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Signs and symptoms that may require medical attention:

There are many different gynecological problems that could occur during adolescence. Mothers should be sure to talk with their daughters about all of the normal changes that will be occurring in the body during this time of physical maturation and development, so that any abnormal changes can be examined right away. Be sure to discuss the following:

*Vaginal bleeding and discharge are a normal part of your menstrual cycle. However, if you notice anything different or unusual, consult your physician before attempting to treat the problem yourself.

*Symptoms may result from mild infections that are easy to treat. But, if they are not treated properly, they can lead to more serious conditions, including infertility. Vaginal symptoms may also be a sign of more serious problems, from sexually transmitted diseases (STDs).

*Consult your physician if you have any of the following symptoms:

*Bleeding between periods.

*Frequent and urgent need to urinate, or a burning sensation during urination.

*Abnormal vaginal bleeding, particularly during or after intercourse.


*Pain or pressure in your pelvis that differs from menstrual cramps.

*Itching, burning, swelling, redness, or soreness in the vaginal area.

*Sores or lumps in the genital area.

*Vaginal discharge with an unpleasant or unusual odor, or of an unusual color.

*Increased vaginal discharge.

*Pain or discomfort during intercourse.

Recognizing symptoms early and seeing a physician right away increases the likelihood of successful treatment.







Vaginitis refers to any inflammation or infection of the vagina. This is a common gynecological problem found in females of all ages, with most females having at least one form of vaginitis at some time during their lives. When the walls of the vagina become inflamed, because some irritant has disturbed the balance of the vaginal area, vaginitis can occur.




Bacteria, yeast, viruses, or chemicals in creams or sprays, can cause vaginitis. Sometimes, vaginitis occurs from organisms that are passed between sexual partners. In addition, the vaginal environment is influenced by a number of different factors including a female’s health, her personal hygiene, medications, hormones (particularly estrogen), and the health of her sexual partner. A disturbance in any of these factors can trigger vaginitis.




The following are the most common types of vaginitis:

*Candida or “yeast” infection.

*Bacterial vaginosis.

*Trichomoniasis vaginitis.


*Gonococcal vaginitis.

*Viral vaginitis.

*Non-infectious vaginitis.

Each of these types of infection has a different cause and can present different symptoms, making diagnosis often complicated. In addition, more than one type of vaginitis may be present at the same time, with or without symptoms being present.




Yeast infections, as they are commonly called, are caused by one of the many species of fungus known as candida, which normally live in the vagina in small numbers. Candida can also be present in the mouth and digestive tract in both males and females.

Since yeast is normally present and well-balanced in the vagina, infection occurs when something in a female’s system upsets this normal balance. For example, an antibiotic to treat another infection may upset this balance. In this case, the antibiotic kills the bacteria that normally protects and balances the yeast in the vagina. In turn, the yeast overgrows, causing an infection. Other factors that can cause this imbalance to occur include pregnancy, which changes hormone levels, and diabetes, which allows too much sugar in the urine and vagina.


What are the symptoms of a vaginal candida infection?

The following are the most common symptoms of a candida infection. However, each adolescent may experience symptoms differently. Symptoms may include:

*A thick, white, cottage cheese-like vaginal discharge that is watery and usually odorless.

*Itchiness and redness of the vulva and vagina.

The symptoms of a vaginal candida infection may resemble other conditions or medical problems. Always consult your physician for a diagnosis.



While any female can develop a yeast infection, the following females may be at an increased risk for the condition:

*Females who have had a recent course of antibiotics.

*Females who are pregnant.

*Females who have diabetes that is not well-controlled.

*Females who are using an immunosuppressant medication.

*Females who are using high-estrogen contraceptives.

*Females who have a thyroid or endocrine disorder.

*Females who are undergoing corticosteroid therapy, which slows the immune system.




In addition to a complete medical history and physical and pelvic examination, diagnostic procedures for vaginal candida infections often include a microscopic examination of the vaginal discharge.




Specific treatment for candida will be determined by your physician based on:


*Your age, overall health, and medical history.

*Severity of the symptoms.

