smoke.
You begin having sexual intercourse at an early age (before age 18).

What is Pelvic Inflammatory Disease?

Pelvic Inflammatory Disease (PID) is not a single illness but a broad term covering a variety of infections of the internal reproductive organs - the ovaries, fallopian tubes, uterus, ligaments supporting the uterus, and even the abdominal lining. PID is the most common, preventable cause of infertility in the United States. It can cause scarring of the fallopian tubes leading to blockage of the tubes.

PID is also the leading cause of ectopic pregnancy because if the fallopian tube is damaged from PID, the fertilized egg may attach to the inside wall of the tube instead of inside the uterus. An untreated ectopic pregnancy can lead to rupture of the tube, bleeding into the abdomen, and can result in death.

The most common symptom of PID is a dull abdominal ache. Other signs include fever, vaginal discharge (often the first sign), abnormal uterine bleeding, fever and chills and sometimes nausea and vomiting. The symptoms vary among women and some women do not have symptoms at all. Sexual activity and movement often makes them worse.

Cause

There are several bacteria that can cause PID. Neisseria gonorrhea and Chlamydia trachomatis are the most common. Both are sexually transmitted. The infection usually begins in the vagina, travels up through the cervix to the rest of the reproductive organs.

Gonorrhea-associated infections generally begin quickly with severe symptoms. With Chlamydia, the symptoms may be mild and develop slowly over months or even years.

Another possible cause of PID is the introduction of organisms into the reproductive tract after an induced abortion, following the birth of a child, or by the insertion of an Intrauterine Device (IUD).

Risk Factors

Since the most common causes of PID are sexually transmitted, sexual activity is the largest risk factor for PID. Age is also a factor. Approximately 75% of all cases of PID occur in women under the age of 25. Younger women appear to be more susceptible to Chlamydia and gonorrhea associated infection than older women.

There is a direct relationship between the number of sexual partners a woman has and her risk for PID. The more partners she has, the greater the risk.

Treatment

Because PID is generally caused by a mixture of bacteria, your physician will probably prescribe a combination of antibiotics. Since most cases are caused by sexually transmitted diseases, do not have intercourse with your partner until he has also completed his treatment. It is very important that you finish all the medication, even if the symptoms go away before treatment is finished.

It is important to see your doctor or midwife a few days after starting treatment to ensure the antibiotics are working. If your condition isn't improving, you may need to be hospitalized for IV antibiotics.

Resting as much as possible can help speed along your recovery. Pain medication, hot baths, or a heating pad applied to the lower back and abdomen may help relieve the discomfort of PID. <Back to Top>

What is Polycystic Ovarian Syndrome?

Polycystic ovarian syndrome (PCOS) is the most common hormonal disorder in women of reproductive age, affecting up to 10% of the population. PCOS is one of the leading causes of female infertility and is associated with long-term health risks of heart disease and diabetes. Three features of PCOS are 1) enlarged ovaries containing multiple, small cysts; 2) excess androgens (male hormone); and 3) chronic amenorrhea (missed periods).

Symptoms of PCOS

Hirsutism (excess body and/or facial hair), particularly on the chin, upper lip, breasts, inner thighs and abdomen
Irregular ovulation or lack of ovulation - along with irregular or no periods. Women with PCOS may have oligomenorrhea (8 or fewer periods a year), amenorrhea (absence of periods), or polymenorrhea (too frequent periods)
Obesity
Acne and/or oily skin (particularly severe acne as a teenager or acne that persists into adulthood
Infertility
Ovarian cysts
Insulin resistance
Hair loss or balding
Acanthosis nigricans (darkening of the skin, usually on the neck - is also a sign of insulin problems)
Skin tags - small pieces of excess skin in armpit and neck area

The specific symptoms may have varying combinations, depending on the woman's genetic makeup.

Enlarged ovaries containing many small cysts, which are the result of incomplete ovulation, often accompany PCOS. During the normal ovulatory process, the egg matures in an ovarian follicle which then ruptures and releases the egg. In women with PCOS, high levels of androgens ("male hormones") stop the egg's development, leaving an enlarged follicle containing a dead egg. These cysts often look like a string of pearls on ultrasound. Not all women with cysts have PCOS, not all women with PCOS have cysts.

The most visible symptoms of PCOS stem from excessive levels of androgens, such as testosterone. In women, androgens are produced in the ovaries, adrenal glands and fat cells. Androgens are often thought of as "male hormones" but in reality they are present in both males and females, with men having higher levels. In men, androgens are responsible for male traits and reproductive function. Androgens include testosterone, DHT (dihydrotestosterone) and estradiol. In women, excessive androgen levels are responsible for such symptoms as hirsutism and acne. In more severe cases, "virilization" may occur, including an enlarged clitoris, balding at the temples, a deepening voice and muscle growth.

Diagnosis

PCOS is a diagnosis of exclusion, other possible causes of irregular periods or hyperandrogenism must be ruled out. The diagnosis is made through a careful history of symptoms along with physical findings, blood work and ultrasound testing. Blood tests which may be performed to aid in the diagnosis include:

Thyroid hormone (low thyroid symptoms are similar to PCOS)
Prolactin level (high levels may have symptoms similar to PCOS)
Androgen levels - including DHEAS and testosterone high levels are associated with PCOS and cause the "male-like" symptoms
FSH (follicle stimulating hormone) and LH (luteinizing hormone) levels - a high ratio of LH to FSH is characteristic of PCOS. FSH promotes the development of egg-containing follicles in the ovaries. LH stimulates ovulation and encourages the empty follicle to revert to glandular tissue
Ultrasound may be performed to look for the characteristic pictures of multiple cysts
The woman may also be tested for other conditions that are strongly linked to PCOS (such as Type II Diabetes, high blood pressure, and elevated lipids - cholesterol and triglycerides)

Cause

While the imbalances that cause the symptoms are becoming better understood, the trigger for PCOS is unknown although genetics are suspected to play a role. One study has shown a possible connection between a gene that helps the body use insulin and PCOS. Other studies have shown that excess insulin production stimulated the production of testosterone and leads to insulin resistance, which is a precursor to Type II diabetes. Insulin also inhibits the production of a hormone that absorbs testosterone.

Treatment

There is no cure for PCOS. The treatment of PCOS is generally symptomatic and centers on life-style modifications and medication. PCOS is strongly linked to obesity and insulin resistance (a precursor to Type II Diabetes). For women with PCOS who are obese, a treatment program that incorporates a diet and exercise program is desirable. About 1/2 of the women who have PCOS and are obese have insulin resistance or Type II Diabetes.

To treat irregular or infrequent periods, oral contraceptives may be prescribed to regulate the periods. If the woman is unable to tolerate or is reluctant to take oral contraceptives, she should take progestin periodically to induce a period - four periods a year are desirable to reduce the risk of endometrial (the lining of the uterus) cancer.

Spironolactone, a diuretic, may be prescribed for symptoms from the overproduction of androgens - hirsutism, acne and oily skin. Electrolysis or laser procedures can remove unwanted hair permanently.

