So many women, whether young, middle aged or menopausal, will experience abnormal vaginal bleeding or spotting between periods at some time in their lives.
In fact, it would be uncommon for any woman to not have abnormal bleeding at some point. By the time many of you have made an appointment and come in, you have researched the bleeding on the Internet. Of course the first thing it says is, 'Abnormal Vaginal bleeding can be caused by cancer, especially if it happens after sex, after menopause or in between your periods.
But, this statement does not take into any number of important factors, such as: Did the bleeding occur with ovulation? Are you menopausal and on hormones? Did you miss a birth control pill? Do you always have regular cycles? Are you under a lot of stress? Rather, it just carelessly throws out a blanket statement about cancer which scares many of you.
Vaginal bleeding is considered to be abnormal if it occurs when you are not expecting your menstrual period, if your menstrual flow is lighter or heavier than what is normal for you, or if it occurs at any time in life when it is not expected, such as before age 9, during pregnancy, or after menopause. Abnormal bleeding is very common, and even though it can cause alarm, most of the time it does not indicate a serious condition.
In women of childbearing age, early pregnancy should always be considered, even in women on birth control pills or with an IUD in place. Also, ovulation can cause mid-cycle bleeding. Hormone imbalance, such as occurs during menopause, or Polycystic Ovarian Syndrome (PCOs) - the most common hormone imbalance in young women - can also be the cause.
Medications such as birth control pills, antibiotics, oral or IV steroids that are used in asthma or severe allergies, and various allergy medications could also be a factor. Any Infection of the vagina, cervix, uterus, fallopian tubes, or ovaries may also cause vaginal bleeding, especially after intercourse or douching (which is not recommended at any time for any reason). Of course, Pelvic Inflammatory Disease (PID) which causes inflammation or infection of the uterus, fallopian tubes, or ovaries could also be the cause.
The possibility of a tampon or other object left or put into the vagina and then forgotten can also cause bleeding, and therefore the vagina should be inspected. An ultrasound is useful to see if there are other causes like uterine fibroids or ovarian cysts. Extreme emotional stress and excessive exercise can cause frequent, excessive bleeding or absence and irregular bleeding.
Lastly, tests may be conducted to evaluate for female cancers like cervical, vaginal, uterine, Fallopian tube or ovarian cancer. Most of the time this will take a number of exams and tests to confirm. It is important to go see your doctor if you have abnormal bleeding so you can be reassured and evaluated properly.
I hope you have a wonderful week and be safe out there.
Dr. Susan L. Boyd, MD
So many women, whether young, middle aged or menopausal, will experience abnormal vaginal bleeding or spotting between periods at some time in their lives.
Good Morning Everyone! I always look forward to this time we have to learn and figure things out together. You all have been so awesome and brave with your questions that it has really provided a way for you to help each other. Each time you put it out there and voice your concerns, it opens a way for others to see they weren't alone.
This week was no exception. I had three of you, plus several patients in the office, ask me the same question:
"Dr. Boyd how can I feel more confident with myself during sex?"
I think this may depend on different things for everyone, right? First of all, it is so important that you feel comfortable with your partner and that your partner makes you feel comfortable sexually (and likes your body, so you feel good about yourself during sex). If you don't feel free to express yourself naturally during sex, or sense that your partner is uncomfortable, it can help a lot to talk to each other. Often when there is tension during sex, and you can't talk about it, you will feel less confident and it will prevent you from initiating new things.
Often couples fall into habits due to busy schedules and forget to make time for each other. Both may work all day and, once home, the evenings are filled with family, homework and dinnertime. Sex may be left for the middle of the night or early morning awakenings with a nudge, and, even though you are thoroughly exhausted, you give in. It just feels like one more thing to do before you can have a few hours of peaceful sleep.
Another very common reason for women to feel less confident can be the extra weight that is slow to leave after childbirth. Seriously, who are those women that lose all their baby weight in 3-4 weeks? For most of us, it took nine months to put it on and it's going to take another 6-9 months afterwards to get it back off - and that's if we work at it. Geezz!!
There aren't very many of us who feel sexy at 8-9 months pregnant, with a black lace nighty on, milk dripping from our nipples, swollen feet and ankles and a belly so big we can't even shave ourselves properly. And, it just doesn't feel much better after either, when your belly is still big because the uterus hasn't returned to normal size, our nipples are really leaking now, and our hormones are completely messed up.
Of course, if you've had an episiotomy, vaginal tear, or a c-section scar that has to heal, this can be not only physically painful, delaying the ability and desire to reconnect intimately with your partner, but it can also have a profound psychological and emotional effect on sexual intimacy.