*Your tolerance for specific medications, procedures, or therapies.

*Expectations for the course of the condition.

*Your opinion or preference.



*Anti-fungal, vaginal creams and suppositories.

*Vaginal tablets.




While yeast infections are the most commonly discussed vaginal infection, bacterial vaginosis (BV) is actually the most common type of vaginitis in females of reproductive age. This infection is caused by a bacteria, not yeast. With a bacterial vaginosis infection, certain species of normal vaginal bacteria grow out of control and trigger inflammation. The cause of bacterial vaginosis is not known.

The following vaginal discharge changes can signal a vaginal, cervical, or sexually transmitted infection:

*changes in color, quantity, or texture of the fluid

*an unpleasant odor

*bleeding, spotting, or bloody discoloration

*itching and burning of the vagina or vulva




The following are the most common symptoms of bacterial vaginosis. However, each adolescent may experience symptoms differently. Symptoms may include:

*A milky, thin discharge at times, or a heavy, gray discharge.

*“Fishy” odor of discharge.

The symptoms of bacterial vaginosis may resemble other conditions. Always consult your physician for a diagnosis.




Specific treatment for bacterial vaginosis will be determined by your physician based on:

*Your age, overall health, and medical history.

*Severity of the symptoms.

*Your tolerance for specific medications, procedures, or therapies.

*Expectations for the course of the condition.

*Your opinion or preference.

Bacterial vaginosis is generally treated with oral antibiotics.


                            WHAT IS TRICHOMONIASIS?     


Trichomoniasis, trichomonas, or “trich” as it is commonly called, is a sexually transmitted infection. It is caused by a one-celled parasite called Trichomonas vaginalis which passes between partners during sexual intercourse. Since most males do not present symptoms with trichomoniasis, the infection is often not diagnosed until the female develops symptoms of vaginitis.




The following are the most common symptoms of trichomoniasis. However, each adolescent may experience symptoms differ- ently. Symptoms may include:

*A frothy, often musty-smelling, greenish-yellow discharge.

*Itching in and around the vagina and vulva.

*Burning during urination.

*Discomfort in the lower abdomen.

*Pain during intercourse.

Some females with trichomoniasis are asymptomatic. The symptoms of trichomoniasis may resemble other conditions or medical problems. Always consult your physician for a diagnosis.




Specific treatment for trichomoniasis will be determined by your physician based on:

*Your age, overall health, and medical history.

*Severity of the symptoms.

*Your tolerance for specific medications, procedures, or therapies.

*Expectations for the course of the condition.

*Your opinion or preference.

Both partners must be treated for trichomoniasis to avoid reinfection. Treatment generally involves taking oral antibiotics. If a female has more than one sexual partner, each partner (and any of their other partners) should also be treated.




Chlamydia is the most commonly occurring sexually transmitted disease in the United States, although it often goes undiagnosed. If left untreated, chlamydia often leads to pelvic inflammatory disease (PID), which increases a female’s risk of infertility, pelvic adhesions, chronic pelvic pain, and ectopic pregnancy.

Chlamydia, caused by the bacterium chlamydia trachomatis, exists in a number of different strains. This form of vaginitis is most commonly diagnosed in young women between the ages of 18 and 35 who have multiple sexual partners.




Unfortunately, many females have no symptoms, thus prolonging diagnosis and treatment and possibly spreading the disease. The following are the most common symptoms of chlamydia. However, each adolescent may experience symptoms differently. Symptoms of chlamydia may include:

*Increased vaginal discharge.

*Light bleeding, especially after intercourse.

*Pain in the lower abdomen or pelvis.

*Burning during urination.

*Pus in the urine.

*Redness and swelling of the urethra and labia.

The symptoms of chlamydia may resemble other conditions or medical problems. Always consult your physician for a diagnosis.




Specific treatment for chlamydia will be determined by your physician based on:

*Your age, overall health, and medical history.

*Severity of the symptoms.

*Your tolerance for specific medications, procedures, or therapies.

*Expectations for the course of the condition.

*Your opinion or preference.

Generally, treatment for chlamydia involves taking antibiotics.