A steroid such as dexamethasone may be prescribed in very low doses if the primary source of excess androgens seems to be the adrenal glands (as evidenced by high levels of DHEAS).

For infertility, the first line treatments are metformin and clomiphene citrate (Clomid, Serophene).

Hyperinsulinism appears to play a major role in the pathogenesis of PCOS. Elevated insulin levels may increase the luteinizing hormone which in turn stimulates ovarian androgen secretion. Recently the insulin-sensitizing drug metformin (Glucophage) has been found to have beneficial effects on periods and the infertility associated with PCOS.

Although the insulin resistance of PCOS is independent of body mass, the hyperinsulinemia may be aggravated by obesity so weight loss is beneficial in obese women. <Back to Top>

What is Premenstrual Syndrome (PMS)?

Premenstrual syndrome (PMS) is a term used to describe the abnormal symptoms many women experience one to two weeks before the beginning of their period. Physical symptoms, accompanied by mood swings and depression, are the classic signs. Thirty to forty percent of American women have symptoms severe enough to interfere with their daily lives, while three to five percent have symptoms severe enough to be incapacitating.

PMS symptoms can occur any time after ovulation, approximately two weeks after the beginning of your period.

Symptoms of PMS

Behavioral

Increased irritability
Feeling anxious
Crying spells
Depression
Forgetfulness
Difficulty concentrating

Physical

Breast swelling or tenderness
Headaches
A "bloated" feeling or temporary weight gain of a few pounds
Nausea or constipation followed by diarrhea at the start of menstruation
Acne
Swelling of hands or feet
Increased appetite or thirst
Food cravings
Fatigue or insomnia

All PMS symptoms should disappear rapidly once menstruation begins.

Cause

PMS has been described as far back as Hippocrates. Modern investigation of PMS began in the early 1930's when it was called "premenstrual tension". To date though, investigators have been unable to find a cause. For many years, research has focused on estrogen and progesterone, two hormones produced by the ovaries. Another theory links serotonin levels (a neurotransmitter in the brain) with PMS symptoms. Other theories that have been advanced - a deficiency of endorphins, defects in the metabolism of glucose or B6, low concentrations of zinc, magnesium or calcium and an imbalance in the body's level of acidity. No conclusive evidence has been found to support any of these theories. Research has found though, that PMS responds to a variety of treatments.

Diagnosis

There are no diagnostic tests for PMS. It is generally diagnosed through a process of elimination. To aid in diagnosis, you should keep a diary for several months of symptoms; when they appear, their severity, and when they subside. You and your health care provider then can review your record in order to come up with a treatment plan.

Treatments

Lifestyle and Dietary Changes

Decrease Caffeine - Caffeine can exaggerate certain PMS symptoms, such as irritability, anxiety, insomnia, and nervousness.
Avoid salt - Many women gain a few pounds in the second half of the menstrual cycle due to water retention. Avoiding salty foods can help decrease the bloating. Since brain cells can also retain fluid, decreasing salt may also help headaches and aid in concentration. Along with the sodium reduction it is important to drink at least 8 to 10 glasses of water a day. Water acts as a natural diuretic, along with its normal role in cellular function.
Avoid sugar - Eating sugary foods can set off a vicious cycle of sugar cravings. Blood sugar swings can cause a disruption in hormonal production and distribution.
Stop smoking - Nicotine can exaggerate PMS symptoms much the same as caffeine.
Decrease alcohol intake - Alcohol can intensify symptoms because it depletes the body of B vitamins, disrupts the metabolism of carbohydrates, and affects the liver's ability to process hormones.
Increase Calcium - Taking 1200 mg of chewable calcium carbonate a day can decrease symptoms by as much as 50%. Improvements are noted during the third cycle of treatment.
Increase Exercise - Women who exercise regularly have milder PMS symptoms. You should participate in some type of aerobic exercise for 20 to 30 minutes at least 3 times a week.
Increase Magnesium - 200 mg of Magnesium a day may reduce fluid retention, breast tenderness and bloating by 40%. Improvements are noted during the second cycle of treatment.

Medications

Over the counter PMS preparations - There are a number of OTC PMS medicines available containing a medication for headaches and pain along with a mild diuretic.
Oral Contraceptives (Birth Control Pills) - Taking birth control pills or changing prescriptions if already on the pill can decrease symptoms for many women.
Spironolactone - A diuretic that has been shown in some studies to decrease bloating and mood-related symptoms.
NSAIDS - NSAIDS are prostaglandin inhibitors. They work best if taken before the onset of symptoms. They work on headaches, cramping, and may reduce the amount of blood loss. (Examples of NSAID's available over the counter are Advil, Motrin, Aleve, and Nuprin).

What are Sexually Transmitted Diseases (STDs)

While HIV and AIDS are the most feared of all the sexually transmitted diseases and generally the first to come to mind, other STDs are more prevalent. In order to avoid any STD it is important to know how it is spread, its symptoms and its treatment. STDs infect women and men of all races, backgrounds and socio-economic levels. Unfortunately, about 2/3 of these infections are diagnosed in people under the age of 25 with a significant number of these being teenagers.

The incidence of STDs is rising. People who have more sexual partners and young people who become sexually active at an earlier age have an increased risk of STDs.

Unfortunately, many STDs have no symptoms, especially in women. But, these infections can still be spread to sexual partners and the health problems caused by sexually transmitted diseases tend to be more severe for women than men. Some STDs, especially Chlamydia and gonorrhea, can spread from the vagina to the uterus and fallopian tubes causing PID- pelvic inflammatory disease. The scarring left by PID can lead to infertility or ectopic pregnancies (a pregnancy outside the uterus which if not terminated early can lead to death.) HPV can cause cervical cancer and other cancers of the genitals. Undiagnosed STDs can be passed from mother to baby before and during delivery. Some infections are easily cured while others can lead to permanent impairment or death.

To prevent STDs you should:

Learn to recognize the symptoms in yourself or partner.
Do not have sex if you or your partner have symptoms of an STD and have not seen a health professional.
Ask your partner about exposure to STDs.
Use condoms correctly and consistently.
Have regular checkups for STDs, even in the absence of symptoms.
Obtain a Hepatitis B vaccine.

You may be at high risk for sexually transmitted diseases if:

You have had more than one sexual partner in your lifetime.
You know or suspect your partner has had sex with other partners.
You have shared IV drug needles, or have had sex with someone who has.
You received blood between 1978 and March of 1985 or have had sex with someone who has.
You have had sexual contact with a hemophiliac.
You have had an STD in the past.

If you think you are at risk for a sexually transmitted disease - get tested. Any information you share with your healthcare professional is confidential. When diagnosed early almost all STDs can be treated effectively if not cured. It is important to always finish all the treatment prescribed.