I have met so many wonderful husbands and partners of the women for whom I have cared, that have amazed me with the love and compassion they have. Especially in childbirth, realizing that just because a woman's body is built to have babies, it doesn't make it easy or painless. They admire the strength and courage it took. I have watched as they work with their partners and wait with patience. Hats off to you, guys.
Just like with menopause, I have tried to explain to the men when they come in with their wives wondering, "What happened? She's not the same person anymore. I think she hates me! Help her Doc!" I tell them, "Now just imagine that all of a sudden you were castrated, or for some reason your testicles, right now, today, just stopped making testosterone?" "How do you think you would feel? A little weird? Crazy? Like crying? Well, that's what's going on with her. Her ovaries just stopped making all her female hormones." Men understand that, you know? Menopause is another reason women can lose confidence sexually, just like the others we talked about.
Women lose their sexual desire and experience vaginal dryness, abnormal vaginal discharge and odors due to hormone changes and generally feel as though they are not as desirable as when they were younger. Hormones help with emotional stability and confidence (true for men as well), so it is important to have a physical and blood tests to check for overall health at this time to evaluate for hormonal imbalance.
It's like the joke someone told me, ‘When you're young and you're going into puberty, everyone tells you, ‘Girl you are becoming a woman now.’
But when you reach menopause and go through the ‘change of life,’ no one can tell you what you're going to change in to!” That's for sure - women can feel like they are losing their mind. That's why it's called a HYSTERectomy and not a UTERectomy, because years ago, they thought if they removed the uterus, they would remove a woman's hysteria!
We've come a long way since then, and we don't use the term "she's hysterical" or "nervous breakdown" much anymore. Now we understand a lot more about hormones and hormone balance, which has helped so many women over the past 50 yrs.
The last thing I want to say on this question, and one I really do get asked about a lot, concerns my patients’ most significant worries and causes of lost confidence: The battle with vaginal odor and excessive discharge.
Most of you have had problems with this since your early teens or 20's and have seen multiple doctors who all say the same thing, "Don't douche. It will make it worse and it will keep coming back because you will destroy the natural vaginal flora." Then they give you a script for the same vaginal gel or pills you've taken your whole life, and it goes on and on.
Of course, it was your big sister, mom, cousin, or grandma who showed you about douching anyway a long, long time ago, and how else should we clean out up there anyway? Old blood from your period, semen from sex, smelly discharge…you certainly don't want to smell during sex and especially with oral sex! How embarrassing. We all can relate to that.
That's why when I learned about WaterWorks, after 17 years of working as an Ob/Gyn, I was so excited. Finally, an all natural way for women to have good feminine hygiene and cleanse inside the vagina without destroying the natural flora. The natural flora is necessary to maintain a low pH in the vagina and allows it to be self-cleaning.
This is something that women could use everyday in the privacy of their own homes, and it requires no chemicals, pharmaceuticals, and no
prescriptions. It is FDA-cleared and it looks like a reusable douche, but it uses only natural tap water and a patented, medical grade stainless steel nozzle.
When the stainless steel reacts with the vaginal mucosa, a reaction takes place that destroys vaginal odor. Most women have results the first time they use it and never have odor again. You hang it in your shower; it is reusable; and you can use it to rinse out old blood, semen, or excess discharge or simply use it as part of your daily cleansing routine.
I know this will go a long way to helping you feel more confident sexually, as you won't be worried about vaginal odor. I hope this information helps you and your family and friends. Have a wonderful week. You all deserve it!
Dr. Susan Boyd
We have talked about the common lumps and bumps we get on our labial and vaginal area in recent blogs, but I want to talk about the difference and describe for you the sores and rashes that can be a sign of something worse.
As background, vulva is the general name given to the external parts of the female genitals. It includes: the mons pubis (the pad of fatty tissue covered with pubic hair); the clitoris; labia majora (the outer lips); labia minora (the inner lips); the vestibule (area immediately surrounding the vaginal opening); the urinary opening; vaginal opening; and the perineum (area of skin between the anus and vagina). The appearance of the vulva can vary greatly between women. For example, although the labia minora are referred to as the 'inner lips', it is quite normal for them to extend outside the labia majora.
Dermatitis is the most common cause of chronic vulvar symptoms, such as painful intercourse, increased or foul-smelling vaginal discharge and painful urination. In some cases, vulva dermatitis can be caused by a genetic predisposition to allergies and hypersensitivity. This can be so embarrassing and frustrating because it causes a lumpy, bumpy feel and intense redness and rashes. This can take away all the fun and enjoyment from intimacy.
