Hormonal imbalance is not a condition exclusive to menopause. An imbalance of hormones can occur at any time in a woman’s reproductive life and can be caused by a number of factors. Besides peri-menopause and menopause affecting the normal fluctuation of hormones, other possible factors may include changes in medication, thyroid disorders, adrenal gland disorders, stress, changes in body weight or the presence of other medical conditions. A hormonal imbalance can lead to a wide variety of symptoms including irregular or abnormal uterine bleeding, decreased libido, change in mood, anxiety, fluctuations in weight, sleep disturbances, headaches, hot flashes/night sweats, fatigue and mental fogginess. Treatment options for hormonal imbalance will depend upon the identified cause, but may include lifestyle changes, herbal remedies, anti-depressant therapy, adrenal supplementation and/or hormone replacement therapy.
There is a wide variety of hormonal preparations (pills, creams, suppositories, injections, patches and hormone pellets) available today, which allows us the ability to tailor hormone treatment to the individual patient. We also utilize both blood and saliva hormone testing to properly monitor hormone replacement therapy. We support the recommendation from The American College of Obstetricians and Gynecologists (ACOG) to continue hormone therapy at the smallest effective dose for the shortest period of time necessary to reduce symptoms associated with menopause. We encourage our patients to be fully educated on the benefits and risks associated with hormone replacement therapy.
Abnormal Uterine Bleeding
The menstrual period is the time during a woman’s cycle when bleeding occurs. Typically, bleeding lasts from 3-7 days and occurs every 25-31 days. Abnormal uterine bleeding refers to menstrual bleeding that occurs on an irregular basis, lasts longer than 7 days or is heavier than normal. There are many different causes of abnormal uterine bleeding, such as hormonal imbalance, anatomic abnormalities such as uterine fibroids or polyps, and uterine hyperplasia. Evaluation for abnormal uterine bleeding may include blood work, pelvic ultrasound and/or an endometrial biopsy. Depending on the cause, treatment options may include hormonal medications, IUD insertion, dilation & curettage (D&C) , endometrial ablation or more definitive treatment, such as a hysterectomy.
Painful Periods (Dysmenorrhea)
More than half of menstruating women have some pain for at least 1-2 days each month. Usually, the pain is mild. Sometimes the pain is severe enough to keep you from participating in normal activities. When the pain is this severe it is called dysmenorrhea. Painful periods are the leading cause of women missing work and school.
Dysmenorrhea is often a natural result of uterine contractions during menstruation. In such cases, hormonal medications or anti-inflammatory medications may be helpful in reducing the symptoms of pain. However, a proper evaluation is needed to rule out secondary causes of dysmenorrhea, which may include uterine fibroids, adenomyosis or endometriosis.
Uterine fibroids are benign, non cancerous growths located inside or outside the uterine wall. They are the most common type of growth found in a woman’s pelvis. They occur in about 20-25% of all women. Often times, uterine fibroids do not cause any symptoms, but significant pain, pain during intercourse, pelvic pressure, infertility and irregular bleeding can result. Female hormones tend to play a role in stimulating the growth of uterine fibroids; therefore fibroids often shrink during menopause as the female hormones decline in production.
Symptoms and treatment options depend upon the size, number and location of uterine fibroids. A pelvic exam and pelvic ultrasound are useful in evaluating uterine fibroids. Medication therapy may be recommended to reduce symptoms and possibly shrink the size of fibroids. Endometrial ablation can be successful in removing only small fibroids. In some cases, a myomectomy or hysterectomy is indicated to remove the uterine fibroids surgically.
Adenomyosis occurs when endometrial cells implant within the muscular walls of the uterus, rather than remain in the uterine lining. Symptoms of adenomyosis may include heavy or prolonged menstrual bleeding, painful periods, pain during intercourse and bleeding between periods. A pelvic exam may reveal an enlarged and tender uterus.
Anti-inflammatory and hormonal medications may be helpful in reducing the symptoms associated with adenomyosis, but a hysterectomy is the most definitive treatment.
Endometriosis occurs when endometrial cells from the uterine lining seep through the fallopian tubes and implant on other structures or organs within the pelvic area. The most common symptom associated with endometriosis is pain in the pelvic region and/ or lower back mainly during the menstrual period. Other symptoms may include pain during intercourse, gastrointestinal upset or pain, abnormal uterine bleeding, infertility and fatigue.
A laparoscopy is the only definitive method of diagnosing endometriosis. This allows your doctor to visualize the endometrial implants inside the pelvic cavity with a small camera. If endometriosis is suspected or diagnosed with a laparoscopy, possible medication treatments to minimize symptoms may include birth control pills, GnRH agonists (ie. Lupron® and Synarel®) to block the menstrual cycle, progestin-only compounds and anti-inflammatory medications. Surgery to remove endometrial implants is often the best choice in cases of severe endometriosis that is resistant to medication management.