The following are common STD’s:

Chlamydia
Gonorrhea
Genital Herpes
Syphilis
Hepatitis
Molluscum Contagiosum
Pubic Lice/Crabs
Venereal Warts
HIV/AIDS

Chlamydia

Chlamydia is one of the most common sexually transmitted infections in the US, affecting 3-5 million women and men a year. It has been referred to as a "silent epidemic" because the infection has no symptoms in two-thirds of all infected women and half of the infected men. Forty-six percent of females infected with Chlamydia are between the ages of 15 and 19 years of age. Women between the ages of 20 to 24 represent about 33%.

The bacteria that cause Chlamydia in the US, Chlamydia trachomatis, can infect the mucous membranes in the penis, vagina, cervix, anus, urethra or eye. In women, the infection generally begins on the cervix and if untreated can spread to the fallopian tubes or ovaries causing PID (pelvic inflammatory disease.) PID can result in sterility by scarring and blocking the fallopian tubes. In men, Chlamydia can cause epididymitis if it spreads from the urethra to the testicles. Untreated, epididymitis can cause sterility in men.

Symptoms

Unfortunately, Chlamydia often has no symptoms. When there are symptoms, they may begin in as few as five to ten days following exposure.

Symptoms for women may include:

bleeding between periods
vaginal bleeding after intercourse
abdominal pain
painful intercourse
low grade fever
painful urination
cervical inflammation
abnormal vaginal discharge
mucopurulent cervicitis (MPC) - a yellowish discharge from the cervix that may have a foul odor.

Untreated Chlamydia can lead to pelvic inflammatory disease. The symptoms of PID include:

lower abdominal pain
fever
vomiting
abnormal mucus discharge
longer and/or heavier periods
increased cramping with periods
pain during intercourse
fatigue, weakness

In men the symptoms are similar to the symptoms for gonorrhea. They may appear early in the day and be mild so men may not take them seriously. The symptoms may include:

pus, watery or milky discharge from the penis
pain or burning with urination
redness and swelling in the testicles

In men and women, Chlamydia affecting the rectum can cause itching, bleeding, mucus discharge and diarrhea. Touching the eye with infectious secretions can cause an eye infection characterized by redness, itching and a discharge.

Diagnosis

In women, Chlamydia is diagnosed through examination of the cervix and cervical discharge. A lab culture of cells taken from the cervix, urethra, penis or anus can be sent to the laboratory.

A pap test cannot diagnose Chlamydia, but it may indicate that a Chlamydia test would be appropriate.

Treatment

Chlamydia is a treatable infection when addressed promptly. Both partners must be treated at the same time and sexual intercourse should be avoided until all treatment is finished. Chlamydia is treated with antibiotics.

When being treated for Chlamydia, remember:

Take all the prescribed medication. Symptoms may go away before all the bacteria are eradicated from your body.
Make sure your partner is treated at the same time you are so you don't re-infect each other.
Make a follow-up visit for a "test of cure" to be sure the bacteria are gone before resuming sexual intercourse.
Don't share your medicine with anyone.

Affects of Chlamydia on Pregnancy

Twenty-fifty per cent of children born to women with Chlamydia will be infected. These infants may develop ear infections, eye infections that can lead to blindness, and pneumonia. Ear and respiratory infections in infants caused by Chlamydia are harder to treat than Chlamydia infections in adults.

Chlamydia infections may also cause heavy bleeding before delivery. <Back to STDs>

Gonorrhea

Gonorrhea is a curable sexually transmitted disease caused by the bacterium Neisseria gonorrhea. Gonorrhea is spread through sexual intercourse, whether it is vaginal, oral or anal. Gonorrhea can also be passed to a newborn during delivery.

As with Chlamydia, gonorrhea is a leading cause of infertility. The most common site of initial infection in women is the cervix and the urethra. If left untreated, the infection can spread to the uterus and fallopian tubes resulting in PID (pelvic inflammatory disease.) PID causes scarring of the fallopian tubes, which may lead to infertility or ectopic pregnancy, in which a fertilized egg is implanted outside the uterus, most frequently in the fallopian tube. Ectopic pregnancy can be life threatening.

Symptoms

The symptoms of gonorrhea usually appear two days to three weeks after exposure to the infection. Unfortunately, you can be infected for months and never know it. Sometimes when symptoms do occur, they are mild.

Women may have:

a vaginal discharge
painful, burning sensation with urination
lower abdominal pain and fever
pain with intercourse

If the symptoms are ignored and the infection goes untreated, the bacteria can spread to the uterus, fallopian tubes and ovaries causing PID (pelvic inflammatory disease.) PID causes scarring that can lead to infertility or ectopic pregnancies.

Men may have:

painful burning sensation with urination
milky white to yellow discharge from the penis
redness and swelling around the opening of the penis
pain and swelling in the testicles

Diagnosis

Gonorrhea is diagnosed from a DNA test using swab specimens from the cervix, rectum, throat or urethra.

Treatment

The infection can be cured by antibiotics. It is important to complete all the medication, even if you have no symptoms or your symptoms go away. All partners must be treated at the same time, you should abstain from intercourse until both of you have finished the medication.

Pregnancy

Pregnant women with gonorrhea are at increased risk of premature delivery. Transmission to the infant during birth can cause severe eye infections. <Back to STDs>

Genital Herpes

Genital herpes is a contagious viral infection, most often acquired through sexual contact. The viruses that cause genital herpes are related to the group of viruses that include chicken pox and mononucleosis. HSV1 (Herpes Simplex Virus 1) most commonly causes sores around the mouth while HSV2 (Herpes Simplex Virus 2) is associated with sores on the genitals. Both viruses, though, can cause sores around the mouth or on the genitals.

It is estimated that 45 million Americans harbor the HSV virus; this is one of every four Americans. As many as 75% of the people infected with genital herpes may be asymptomatic. They can unknowingly pass the infection onto their sexual partners.

Herpes is passed through skin-to-skin contact with the affected area with someone who is infected, generally during sexual activity. HSV can be introduced to the genital area through oral sex. About 20% of the new outbreaks of genital herpes are the result of oral sex. The virus is spread rarely if ever, through contact with bath towels, toilet seats or hot tubs. The virus does not survive long outside the human body. Once the virus enters the genital area it camps out in the nerves at the base of the spine until it is stimulated to grow again.

The severity and length of herpes outbreaks varies from person to person. The outbreaks usually become less frequent over time.

Symptoms

The classic symptom of a genital herpes outbreak is a cluster of painful ulcers on the labia and/or buttocks. As many as 2/3 of all men and women infected with herpes never have any symptoms, or have mild symptoms that they mistake for a rash or mosquito bite. The remaining 1/3 are not so lucky.

About 2 to 10 days after the herpes virus enters the body, flu-like symptoms may appear. These include swollen glands, fever, chills, muscle aches, fatigue and nausea. Ulcers begin as small red bumps that advance to painful fluid filled blisters. These blisters rupture becoming ulcers that ooze and bleed. After 3-4 days scabs form and the ulcers heal without scarring. The first episode lasts from 2 to 3 weeks.