The following are good rules of thumb to follow to help with prevention and healing:
- Wear cotton underwear for daily use (save the lace and G-strings for your intimate occasions)
- Watch for allergies or sensitivities, especially latex in condoms or diaphragms, over-the-counter vaginal medications or soaps, laundry detergents, and lotions
Some of the most common, non-cancerous reasons for vulvar bumps are Genital herpes, Genital warts, Granuloma inguinale, Chancroid, Bechet's, Pagets of the vulva, Lichen Sclerosis (now known as Vulvar Hyperplasia) along with leukoplakia, neurodermatitis, Bowen's disease, hyperplastic vulvitis, Kraurosis vulva and erythroplasia of Queyrat.
Genital herpes is caused by the herpes simplex virus (HSV). It is transmissible through vaginal, anal or oral sex. Symptoms appear within 2-14 days of exposure and include flu-like symptoms and painful blisters in the genital area. Some people only experience one outbreak while others will have several. A minority of those infected experience frequent recurrences. There is no cure for genital herpes, but antiviral medications can help reduce the duration and severity of an outbreak and prevent transmission to a partner. Keeping the area clean and dry and bathing with a saline solution will help relieve discomfort and assist healing.
Genital warts are caused by particular types of the human papilloma virus (genital HPV). Genital HPV is also transmissible through vaginal, anal or oral sex. Warts can be found on the vulva, clitoris, cervix, inside the vagina or urethra and in or around the anus. They can be flesh coloured or pink and come in a variety of sizes and shapes, occurring singularly or in clusters. The warts do not usually cause pain. Warts can be treated with chemical applications, ablation (freezing, burning or use of laser to remove warts) or a cream that enhances the body's immune response to the viral infection. Warts DO NOT come and go. Once there, they stay until removed.
Psoriasis on the Vulva may or may not be itchy, and does not affect the vaginal mucosa. Symptoms include scaly, silvery or red plaque. Women with psoriasis of the vulva often have the skin condition elsewhere on their body as it is an autoiimmune system disorder. Treatment includes the use of topical steroids and a low dose coal tar cream.
Behçet's syndrome is a disease characterised by recurrent aphthous ulcers, possibly ulcers of the vulva. These usually occur on a cyclical basis related to the menstrual cycle.
Paget's disease of the vulva is a rare skin disease but can cause extreme itching along with red or white patches.
A common benign condition which can occur at any age, but that is more common in the post-menopausal patient, is lichen sclerosis. Now called squamous cell hyperplasia, it presents with intensive itching. White patches are frequently seen along with evidence of excoriation from scratching. Biopsy reveals an increase in the thickness of the top layer of the epidermis (hyperkeratosis) and irregular thickening of the Malpighian layer (acanthosis). This latter process produces a thickened Vulvar skin. It responds to the use of high strength topical cortical therapy - Clobetasol ointment appears to be the treatment of choice. If you stop the treatment, it will reoccur, as it is a lifelong treatment. If left untreated, lichen sclerosus can cause severe scarring of the vulva (including the shrinking of the labia and narrowing of the vaginal entrance). Lichen Sclerosis is known as a Vulvar dystrophy or vulvar intraepithelial neoplasia (VIN).
Neoplasia (VIN) can develop in women of any age. Its frequency appears to be increasing among younger women. Today, the average age for VIN is said to be about 50 years of age. The presence of a distinct mass, bleeding or discharge, strongly suggests invasive cancer and not VIN. VIN is often asymptomatic and presents as a whitening or hyperpigmentation of what appears to be normal vulvar skin. Over half of the women have multiple lesions all thought to be related to HPV virus infection. The lesions are located in the non-hairy portion of the vulva in 85-95% of cases. Biopsy is essential to confirm the diagnosis and distinguish it from the benign lesions described above and surgical excision has been the mainstay of therapy. Symptoms of VIN may include itching and burning in a specific area of the vulva, raised brown, red, pink or white lesions, warty lesions or persistent erosions or ulcers.
The vulva can also develop skin cancers such as melanoma and basal cell and squamous cell carcinomas. HPV seems to be the main culprit in many female cancers. Treatment for vulvar cancer depends on how advanced the cancer is when diagnosed. Early detection of vulval cancer is important as it improves the chances of successful treatment. Once again, surgery is the most common treatment for vulval cancer. Radiation therapy and/or chemotherapy may also be used.
I hope this helps you. The most important thing is if you feel something is wrong or have non-healing sores, go see you doctor.
Have a wonderful week.