Most ovarian masses or cysts are benign. The most common ovarian mass in a woman of reproductive age is a functional ovarian cyst, which usually resolves in 1-3 months. Functional cysts occur if the follicle within the ovary fails to release an egg, and the fluid within the follicle creates a cyst. Common symptoms may include abdominal discomfort, pain during intercourse, and pelvic pain or pressure.
If an ovarian cyst is suspected, our providers may recommend a pelvic ultrasound and blood work to check a CA-125 level. Ovarian cysts that appear to be benign are often assessed by an ultrasound in 1-3 months to check for resolution. Surgery is indicated if a patient has persistent symptoms related to the ovarian cyst, if the cyst is very large and fails to resolve, or if there is a suspicion for ovarian cancer.
Polycystic Ovarian Syndrome
Polycystic ovary syndrome (PCOS) is a common condition of hormonal imbalance that can lead to irregular, often infrequent menstrual cycles, difficulty getting pregnant, weight gain and signs of elevated testosterone levels, including acne and unwanted hair growth on the face and body. Also, a pelvic ultrasound often shows “polycystic- appearing” ovaries. Symptoms are variable among patients and may or may not include all of the listed characteristics.
Blood work is often necessary to rule out the presence of other conditions and confirm the diagnosis of PCOS. Possible treatments may include lifestyle changes, oral contraceptives, cyclic progesterone, and anti-androgen medications (ie. Spironolactone®). Infertility treatments for patients with PCOS may include insulin- sensitizing medications (such as Metformin®) and medications that stimulate ovulation (such as Clomid® and Femara®). Please refer to the educational handout on PCOS for more information.
Vaginitis is an inflammation of a woman's vagina most often due to an overgrowth of yeast or bacteria within the vagina. Common factors that can lead to vaginal infections include the use of certain medications, hormonal changes, frequent douching, and sexually transmitted infections. Vaginitis can lead to an increase in vaginal discharge, itching, irritation, odor and/or pain during intercourse.
Proper diagnosis is important and may include a pelvic exam, examination of vaginal discharge under the microscope, and a vaginal culture. Treatment for vaginitis is dependent upon the cause of infection, but may include oral medications or vaginal suppositories. There are many prevention measures that can help reduce the risk of developing vaginitis. Please refer to the educational handout on vaginal infections for more information.
Birth Control Options
Birth control (or contraception) is used to prevent pregnancy, and this is often a very personal choice for a woman. It is important to consider the efficacy, side effects, risks, and benefits associated with each form of birth control available. There is a wide variety of birth control options available for women today, including combined oral contraceptive pills and progesterone-only pills, vaginal rings, diaphragms, Depo-Provera®, IUD insertion, Essure® and tubal ligation. Many women also use the “rhythm method” or “natural family planning” to avoid pregnancy by practicing periodic abstinence during the most fertile times in the menstrual cycle.
Sterilization is a permanent method of birth control to prevent pregnancy. The procedure for women is called tubal ligation (this can be done via laparoscopy) and for a man is called vasectomy. Essure® is a non-surgical option for preventing further pregnancies.
Infertility is defined as not being able to conceive after 6-12 months of having sex without birth control. An infertility evaluation is helpful in determining the cause of infertility if you have been trying to achieve pregnancy without any success. If you experience irregular cycles off of birth control, we recommend an evaluation before you start trying to conceive.
An infertility evaluation may include a physical exam and health history, blood work (performed on day 3 and day 21 of your cycle), at-home ovulation kits, pelvic ultrasound, hysterosalpingogram (HSG), and a semen analysis. A treatment plan is then developed based on your test results. Recommended treatments may include lifestyle changes, medication, or surgery. We can make referrals for assisted reproductive procedures if needed.
PMS is a collection of physical and emotional symptoms most often experienced just prior to and during the menstrual cycle. Symptoms usually occur 1-2 weeks prior to the onset of your period and usually go away after your period starts. PMS symptoms may include fatigue, trouble sleeping, bloating, changes in bowel movements, tender breasts, headache, appetite changes, trouble concentrating, irritability, anxiety, and depression. It is helpful to keep track of your symptoms over the period of a few months on a calendar and bring the completed calendar with you to your appointment.
PMS treatment options may include lifestyle changes, nutritional supplements, anti- inflammatory medications, hormonal medications, and anti-depressants.
Osteoporosis is the most common type of bone disease. It is estimated that about 1 out of 5 American women over the age of 50 have osteoporosis and half of all women over the age of 50 will have a fracture of the hip, wrist or spine. There are no symptoms in the early stages of the disease.
Bone density studies aid in the diagnosis of osteopenia and osteoporosis, which are disorders characterized by low bone mass and an increased risk for fractures. Osteopenia means your bone mass is below normal, but not yet at the level of osteoporosis. If left untreated, osteopenia will likely develop into osteoporosis. Bone density scans report findings using a T-score value.