After the initial outbreak heals, the virus remains in the body, hiding in the nerves at the base of the spinal cord in an inactive state. Periodically it can travel through the nerves to the skin at or near the site of the original outbreak. On the skin the virus multiplies and new sores erupt. The virus can also reactivate with no outward signs. At these times the virus can still shed and infect a sexual partner.

The recurrent episodes are generally milder than the initial outbreak and usually last about a week. Often there is a prodrome, or warning symptoms, signaling an outbreak is on the way. Prodromal symptoms include a tingling sensation or itching at the site of infection, pain in the buttocks or down a leg. Sometimes only the prodrome appears, no visible sores erupt or the blisters are very small and barely visible. At other times the red spots develop into open sores that crust over then go away.

Some people may recognize only one to two outbreaks in their lifetime; others may have several outbreaks a year. The number and pattern of outbreaks usually change over time. Researchers do not yet understand why some people have many outbreaks, or why others have so few. They do not yet know what makes the virus reactivate. It is thought the reoccurrences can be brought on by physical or emotional stress, menstruation or immunosuppression.

There is now evidence to suggest that a daily low dose of antibiotic will decrease the chances of HSV transmission to unaffected individuals. The antibiotic provides additional protection against transmission during asymptomatic times when an infected person could be shedding the virus but not have symptoms. This is something to discuss with your health care provider.

Diagnosis

The most common methods used to diagnose genital herpes are a viral culture and a test for viral DNA. For either test a swab of fluid is taken from an active lesion. The tests must be performed before the ulcers scab over. A negative test result does not necessarily mean that herpes is not present. If the lesion appears clinically to be genital herpes, caution should be taken as though the test was positive. If another outbreak occurs, the ulcers should be tested at the earliest sign.

There are blood tests available to test for the presence of HSV-1 and HSV-2 antibodies. Because the body in response to infection makes antibodies, the blood test may not be positive until several weeks after exposure. The blood test is also not site specific, therefore especially in the case of HSV-1, the test may be picking up cold sores.

Treatment

Although there is no cure for herpes, there are several prescription medications that can lessen the severity of the symptoms and decrease the length of the outbreak. The medications interfere with the ability of the virus to reproduce itself. The medications work best if taken at the first sign of an outbreak during the prodrome.

People with recurrent infections (6 or more per year), or who will be delivering a baby soon, may want to take the medication daily to help prevent outbreaks. Those individuals who want to decrease the chances of transmission to an unaffected partner will also want to take the medication daily to provide protection when the virus is present on the skin but not causing any symptoms.

Any time there is an active herpes outbreak it is important to follow a few simple rules to help speed healing and to help prevent transferring the infection to other sites on the body (self inoculation) or to other people.

Keep the area clean and dry to prevent a secondary infection. A portable blow dryer can be used to dry the area after showering or a bath. Panties with a cotton crotch should be worn to allow air to circulate.
Avoid touching the sores, wash your hands after any contact with the sores.
Avoid sexual contact from the time the symptoms first are recognized until the sores are completely healed.

Herpes in Pregnancy

All women who are pregnant should tell their healthcare provider if she or her partner has a history of herpes. During pregnancy the initial or recurrent infections can be more severe.

Babies born to women during an HSV outbreak may become infected. Most infants who are infected came into contact with the virus as they passed through the birth canal. Infection with the herpes virus can cause serious skin infections, damage to the nervous system, blindness, mental retardation or death.

The risk to the newborn is the highest if this is the mother's first outbreak. Usually if there are no active sores at the time of labor the baby can be delivered vaginally. If there is an active infection a Cesarean section may be recommended.

Medication such as acyclovir may be given during the last month of pregnancy to prevent an outbreak close to delivery. <Back to STDs>

Syphilis

Syphilis is a sexually transmitted disease caused by a small spiral-shaped bacteria call Treponema pallidum. Where syphilis once caused devastating epidemics, it now can be easily diagnosed by a blood test and effectively treated with antibiotics. Syphilis occurs in stages. The disease is more easily spread in some stages than in others.

Syphilis is spread through sexual or skin-to-skin contact with someone who is in an infectious stage where the symptoms are present. Syphilis spreads through open sores or rashes containing bacteria that can penetrate the mucous membranes of the genitals, mouth or anus. The bacterium is very fragile so the infection is almost always spread by sexual contact.

Symptoms

Once the bacteria enter the body, the disease may progress through four stages depending on when the treatment is initiated. Left untreated, syphilis can cause blindness, insanity, paralysis, heart disease or death. Symptoms can appear within 10 to 90 days following exposure. The symptoms of syphilis are divided into four stages.

1) Primary Stage

The first sign of syphilis is usually a painless ulcer called a chancre. The chancre may look like a pimple, blister or an open sore. The chancre makes its appearance usually at or near the place where the bacteria entered the body. The chancre may occur inside the body where it will go unnoticed. Unfortunately, only about 10% of the women who develop chancres notice them and the disease is highly contagious during this stage. With or without treatment, the sore will heal (usually within 1 to 5 weeks) but the bacteria within the body will continue to increase and spread. About 1/3 of the people infected will progress to chronic stages.

2) Secondary Syphilis

From 2 weeks to 6 months after the chancre is gone a rash appears consisting of brown sores about the size of a penny. The rash is almost always on the palms of the hands and soles of the feet, but could also appear on other parts of the body. At this stage any physical contact, sexual or nonsexual, with the broken skin of the infected person may spread the disease. The rash usually heals within several weeks to months. Other symptoms that may occur include mild fever, fatigue, headaches, sore throat, swollen lymph glands, loss of appetite, hair loss, muscle, and joint or bone pain. The symptoms tend to be mild, may come and go over the next one to two years and will disappear without treatment.

3) Latent Stage

During this stage the disease is not contagious and there are no symptoms. This stage may last many years. Many people who are not treated will have no further evidence of the disease. Approximately 1/3 of those who have secondary syphilis will go on to develop tertiary syphilis.

4) Tertiary Syphilis

During this stage the bacteria will cause damage to the heart, eyes, brain, nervous system, bones, joints or almost every other part of the body. There can be symptoms such as slurred speech, paralysis, insanity or senility. If left untreated tertiary syphilis can cause death. This stage can last for years, even decades. This is not an infectious stage.

Neurosyphilis

The syphilis bacteria frequently invade the nervous system during the early stages of infection. Approximately 3% to 7% of untreated persons with syphilis will develop neurosyphilis during the early stages. Symptoms may include headache, stiff neck and fever due to the inflammation of the lining of the brain. Some people develop seizures. If the blood vessels are affected, symptoms of a stroke may develop with numbness, weakness or visual complaints. The time from infection to developing neurosyphilis can be as long as 20 years. The course of neurosyphilis and the treatment may be different with patients with HIV infection.