Dr. Susan L. Boyd, MD
The most important thing prior to trying to become pregnant is making an appointment with your Ob/Gyn for a check-up, pap smear, vaginal cultures, blood tests and to get all your questions answered. Usually you will be started on prenatal vitamins with folic acid. It is important to be on prenatal vitamins for 2-3 months prior to conception to help prevent birth defects.
Blood tests can screen for anemia, diabetes, thyroid disease and liver or kidney disease that could interfere with your ability to conceive or impact your pregnancy. The pap and vaginal cultures can identify concerns that can be addressed ahead of time or identify bacterial infections that may interfere with conception.
Sometimes couples will try to conceive for months, only to find out that the sperm is dying within the upper part of the vagina before it even has a chance to enter the cervix. This can be caused by certain bacteria in the vagina, but also can be due to the consistency of the discharge. If it's too thick, the sperm may be unable to move through it. If it is due to an infection, this can be detected and cleared. If the later is the case, a post-coital test may need to be done, where a sample of cervical discharge is taken and examined under the microscope right after intercourse to determine the number of living sperm.
It is important to keep track of your cycles monthly on a calendar by noting what day they start. By doing this, you can begin to predict when you are ovulating. There are ovulation predictor kits available at drug stores that are similar to pregnancy tests. They have strips in them that are used to dip in your urine and when a color change is noted, it can indicate ovulation. This can be useful for knowing when the egg is available for fertilization - the best time to have sex.
If your periods are not regular and do not come monthly, ovulation can be impossible to predict. In fact, ovulation may not be happening at all or rarely. In these cases, it may be necessary to seek out help from a fertility specialist.
Also your doctor may want to send you for an ultrasound to make sure there are no ovarian or uterine abnormalities that could interfere with a healthy pregnancy. If you have suffered with endometriosis, you may also need an HSG (hystosalpinogram), which will determine whether your fallopian tubes are patent (open) and able to catch the egg and allow it to travel down the tube to meet the sperm to be fertilized.
It seems that many women, who have had either a miscarriage or an elective termination of an earlier pregnancy, can have worries and doubts in their minds about whether they can get even get pregnant now that they want to. If you are one of these women, what you should know is that if you did not have an infection afterward and if your periods have been normal since that time, you should have no trouble getting pregnant and having a baby now.
It is so important to try to be as healthy as you can be. Women should lose weight and stop smoking (or cut down). Men should stop or reduce tobacco, marijuana and caffeine use also, as nicotine, caffeine and THC can dramatically affect sperm count. Some of the prenatal vitamin companies are coming out with a vitamin for dads-to-be, but any complete vitamin for men will do. There are also some great diets for dads-to-be that can be looked up on the Internet. These diets can help increase sperm count. Some of which have been known to actually triple sperm count.
Getting pregnant shouldn't be so complicated, and it's not- the 'getting' part is fun! But when you try and try and it doesn't happen, it can be heartbreaking. Just don't lose hope and keep in touch with your doctor. If you feel like your doctor is not communicating properly with you, search until you find the right one.
I hope you all have a happy and safe week.
Dr. Susan Boyd
This week Lori wrote in and had a question about douching, as she had heard it could hurt her chances of becoming pregnant.
We have discussed many complications of douching previously, but I think it is worth repeating, as it so important. Many women struggle with unwanted vaginal discharge and slight changes in odor that can occur during the month and that have nothing to do with any type of vaginal infection, whether yeast or bacterial.
The wide availability of premixed over-the-counter douching products has given women a false belief that they are safe to use. In fact, many women are taught by their mothers and grandmothers that this is what women should do as part of their feminine hygiene ritual.
Douching solutions can contain betadine, vinegar, chemical solutions and/or fragrances which can cause an imbalance of the normal vaginal environment. This can lead to all kinds of vaginal infections and irritations that seem to never totally go away or get better.
The vagina is self-cleaning and maintains a low (acidic) pH. Douching, sex, hormone changes, menstrual blood and infections can each change the normal pH.
Douching forces fluid into the vagina, which can also force infection through the cervix into the uterus and fallopian tubes and even into the abdomen & pelvis. This is very dangerous as it can cause an infection called PID (pelvic inflammatory disease) that can infect your entire uterus and pelvis, requiring admission to the hospital for IV antibiotics. If PID is caught early, everything may resolve, however, women can end up with tubal scarring that is so severe they require in vitro-fertilization to become pregnant. So yes, in this way, douching can certainly hurt your chances of becoming pregnant.
The struggle to want to feel clean & wash away odors may make you wonder if the risks of traditional douching are worth it. They are not. But there is an alternative. Using the WaterWorks Therapeutic Cleansing System is the simplest way we have to safely maintain feminine hygiene without the worries of disrupting the normal vaginal flora or causing infection. Rather than forcing fluids upwards into the vagina, the patented design of the stainless steel WaterWorks nozzle allows water to flow gently downwards between the nozzle and the vaginal walls discouraging the incidence of pelvic inflammatory disease (PID).