- T-score of +1 to -1 indicates normal bone mass
- T-score of -1 to -2.4 indicates osteopenia
- T-score of -2.5 or less indicates osteoporosis
Depending upon your bone density study result, possible recommendations may include addition of calcium and vitamin D supplements, weight-bearing exercises, smoking cessation if applicable, and addition of a medication.
Most women experience breast changes at some point in time. They may notice a breast lump, bump, skin change or nipple discharge. These may be related to your age, medications, infection or due to hormone changes. Common causes of beast changes include fibrocystic breast disease, cysts, blocked or clogged milk ducts, lactating in non-pregnant women, fibroadenoma, or injury. It is important to see your healthcare provider if you notice any changes. Yearly screening mammograms are advised for all women over 40 years of age. Screening mammograms are performed in our office by a trained mammogram technician. Diagnostic studies may be ordered by your provider if indicated.
Pain During Intercourse
When a woman feels pain while having sexual intercourse, it is call dyspareunia. Nearly 2 out of 3 women have it at some time during their lives. It may be caused by physical problems or due to psychological concerns. Possible physical causes include vaginal dryness or atrophy, vaginal infections, uterine fibroids, ovarian cysts, adenomyosis and endometriosis. Treatment is focused on the underlying cause, and can help to reduce or eliminate the problem.
Genital Warts (HPV)
There are numerous strains of Human Papillomavirus (HPV). Some high-risk strains of HPV can lead to pre-cancerous changes or dysplasia of the cervix. Other strains of HPV cause warts on the skin. Genital warts are caused by HPV infection that is spread during sexual contact. The virus can be transmitted even if warts are not visible on the skin. It can take weeks to months to even years after infection for genital warts to become noticeable.
Genital warts usually appear as flesh-colored growths that are raised or flat and may resemble the appearance of cauliflower. They can be found inside or outside the vagina or anus. Genital warts are often asymptomatic, but may cause vaginal irritation or itching. Possible treatments may include TCA treatment in the office, patient-applied medications, cryotherapy, or surgical excision.
Abnormal Pap Smears
The pap test checks for changes in the cervix that may become cancer. Abnormal cells may also be referred to as dysplasia or cervical intraepithelial neoplasia (CIN). In women who have regular pap tests, abnormal changes are almost always caught early and are rarely indicative of cancer being present. The main cause of abnormal pap tests is the human papillomavirus (HPV).
HPV is an extremely common infection that is passed via sexual contact. Most often the body will clear an HPV infection on its own, but sometimes the HPV will persist. The longer HPV is present and the older the woman, the greater the chance of developing cervical dysplasia.
Dysplasia and CIN are graded as mild, moderate, or severe. Mild dysplasia often goes away on its own, but moderate to severe dysplasia indicates more serious changes that will likely require treatment. Depending on the results of your pap test, you may be encouraged to repeat the pap test at a later date or be advised that further testing is required. Further testing may include a colposcopy and biopsy. Recommended treatment of cervical dysplasia or CIN may include cryotherapy, Loop Electrosurgical Excision Procedure (LEEP), TCA treatment, or close monitoring.
Sexually transmitted infections do not always cause symptoms. If you have a new partner or have engaged in unprotected sex, then you are possibly at risk for acquiring a sexually transmitted infection. Sexually transmitted infections are common, and it is important to know if you have been exposed to a sexually transmitted infection so you can receive the proper treatment. Testing usually includes vaginal cultures and blood work.
Pelvic Organ Prolapse
Almost half of all women who have had a baby develop some degree of pelvic organ prolapse, although these problems can also occur in women who have never had children. Pelvic organ prolapse occurs when the muscles and tissue that makes up the “pelvic floor” can no longer hold the pelvic organs in place. Factors such as aging, childbearing, intense physical activity, chronic constipation and obesity can lead to weakening of the pelvic floor and prolapse of pelvic organs into the vagina.
Types of pelvic organ prolapse include uterine prolapse, vaginal vault prolapse (top of vagina descends after hysterectomy), bladder prolapse (cystocele), intestinal prolapse (enterocele), and rectal prolapse (rectocele).
Symptoms of pelvic organ prolapse can include a bulging sensation in the vagina, feeling of pelvic fullness or heaviness, appearance of organs bulging out of the vagina, lower back pain, urinary incontinence, problems with bowel movements, sexual difficulties, and problems inserting tampons. Often times, these symptoms worsen towards the end of the day or with standing, lifting, straining or coughing.
Treatment for pelvic organ prolapse varies depending upon the type and severity of prolapse, but recommendations may include vaginal estrogen, kegel exercises, pessary insertion, hysterectomy, and/or prolapse repair surgery.