Diagnosis

There are three ways to diagnose syphilis. 1) A doctor's recognition of the signs and symptoms, 2) microscopic identification of the syphilis bacteria collected from a surface scraping of an ulcer or chancre or 3) blood tests (the most common way to diagnose syphilis.) A blood test may show a false negative test for up to 3 months after infection. There may be a false positive test result in people with an autoimmune disorder (such as Lupus.)

Treatment

Syphilis is usually treated with penicillin given by injection. There are other antibiotics that can be used in patients who are allergic to penicillin. The disease usually becomes non-infectious 24 hours after beginning therapy. Because some people don't respond to the usual dose of penicillin it is important to have follow-up blood tests. Those with neurosyphilis may need to be tested for up to two years following treatment.

Antibiotics can cure syphilis in all stages, but in tertiary syphilis damage already done to organs of the body cannot be reversed.

Effects of Syphilis in Pregnant Women

Syphilis crosses the placenta to the fetus after 16-18 weeks gestation and about 1/4 of infected pregnancies result in stillbirth or neonatal death.

Some infants with congenital syphilis display symptoms at birth, but most will develop symptoms between 2 weeks and 3 months later. The symptoms may include: skin sores, rashes, fever, weakened or hoarse crying sounds, swollen liver and spleen, jaundice (yellow skin and whites of the eyes), anemia and birth defects. If the infant is not treated early, blindness, brain damage and problems with growth and development may appear. As the children grow older and become teenagers they may develop late-stage syphilis including damage to their bones, teeth, eyes, ears and brain. <Back to STDs>

Hepatitis

Hepatitis is an inflammation of the liver. Viruses or other factors, including alcohol abuse, certain medications, and trauma can cause it. Some cases of hepatitis are not a serious threat to health, but the disease can become chronic and can lead to liver failure and death.

There are four major types of viral hepatitis:

Hepatitis A - the infection caused by the hepatitis A virus is usually mild and does not become chronic. The virus is most commonly spread by food and water contamination, although it can be passed through sexual practices involving oral-anal contact.
Hepatitis B - the infection caused by the hepatitis B virus (HBV) is most often passed to a sexual partner during sexual intercourse, especially during anal sex. HBV can also be passed through contact with infected blood (such as with shared needles or a needle stick with contaminated blood.) or from a mother to her newborn. The infection may be mild or severe and acute or chronic.
Non-A, Non-B - this infection is primarily caused by the Hepatitis C virus (HCV). The infection is usually mild, but is more likely than HBV to lead to chronic liver disease. With new blood donor screening tests, the likelihood of being infected with HCV has diminished. It is now most often contacted through shared needles or an accidental needle stick in a health care setting. Although it can be spread sexually, it is much less likely.
Hepatitis E - this is another type of non-A, non-B hepatitis. The virus is usually found in areas with poor sanitation. It has not been found in the US and is not spread through sexual contact.
Delta Hepatitis - the hepatitis D virus (HDV) only produces disease when HBV is present. Most cases have occurred in people who are frequently exposed to blood or blood products (hemophiliacs) or among drug users sharing contaminated needles.

Transmission

HBV, HCV and HDV are spread in the following ways:

Through sexual intercourse with a contaminated person without the use of a condom.
Sharing contaminated needles among users of injected street drugs.
Needle stick accidents in a health care setting.
Mother to child transmission of HBV during birth.
Transfusions of blood or blood products. Until recently blood transfusions were the most frequent cause of hepatitis C. Blood banks in the US now routinely screen donated blood for HBV and HCV. Tests for HBV also screen out HDV. Now the risk of acquiring hepatitis through a blood transfusion is very low.
Personal contact with an infected person. HBV, HCV and HDV can be spread to a household member if they come into contact with virus-infected blood or body fluids - usually through cuts and scrapes, semen (sexual intercourse without a condom) or by sharing personal items such as razor or toothbrush.

Symptoms

Forty percent of those who have been infected with viral hepatitis have no symptoms. When symptoms are present they can range from mild to severe. The most common early symptoms are mild fever, headache, muscle aches, fatigue, loss of appetite, nausea, vomiting or diarrhea. Later symptoms may include dark and foamy urine and pale feces, abdominal pain, and jaundice (yellowing of the skin and the whites of the eyes).

Some patients with a more severe form of hepatitis B may develop short-term arthritis like symptoms. Many of those with HBV only develop flu-like symptoms. Very severe HBV is rare but can be life-threatening. Early signs, including personality changes and agitated behavior, require immediate medical attention.

Some people, who are infected with HBV or HCV but have no symptoms, become chronic carriers. There are an estimated 1.5 million HBV carriers in the US (300 million carriers worldwide.) About 90% of the babies infected at birth with HBV become chronic carriers. At least ½ of all HCV carriers, whether or not they had symptoms, go on to develop chronic liver disease.

Diagnosis

Several blood tests can detect HBV, HCV or HDV even before symptoms develop. A number of blood tests can also be performed to determine how well the liver is functioning.

Treatment

Bed rest, a healthy diet and no alcoholic beverages is generally the recommendation for treating the acute symptoms of viral hepatitis. Because it is a virus, not a bacteria, there is no cure for viral hepatitis.

Interferon alpha may be used to treat chronic HBV and HCV. Interferon alpha is a genetically engineered form of a naturally occurring protein. The drug improves liver function and may decrease symptoms, although interferon alpha has its own side effects (headache, fever and flu-like symptoms.) Some patients don't respond to the drug, while with others the benefits decrease over time.

Pregnancy

Because HBV can be transmitted during childbirth pregnant women should have a blood test to see if they are a chronic carrier of HBV. If a woman tests positive for HBV, the baby can receive hepatitis B immune globulin and a vaccination for HBV immediately after birth. Immune globulin offers temporary protection and the vaccine provides a longer lasting immunity.
<Back to STDs>

Molluscum Contagiosum

Molluscum Contagiosum is a benign viral infection of the skin. It most often affects young children who pass it to each other through saliva. In adults the virus is sexually transmitted and the lesions are usually on the genitals, lower abdomen, buttocks or inner thighs. The rash caused by Molluscum Contagiosum causes painless wart-like bumps. Molluscum is caused by a poxvirus. The rash usually develops 2 to 7 weeks after exposure. Molluscum is spread by direct contact with infected skin and can be spread to self or other people.

Symptoms

Molluscum causes normal skin to grow into bumps. There is no pain or discharge associated with the bumps unless they are accidentally cut.

Diagnosis

Diagnosis is made by observation by an experienced practitioner.

Treatment

Molluscum is treated by destroying the infected skin. The lesions can be destroyed using liquid nitrogen, a laser or by burning them off with an acid solution. <Back to STDs>

Pubic Lice, Crabs

Pediculosis is a tiny crab-like parasite that is usually found in the pubic hair of infected men and women and occasionally in the hair of the chest, armpits, eyelashes and eyebrows. The more common names are pubic lice or crabs. The lice survive on human blood. Usually the parasites are spread through sexual contact, although in a few cases they have been picked up through contact with infected bedding or clothing.