                            WHAT IS GONOCOCCAL VAGINITIS?    


Vaginitis can also be caused by the bacterium Neisseria gonorrhoeae (N. gonorrhoeae) - the same bacterium that causes the sexually transmitted disease known as gonorrhea.




In pre-pubertal children, the most common infection occurs in the genital tract, with vaginitis as the most common symptom. In adolescents who are sexually active, gonococcal infections may occur along with other types of vaginal infections, and are similar to gonococcal infections in adults. The following are the most common symptoms of a gonococcal infection. However, each ado- lescent may experience symptoms differently. Symptoms may include:

*Yellowish or bloody vaginal discharge (females) or yellowish white discharge from the penis (males).

*Painful or burning urination (males and females).

*Swollen or painful testicles (males).

*Vaginal bleeding during intercourse (females).

*Lower abdominal (pelvic) pain during intercourse (females).

The symptoms of a gonococcal infection may resemble other conditions or medical problems. Always consult your physician for a diagnosis.




Specific treatment for a gonococcal infection will be determined by your physician based on:

*Your age, overall health, and medical history.

*Severity of the symptoms.

*Your tolerance for specific medications, procedures, or therapies.

*Expectations for the course of the condition.

*Your opinion or preference.

If left untreated, gonococcal infections can lead to serious conditions such as pelvic inflammatory disease (PID), which increases a female’s risk of infertility, pelvic adhesions, chronic pelvic pain, and ectopic (tubal) pregnancy. Because of these risks, early treat- ment of the infection with antibiotics is essential. Treatment of sexual partners is also necessary to prevent reinfection and further spread of the disease.




Viruses are a common cause of vaginitis, with most being spread through sexual contact. One type of virus that causes viral vagi- nitis is the herpes simplex virus (HSV, or simply herpes) whose primary symptom is pain in the genital area associated with lesions and sores. These sores are generally visible on the vulva, or vagina, but occasionally are inside the vagina and can only be found during a pelvic examination. Often stress or emotional situations can be a factor in triggering an outbreak of herpes.


Another source of viral vaginitis is the human papillomavirus (HPV), a virus that is also transmitted through sexual contact. This virus causes painful warts to grow on the vagina, rectum, vulva, or groin. However, visible warts are not always present, in which case, the virus is generally detected by a Pap test.


                            WHAT IS NON-INFECTIOUS VAGINITIS?    


Non-infectious vaginitis usually refers to vaginal irritation without an infection being present. Most often, this is caused by an aller- gic reaction to, or irritation from, vaginal sprays, douches, or spermicidal products. Noninfectious vaginitis may be also be caused


by sensitivity to perfumed soaps, detergents or fabric softeners.




The following are the most common symptoms of non-infectious vaginitis. However, each adolescent may experience symptoms differently. Symptoms may include:

*Vaginal itching.

*Vaginal burning.

*Vaginal discharge.

*Pelvic pain (particularly during intercourse).

The symptoms of non-infectious vaginitis may resemble other conditions or medical problems. Always consult your physician for a diagnosis.




Specific treatment for non-infectious vaginitis will be determined by your physician based on:

*Your age, overall health, and medical history.

*Severity of the symptoms.

*Your tolerance for specific medications, procedures, or therapies.

*Expectations for the course of the condition.

*Your opinion or preference.

Treatment for non-infectious vaginitis generally includes estrogen creams or oral tablets, which can restore lubrication and decrease soreness and irritation.







Vulvitis is simply an inflammation of the vulva, the soft folds of skin outside the vagina. This is not a condition but rather a symp- tom that results from a host of diseases, infections, injuries, allergies, and other irritants. Diagnosing and treating this condition can be frustrating because it is often difficult to determine the specific cause of the irritation.




Vulvitis may be caused by one, or more, of the following:

*Scented or colored toilet paper.

*Perfumed soaps or bubble baths.

*Shampoos and hair conditioners.

*Laundry detergents (especially enzyme-activated “cold water” formulas).

*Vaginal sprays, deodorants, douches and powders.


*Douches that are too strong or used too frequently.

*Hot tub and swimming pool water.