WaterWorks can be used every day when you shower. It uses only natural, plain tap water to clean the vagina. Its medical grade stainless steel nozzle and running water react with the vaginal mucosa to remove unwanted odors to give you more confidence. Many women use it after sex to rinse out semen right away, which can help prevent vaginal discharge and odor afterwards. I've had patients who have struggled with odor for years who find they have no odor after the first use! You can imagine their relief.
It's just not worth the risk to use any other type of traditional douche.
I hope this helps explain and answer your question this week.
Dr. Susan Boyd
This week’s question comes from one of our blog readers.
"Dr. Susan, how can I protect myself and reduce my chances of getting cervical cancer?"
With the rise of HPV infections & lesions showing up in places like the tongue, throat and anal and labial areas, everyone is becoming concerned. HPV (Human Papilloma Virus), is in the condyloma (genital wart) family. But unlike other genital warts, HPV warts are flat and cannot be detected without placing a special solution on the area. The solution reacts in such a way that the HPV lesions turn a whitish color, and this helps in diagnosis and treatment.
Since HPV is transmitted sexually, the best way to protect yourself from infection is to ensure safe sexual practices. Condoms are the best way to prevent most STD's, but it is thought that the HPV virus is so small that it can escape through a condom’s tiny pores. The addition of spermicidal foams and jellies can help.
The biggest breakthrough in the past few years has been the introduction of a vaccine initially approved for females age 8 to 27. Now the vaccines approval has been extended to males of the same age. This will hopefully be the #1 way to prevent transmission.
Women are typically at higher risk for acquiring these types of STDs as we are the semen recepors. Men, on the other hand, are depositors. Because we are the receptors of the semen, if the semen is infected, we serve as little incubators.
That is why it is so nice to use the WaterWorks cleansing system. WaterWorks can be used immediately after sex to rinse out semen quicklyreducing the time HPV can sit in vagina. Not only does WaterWorks function to reduce vaginal odors, it can also be used for daily feminine cleansing.
If you have not spoken to your healthcare provider about getting the HPV vaccine, it is a good idea to at least get information to read about it.
Please send me an email if you have any more questions about HPV or any other topic.
Dr. Susan Boyd
This week’s question comes from a reader who is experiencing many problems as she goes through menopause. And like many of you, she has begun to experience some of the long-term side effects of hormone imbalance that go way beyond hot flashes, night sweats and irregular menstrual cycles.
Q: Since I started menopause sex has become more and more painful. Is there anything I can do to make it better?
I love this question. Why? Because it illustrates that menopause makes such an impact on a woman's life that it can even affect the way she experiences intimacy. Some women may go from enjoying an active, loving sexual relationship with their partners, to wanting to avoid sex altogether. This can be frustrating, as it puts strain on relationships, and can be scary as women wonder if there is any hope of restoring what they once had. The answer to this, of course, is yes, but it is important to try to stay positive and share what you're going through with your partner. No one said it would be easy, but if other women have survived this journey, I know you will too.
During menopause, as the levels of hormones drop, it causes the tissues of the vagina to thin significantly and become very dry due to lack of normal lubrication. It is the combined effect of these changes that eventually causes shrinkage of the vagina, and the loss of its ability to stretch.
During the excitement phase of intercourse, the normal response is an increase in vaginal moisture. This enables the erect penis to enter the vagina without difficulty, and the normal elasticity allows a pleasant stretching sensation as the man enters. However, in menopause this elasticity/stretchability is absent, as is the normal lubrication, so after penetration there is no moisture. That is why so many women experience intense burning pain - it is caused from the thrusting motion without lubrication.
The use of vaginal lubricants can help a little bit. Always choose water soluble lubricants rather than lotion, creams or oils, as these can cause vaginal infections. The best thing to do is make an appointment with your doctor to discuss this problem and make sure (through blood tests and exams) that there are no other problems going on. Because the tissues are hormone deficient, it is important to get on a good program of hormone replacement. Women have so many choices today, from traditional estrogen vaginal cream to forms like Bio Identical hormones from compounding pharmacies. After about 4-6 weeks on hormone replacement, you will start to notice the healing and restoration of the vaginal tissues back to pre-menopausal status.
Menopause can be a rough time, but if you work with your doctor and are open to share with your partner, sex can be enjoyed for a lifetime.
Hope you have a great week, and be safe out there!
Dr. Susan Boyd