Symptoms

The main symptom is severe itching in the genital or other affected area. Scratching can transfer the lice to uninfected parts of the body.

Diagnosis

Diagnosis is easy because the lice are visible to the naked eye. They are the size of the head of a pin, oval and grayish, but appear reddish-brown when full of blood from their host. The nits, or tiny white eggs, are also visible clinging to the base of the pubic hair.

Treatment

Lotions and shampoos that kill pubic lice are available both over the counter and by prescription. Pregnant women should not use the over the counter products and should call their health care provider for advice. None of the drugs should be used in or around the eyes. An ophthalmic petroleum jelly should be used for lice in the eyebrows. All persons who also may be infected due to intimate contact should be treated. All clothing and bedding should be dry-cleaned or washed in very hot water (125 degrees F), dried at a high setting and ironed to rid them of any lice or nits. Pubic lice die within 24 hours of being separated from the body while the eggs may live up to six days. <Back to STDs>

Human Papilloma Virus and Condyloma (Venereal Warts)

HPV, or Human Papilloma Virus, may well be the STD of the new millennium. The virus has been studied for a relatively short time but already 80 different genotypes have been identified in the US. Approximately 20 to 30 are known to infect the genital area. Even though the viruses are not a reportable disease, it is believed that 75% of sexually active adults are infected with one or more types of the virus with an estimated 5.5 million new cases a year.

The virus was named "Papilloma virus" because they are known to cause warts, or papillomas. The strains of HPV that cause warts on the hands and feet are different from the strains that cause genital warts. Not all the viruses, though, cause warts. Sometimes the virus lives on the skin without showing any symptoms. Many people with HPV are not aware they are infected. There are strains of HPV that can cause cancers of the vulva or cervix in women, the penis in men or the anus in men and women.

The HPV types that are responsible for genital infections have been divided between "low risk" and "high risk" types, depending upon whether the virus type is associated with genital cancer.

HPV is usually transmitted by sexual contact. The time period between the exposure to the virus and any manifestation of symptoms is unknown. It can be anywhere from several weeks to years making it difficult to know exactly when a person is infected.

Condoms can help avoidance with the virus, but do not prevent it. The only parts of the genitals protected are those covered with latex.

Symptoms

The HPV types that are associated with genital infection are divided into two types - low risk and high risk, depending upon whether they are associated with genital cancers. Low risk HPV is usually associated with genital warts (also known as condyloma accuminata or venereal warts.) Genital warts are small pink or red bumps on the vulva, vagina, cervix penis shaft, urinary opening or anus. Generally they are painless, but there may be burning or bleeding when irritated. Genital warts tend to occur in clusters. They may grow into a cauliflower-like growth.

High risk HPV has been linked to various cancers in both women and men. Nearly all cases of cervical cancer are caused by a high risk HPV virus. These infections can not be seen with the naked eye.

Diagnosis

The diagnosis of genital warts is usually made by a healthcare professional, who simply looks at the area. If there is a question the wart may be removed and sent to a pathologist at a lab for diagnosis.

Often HPV infection may first be suspected after an abnormal pap smear. On the basis of the abnormal pap, a colposcopy may be recommended. During this exam, a health care professional will apply acetic acid to the cervix to help identify HPV infection otherwise invisible to the eye. The solution causes "aceto-white patches" which are especially visible with the use of a colposcope. A colposcope is an instrument that looks like binoculars on a stand that is used to inspect the infected area under magnification. A biopsy may be taken to aid in the diagnosis.

There is a test available to detect the HPV DNA. A swab is taken from the vagina or cervix and sent to a laboratory. The test only indicates whether the virus is being shed at the place and during the time the test is performed. A negative test does not necessarily mean exposure to the virus has not taken place. The result of the DNA test indicates whether the viral DNA detected is low risk type or high risk.

Treatment

As with other viruses, there is no cure for HPV. Genital warts may come and go on their own, or may persist despite aggressive treatment. Treatment of genital warts is easiest when the warts are small and few in numbers.

None of the treatments discussed below will guarantee that the warts won't return and all treatments cause a local irritation. The goal with treatment of genital warts is to remove visible warts and annoying symptoms.

Treatments that are applied by a health care professional include:

TCA (trichloracetic acid) is a chemical painted on the surface of the wart to destroy it. The acid may cause some localized burning as it dries. It takes weekly treatments for a number of weeks to get rid of the warts - they should turn white, shrink and disappear.
Podophyllin is another chemical that can be painted on condyloma. It also causes burning as it dries and should be washed off with soap and water 4 to 6 hours after application.
Other methods used to treat genital warts are cryotherapy (freezing the warts off) and laser therapy (burning the warts off with a beam of light).

There are a few new products that have been introduced that can treat the warts at home:

Podofilox (Condylox) solution or gel can be applied at home twice a day for 3 days, followed by 4 days of no therapy. This regiment can be repeated up to four times.
Imiquimod (Aldara) stimulates the immune system to target the warts. The cream is applied three times a week for up to 16 weeks.

Pregnancy

Genital warts can cause problems during pregnancy. Sometimes they enlarge, causing difficulty with urination. Warts on the wall of the vagina can cause obstruction with delivery.

There are safe ways to treat genital warts during pregnancy. <Back to STDs>

HIV and AIDS

AIDS (acquired immunodeficiency syndrome) is the most severe form of HIV (human immunodeficiency virus.) AIDS was first reported in 1981 and is now a worldwide epidemic. HIV progressively destroys the cells of the immune system thereby damaging the body's ability to fight off viruses, bacteria and fungus that cause disease. Opportunistic infections develop such as pneumonia, meningitis and certain types of cancers. The microbes causing the infections generally wouldn't cause illness in a healthy person; but for a person with a weakened immune system the infections can be life threatening.

An estimated 900,000 Americans are living with HIV currently. During the last ten years HIV infection among women has dramatically increased. In 1992 women made up 13 % of people with AIDS, in 1998 20% of the people living with AIDS were women. AIDS is the third leading cause of death for women in the US ages 25 to 44. In African-American women in this age group AIDS is the number one cause of death.

HIV is transmitted through the blood, semen or vaginal secretions of an infected person. HIV is usually spread by sexual contact with an infected person. It can also spread through sharing contaminated needles or syringes among drug users. Untreated women can pass the infection to their children during pregnancy, birth or through their breast milk.

Although HIV has been found in the saliva of infected people, no evidence exists that the virus is passed through saliva. Saliva appears to have natural compounds that inhibit the infectiousness of HIV. Researchers have found no evidence that HIV is spread through urine, feces, sweat or tears. HIV is not passed through casual contact, through insect bites or stings.

The risk of acquiring HIV from an infected health care worker is extremely low. World wide there have been only two cases documented of an HIV-positive surgeon transmitting the virus to a patient.

Having another sexually transmitted disease such as herpes, gonorrhea, Chlamydia or syphilis appears to make a person more susceptible to acquiring the virus through unprotected sex with an infected person.

