Laura J. Martin, MD
For most women, a couple of irregular menstrual cycles or an occasional yeast infection are just a part of life -- nothing that time or simple treatment won’t cure.
But some gynecological symptoms are mystifying, such as vaginal bleeding that always follows sex or unusual bumps or sores.
When should you call your doctor?
Much of the time, pelvic pain, spotting, itching, and other symptoms don’t turn out to be serious, according to Holly Puritz, MD, FACOG, an obstetrician and gynecologist at The Group for Women in Norfolk, Va.
Even a normal process, such as ovulation, can cause pain. “There’s something you can have mid-cycle, which is called ‘mittelschmerz.’ It’s German for ‘mid-cycle pain,’ ” Puritz says. When ovulation occurs, some women feel a sharp or cramping pain on one side of the lower abdomen. The pain may switch sides from month to month.
“Pelvic pain, if you can pinpoint the timing of it, can actually reassure you,” Puritz says. “If it always happens mid-cycle, lasts two to three days, and goes away, it’s generally not anything abnormal.”
Likewise, abnormal vaginal discharge may signal a sexually transmitted disease, but often, it stems from infections that are easily treated.
Nevertheless, some symptoms can point to serious medical problems. No need to panic, but it’s smart to know when to get help.
Mittelschmerz goes away after ovulation, but if you have pelvic pain that persists or doesn’t ease with simple home treatment, call your doctor, Puritz says.
When a woman has chronic pelvic pain, doctors will check for benign uterine fibroids and endometriosis. They will also look for pelvic inflammatory disease, which usually appears as a triad of pelvic pain, vaginal discharge, and fever, Puritz says.
In some cases, strong pelvic or abdominal pain comes on quickly -- a sign to call your doctor. A ruptured or bleeding ovarian cyst can trigger this type of pain.
“Usually, we’ll treat those patients with some type of analgesic or pain medication and usually, it subsides on its own,” says gynecologist Jessica Shepherd, MD, of the University of Louisville’s department of obstetrics, gynecology, and women’s health.
If a more severe attack of pelvic pain starts suddenly, the ovary may have twisted, cutting off its blood supply. Some women also feel nauseated or vomit.
In addition, abdominal pain and vaginal bleeding may signal an ectopic pregnancy, in which a fertilized egg implants outside of the uterus.
In either situation, get to an emergency room if you can’t reach your doctor.
Fortunately, most pelvic discomfort isn’t related to ovarian cancer, but women should know the disease’s unremitting “constellation of symptoms,” Puritz says. “If you have two weeks of bloating, pelvic pressure, and urinary frequency -- and every day, you have it -- that’s a potential sign that you should be checked for possible symptoms of ovarian cancer.”
Though birth control pills can cause spotting that isn’t serious, you may still want to discuss your prescription with your doctor.
“But if you’re not on any kind of birth control and you have irregular bleeding that lasts for more than a month or two, I think it should always be checked, even though the odds are, we won’t find anything bad,” Puritz says.
Irregular bleeding “covers a host of things,” she says: periods that last longer than normal, bleeding mid-month, having two periods per month, bleeding after sex, and other unusual patterns.
Abnormal bleeding may stem from multiple causes that aren’t serious, among them, perimenopause or uterine fibroids or polyps.
Thyroid problems can affect the menstrual cycle, too, Puritz says.
In nursing mothers and postmenopausal women, vaginal dryness, combined with friction, can cause spotting after intercourse.
But if you bleed every time after sex, “that’s a worrisome sign that the cervix is being easily irritated and usually, it often does that if there’s some infection of the cervix," Puritz says. "It wouldn’t normally do that in a healthy cervix.” Sexually transmitted diseases, such as gonorrhea or chlamydia, can cause cervical lesions that bleed with sex.
If you’re postmenopausal, be especially vigilant about any vaginal bleeding; it’s a potential sign of uterine cancer. “You should be seen right away,” Puritz says. “Uterine cancer, compared to ovarian cancer, is extremely treatable. It’s very curable because it’s generally found in an early stage and it has an early warning sign, which is postmenopausal bleeding.”
Besides postmenopausal bleeding, any vaginal bleeding before puberty or during pregnancy should be checked out, too, Shepherd says.
With vaginal discharge, “abnormal is what the woman decides is abnormal,” Puritz says. “Women know their bodies pretty well.”
Abnormal symptoms include a strong odor; an unusually large amount of discharge; accompanying itching, burning, or irritation; unusual color; or blood in the discharge.
Most causes of abnormal discharge are minor, Puritz says. “Any sort of infection can cause a discharge.” Common ones include yeast infections, bacterial vaginosis, or trichomonas, she says. “They’re all easily treated.”
Because sexually transmitted diseases can also cause abnormal discharge, check in with your doctor to rule out the possibility.
Also be sure to tell your doctor about any persistent, watery discharge, a classic symptom of fallopian tube cancer, which is rare.
Women may have itching without discharge, a problem that Puritz sees frequently when patients use perfumed soaps or personal care products -- especially perfumed lubricant jellies. “All perfume lotions and potions wreak havoc,” she says. “Especially if you have sensitive skin, that can cause a lot of itching and irritation.”
Although genital itching isn’t likely to be serious, it’s still a good idea to tell your doctor if it’s bothersome. The fix might be simple.
However, “if it’s itching and there are skin changes, that would be a worrisome sign,” Puritz says.
For example, a skin condition called lichen sclerosus can cause itching and small, white spots on the vulva. The spots grow into bigger patches that turn thin and crinkled. Lichen sclerosus is an uncommon problem that tends to affect older women, Puritz says.
“It’s something that needs to be medically treated,” she says. Left untreated, the patches can scar and create problems with urination or sex. There’s also a tiny chance that skin cancer may develop in the patches.
Aside from lichen sclerosus, any itchy lesion on the vulva or vagina may need to be biopsied to rule out cancer.
Vaginal dryness in nursing mothers or postmenopausal women can cause spotting after intercourse. Once nursing moms start ovulating again, dryness will ease.
But “vaginal atrophy is really important, especially for postmenopausal women,” Shepherd says. Because older women have less estrogen, their vaginal tissue thins or atrophies and becomes dry and irritated.
Not only does vaginal dryness make sex painful, but vaginal thinning also leaves women more susceptible to infections.
Women shouldn’t be embarrassed to mention vaginal dryness to their doctors, Shepherd says. Women may find relief with estrogen creams, rings, or tablets that are applied or inserted directly into the vagina.
Some women develop sebaceous cysts and skin tags in the groin area, or a pregnant woman may get varicose veins that feel like a lump on the vulva when she stands. “All would be very benign things,” Puritz says.
But some lumps or sores can be serious, so it’s prudent to have your doctor examine them.
Sores in the genital area may point to herpes or cancer, Puritz says. Symptoms of cancer of the vulva include unusual lumps, wart-like bumps, or red, flat sores that don’t heal. Sometimes, the flat sores turn scaly or discolored.
Also, melanoma, a form of skin cancer, can occur on the vulva, Puritz says. Symptoms include bluish-black or brown, raised moles in the genital area, including the opening to the vagina. Patients are often surprised by the disease, she says. “They think that if there’s no sun exposure, you can’t get a melanoma.”
SOURCES:Holly Puritz, MD, FACOG, obstetrician and gynecologist, The Group for Women, Norfolk, Va.Jessica Shepherd, MD, department of obstetrics, gynecology, and women's health, University of Louisville.Merck Manual: "Vulvar Cancer."
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