Symptoms

Many people don't develop symptoms when they are first infected with HIV. Some people, though, develop a flu-like illness within a month or two of exposure to the virus. The symptoms - fever, malaise and enlarged lymph nodes - usually disappear within a week to a month and are commonly mistaken for other viral illnesses. People are very infectious during this period.

It can be a decade or more from the time the virus enters the body to when more severe symptoms appear. During this asymptomatic period, the virus is actively multiplying, infecting and killing cells of the immune system. The virus disables or destroys the T4 cells (or CD4+T cells), which are the immune system's key infection fighters.

As the immune system deteriorates, complications begin to surface. One of the first symptoms to appear in many people is swollen glands, or enlarged lymph nodes, that remain swollen for longer than three months. Other symptoms that may begin to appear include fatigue, weight loss, frequent fevers and sweats, frequent yeast infections (vaginal and oral), persistent skin rashes or flaky skin, PID (pelvic inflammatory disease) that doesn't respond to medication or short term memory loss. Some people develop severe herpes sores in the mouth, genitals or anus.

Symptoms of AIDS

The most advanced stage of HIV infection is known as AIDS. In 1993 the CDC revised the definition of AIDS, to include all HIV infected people who have fewer than 200 T4 cells (healthy adults usually have 1,000 or more.) The definition also includes 25 conditions, mostly opportunistic infections, which effect people with advanced HIV disease. Opportunistic infections develop when the immune system can no longer fight off certain bacteria, viruses and other microbes. The infections can cause such symptoms as coughing, shortness of breath, seizures, mental confusion and forgetfulness, severe and persistent diarrhea, fever, vision loss, severe headaches, weight loss, extreme fatigue, nausea, vomiting, lack of coordination, coma, abdominal cramps, or difficult or painful swallowing.

People with AIDS are particularly prone to various cancers caused by viruses - Karposi's sarcoma, cervical cancer and lymphomas. These cancers are harder to treat and usually are more aggressive in people with AIDS.

Diagnosis

The first tests for HIV antibodies were developed to screen donated blood, and were then expanded to test people at risk for HIV infection. There are two standard tests for HIV; the Enzyme Immunosorbent Assay (EIA) that detects the antibodies that are produced in response to HIV infection and the western Blot test which is a more specific test that can differentiate between HIV antibodies and other antibodies that can react to the EIA. If the EIA test result is positive, it will be repeated using the same blood sample. If that test is also positive then a Western Blot test will be performed on the same blood sample.

HIV antibodies usually do not reach detectable levels until one to three months following infection. It can take as long as 6 months to have enough antibodies created in large enough quantities to show up in standard blood tests.

People who think they have been exposed to HIV should be tested for HIV as soon as they are likely to have developed antibodies. Early testing allows treatment to begin at a time when they are most able to combat HIV and prevent opportunistic infections.

Treatment

The treatment for HIV has been rapidly evolving. The earlier HIV is detected the sooner treatment can be started. If initiated soon after the infection with the HIV virus, the initial viral surge can be decreased. The drugs can delay the gradual weakening of the immune system. The treatment may also reduce the chance of spreading the disease to a partner. The treatments not only decrease the amount of virus in the blood, but also in the bodily fluids.

The first group of drugs used to treat HIV infection are called nucleoside analog reverse transcriptase inhibitors (NRTIs). They work by interrupting an early stage of virus replication. The most well known of these drugs is AZT. These drugs may slow the spread of HIV in the body and delay the onset of opportunistic infections. These medications, though, do not prevent the spread of HIV to others. Non-nucleoside reverse transcriptase inhibitors (NNRTIs), the second group of drugs, also target the enzyme, but work in a different way. The third group of drugs, protease inhibitors, interrupts the virus from making copies of itself once it has entered a cell.

The drugs used do have side effects that can be serious. AZT can cause a decrease in red or white blood cells in the blood, especially in the later stages of the disease. The protease inhibitors can cause nausea, diarrhea and other GI symptoms. There can also be an abnormal distribution of body fat, especially paunches or bumps.

In 1996 a new test was introduced to monitor how well the body is responding to treatment. The viral load test measures the amount of HIV in the blood in terms of "copies per milliliter." A high normal load indicates the person is progressing towards AIDS, while a low viral load indicates the immune system is keeping the infection in check.

Pregnancy

Women can transmit the HIV virus to their babies during pregnancy, birth or through breastfeeding. One fourth to one third of all untreated women will pass the infection on to their babies. If the drug AZT is taken during pregnancy the risk of passing the virus to the child is reduced by two thirds. If AZT is used along with delivering the baby by cesarean section for women with an elevated viral load, the infection rate is dropped to 1%. Women infected with the HIV virus should not breastfeed their babies. <Back to STDs>

What are Thyroid Disorders?

The thyroid is a butterfly shaped gland located across the base of the neck below the Adam's apple and in front of the windpipe that regulates the body's metabolism and organ function. This gland produces hormones that affect nearly every tissue in the body.

Some of the functions the thyroid hormones are involved in include the breakdown of fat tissue, the pace of cell activity, menstrual cycling, heart rhythms, and protein building and breakdown. The thyroid also helps to maintain blood pressure and regulates tissue growth and development. Disorders of the thyroid can affect the cardiovascular system, reproductive system and major organs.

About 20 million Americans have a thyroid disorder of some form, most of them women. The most common thyroid disorder is an under-active thyroid, or hypothyroidism, where the thyroid fails to produce enough hormones. Hyperthyroidism, or an over-active thyroid, occurs when too much thyroid hormone is produced. Sometimes there can be an overgrowth of tissue causing a small lump, or nodule, on the gland. Most nodules are benign, but a small percentage may be cancerous.

How the Thyroid Works

The thyroid gland produces the thyroid hormone levothyroxine (T4) which in turn is converted to another hormone triiodothyromine (T3) in other body tissues. These two thyroid hormones, T3 and T4, travel to all parts of the body where they influence metabolism. One of the roles of the pituitary gland is to regulate the amount of thyroid hormones that are produced. As the pituitary monitors the thyroid hormone level in the blood, it produces its own hormone - thyroid stimulating hormone (TSH), which travels in the blood to the thyroid to stimulate the production of thyroid hormone.

Hypothyroidism

When too little thyroid hormone (TH) is released, the body's metabolic rate decreases and the body slows down. With mild hypothyroidism, there may be no obvious symptoms, but as the thyroid failure progresses, symptoms may begin to emerge. Symptoms of hypothyroidism include:

Fatigue
Intolerance to cold
Depression
Dry, coarse skin and hair, hair loss
Brittle nails
A slow heart rate
Constipation
Trouble with concentration
Poor memory
Irregular or heavy menstruation
Infertility
Muscle aches
High cholesterol
Goiter (or enlarged thyroid gland)

Causes

The leading cause of a hypoactive thyroid is Hashimoto's Thyroiditis, an autoimmune disease. A person's immune system attacks and damages the thyroid gland as though it were a foreign substance. The final result is that decreased amounts of TH are produced.

As there is less TH circulating in the blood, the pituitary gland will produce more TSH, causing the thyroid gland to work harder. This increase in demand may cause the thyroid to grow larger, resulting in a goiter.

Another cause of hypothyroidism can be a hyperactive nodule that causes the rest of the thyroid to be under-active (see nodules below).

Hypothyroidism can occur after treatment for hyperthyroidism (see hyperthyroidism below), or it can occur spontaneously.

Hypothyroidism can occur during pregnancy or postpartum. Hypothyroidism can be difficult to diagnose during pregnancy since the symptoms of fatigue and weight gain can also be normal symptoms of pregnancy. Hypothyroidism can be safely treated during pregnancy with a thyroid supplement. Women who were already on a thyroid medication before pregnancy may need their dose adjusted during pregnancy.

Treatment

The goal is to replace the missing thyroid hormone with a synthetic hormone. The supplement will probably have to be taken for life. Periodic TSH (thyroid stimulating hormone) tests are necessary to monitor the TH levels, as the body's requirement may change over time. Patients should not change their brand of thyroid hormone without consulting with their healthcare provider first.

Hyperthyroidism

When too much thyroid hormone is released, metabolism increases and the body speeds up. Symptoms of hyperthyroidism include:

Tremors
Rapid pulse
Nervousness or irritability
Heat intolerance
Difficulty sleeping
More frequent bowel movements
Decreased menstrual flow
Weight loss
Bulging of the eyes (exothalmos)
Muscle weakness
Goiter (enlarged thyroid gland)

The leading cause of hyperthyroidism is Grave's Disease. Grave's Disease is an autoimmune disease. The body's immune system mistakenly attacks thyroid tissue, causing excessive growth of the tissue leading to an enlarged thyroid. This leads to an overproduction of thyroid hormone. The antibodies may also attack eye muscle and the skin.

A thyroid nodule that overproduces TH can also cause hyperthyroidism. It can develop during or after pregnancy, or after treatment for hypothyroidism with too high a dose of synthetic hormone.

Treatment

An anti-thyroid medication can be given to block the production of thyroid hormone in very young patients with Grave's disease or elderly patients with diseased thyroid glands. Part or all of the thyroid gland may be surgically removed. Often radioactive iodine is given to shut down the thyroid hormone production. Patients then would take synthetic thyroid hormone. Inderal may be prescribed for the tachycardia that can accompany hyperthyroidism.

Thyroid Nodule

A nodule is a lump in the thyroid gland. The nodule will probably be checked with ultrasound or a biopsy to see if it is cancerous or benign. Ninety to ninety-five percent of thyroid nodules are benign. Most nodules don't have symptoms and may never be detected. Some nodules grow large enough to press against the windpipe and cause difficulty with swallowing.

If the nodule is found to be benign, a thyroid hormone may be prescribed to shrink the size of the nodule or it may be removed surgically. If the nodule is found to be cancerous, further treatment will be necessary. Thyroid Cancer can usually be successfully treated. <Back to Top>

What are Vaginal Infections?

Vaginal infections are the most common gynecologic disorder and are usually caused when the normal vaginal flora that are found in the vagina become imbalance. Symptoms of vaginal infections can range from mildly annoying to extremely uncomfortable. The key to successful treatment lies with an accurate diagnosis of the agent causing the infection. Therefore, before you use any over the counter medication such as a treatment for vaginal yeast infection you should be sure it is the right drug to treat the problem. Using the wrong sort of medication may make the situation worse. If you have any doubt you should consult your doctor or mid-wife.

The Most Common Vaginal Infections

1. Yeast Infections

These infections are caused by a fungus called Candida. Yeast may be found in small amounts in the normal vagina. When there is an imbalance in the normal vaginal flora, the yeast can take hold and overgrow. Taking antibiotics that may kill the lactobacilli found in a normal vagina can cause this imbalance.

Lactobacilli excrete hydrogen peroxide, which is a natural disinfectant that acts to maintain the normal balance of organisms in the vagina. Other factors that may lead to the imbalance are pregnancy, taking oral contraceptives, steroid use, obesity, diabetes, wearing clothing that traps heat and moisture (such as nylon), and a diet high in sugars and starches.

The classic symptoms of a yeast infection include vulvar itching, redness and irritation. In severe cases, the vulva may be swollen with fissures, or breaks in the skin. When there is a vaginal discharge, it is thick, white and "cheesy" or curd-like. Your health care provider can diagnose the infection by vaginal culture, or looking at a drop of the vaginal secretions under a microscope.

There are many treatments for yeast infections including oral and vaginal medications, prescription and over-the-counter.

2. Bacterial Vaginosis (BV)

Bacterial Vaginosis is the most common vaginal infection. The bacteria that cause the infection occur naturally in the vagina. The infection occurs when there is an overgrowth and the normal vaginal bacteria are replaced.

The primary symptom of BV is a thin, white, or grayish discharge with an unmistakable fishy odor. The odor usually increases after intercourse or during menstruation. There may be mild irritation or itching, but quite often it is the offensive odor that causes the woman to seek treatment. The diagnosis is made by checking the vaginal pH (it is abnormally high with BV), evidence of the discharge upon exam, the fishy odor, and the abnormal appearance of cells that line the vaginal wall.

BV is treated with antibiotics, either orally or intravaginally. These medications are only available with a prescription. It is important to finish all the antibiotics as prescribed.

3. Trichomoniasis

"Trich" is a common sexually transmitted disease (STD) that is caused by a protozoan. Although it is usually transmitted through sexual intercourse, in rare instances it has been passed through wet towels, washcloths or bathing suits. Trichomoniasis can occur without symptoms. When there are symptoms, they are usually within 4 to 20 days after exposure, although it may be years before the symptoms appear. The symptoms in women include a yellow-green vaginal discharge that may be frothy. The labia may be irritated, red and itchy. There may be spotting after intercourse, and a foul vaginal odor. If the infection involves the urinary tract, there may be burning with urination.

Trichomoniasis is usually diagnosed by culture or by identifying the protozoan under a microscope. Sometimes the infections may be picked up on Pap Smear. The infection is treated with oral antibiotics for the woman and her partner. It is important that both be treated so as to prevent re-infection.

Preventing Vaginal Infections

The vagina is a delicate ecosystem. Douching may disrupt this balance, leading to an overgrowth in yeast or bacteria. If you already have an infection, douching can make it worse. Using scented toilet paper or sanitary napkins, feminine deodorants, spermicides, harsh soaps or detergents can cause irritation, either leading to an infection or making it worse.

Always change out of a wet bathing suit immediately, the yeast and bacteria that cause vaginal infections love moisture. Dry yourself thoroughly after bathing or showering. Avoid tight clothing, especially while exercising, and always wear cotton undergarments that absorb moisture.

Keep the vaginal area clean, always wipe from the labia towards the rectum after a bowel movement to avoid spreading organisms from the rectum to the vagina. <Back to Top>