*Synthetic undergarments without a cotton crotch.

*Rubbing against a bicycle seat.

*Wearing a wet bathing suit for a long period of time.

*Horseback riding.



Any female with certain allergies, sensitivities, infections, or diseases can develop vulvitis. Girls who have not yet reached puberty and postmenopausal women sometimes develop vulvitis, possibly because of inadequate levels of estrogen.




The following are the most common symptoms for vulvitis. However, each adolescent may experience symptoms differently. Symptoms of vulvitis may include:

*Redness and swelling on the labia and other parts of the vulva.

*Excruciating itching.

*Clear, fluid-filled blisters (present when the vulva is particularly irritated).

*Sore, scaly, thickened, or whitish patches (more prevalent in chronic vulvitis) on the vulva.

The symptoms of vulvitis may resemble other conditions or medical problems. Always consult your physician for a diagnosis.




In addition to a complete medical history and physical and pelvic examination, diagnostic procedures for vulvitis may include the following:

*Blood tests.


*Tests for sexually transmitted diseases (STDs).

*Pap test.




Specific treatment for vulvitis will be determined by your physician based on:

*Your age, overall health, and medical history.

*Severity of the symptoms.

*Cause of the condition.

*Your tolerance for specific medications, procedures or therapies.

*Expectations for the course of the condition.

*Your opinion or preference.


Treatment may include:

*Self-help measures (i.e., avoiding external irritants known to provoke vulvitis).

*Sitz baths with soothing compounds (to help control the itching).

*Hydrocortisone creams.


                            PREMENSTRUAL SYNDROME   





Premenstrual syndrome is the name given to a group of physical and emotional symptoms that some women experience on a regular basis in relation to menstruation. The symptoms occur monthly, generally within 7 to 14 days prior to menstruation.

Symptoms may seem to worsen as menstruation approaches and subside at the onset or after several days of menstruation. A symptom-free phase usually occurs following menses..


The severity of PMS symptoms ranges from mild to incapacitating. Symptoms can occur for only one or two days or may begin at ovulation and continue until the onset of menstruation. Symptoms may include

*nervous tension mood swings


*feeling out of control

*water retention

*breast tenderness


*food cravings

Dysmenorrhea (menstrual cramps) is not considered a symptom of PMS. However, a woman can experience both PMS and dys- menorrhea and may decide to seek treatment for both difficuities.




Some estimates say that about 10 percent of menstruating women experience severe premenstrual symptoms. While PMS can occur at any time in a menstruating woman’s life, it generally appears in her late twenties and thirties.




You know whether symptoms interfere with your usual functioning. At present, there is no medical or laboratory test that defi- nitely shows the presence of PMS. It is essential to keep a daily calendar to record the symptoms you experience. If you find that symptoms recur about 7 to 14 days before your period and you have a symptom-free phase after menstrua tion, then you may be experiencing PMS. Seek medical help for further evaluation and treatment if these symptoms are severe or debilitating.




Serotonergic antidepressants are the first-line treatment for PMS at this time. Other medications can be tried. Dietary supple- ments also help some women with PMS. Learning to recognize the symptoms is an important step. Psychological counseling to increase coping skills in conjunction with medical treatment often helps.







Painful menstruation (Painful periods) is when menstrual periods are accompanied by either sharp, intermittent pain or dull, aching pain, usually in the pelvis or lower abdomen.



Painful menstruation affects many women. For a small number of women, such discomfort makes it next to impossible to perform normal household, job, or school-related activities for a few days during each menstrual cycle. Painful menstruation is the leading cause of lost time from school and work among women in their teens and 20’s.

The pain may begin several days before or just at the start of your period. It generally subsides as menstrual bleeding tapers off. Although some pain during menstruation is normal, excessive pain is not. Dysmenorrhea refers to menstrual pain severe enough to limit normal activities or require medication.


There are two general types of dysmenorrhea:

*Primary dysmenorrhea refers to menstrual pain that occurs in otherwise healthy women. This type of pain is not related to any


specific problems with the uterus or other pelvic organs.

*Secondary dysmenorrhea is menstrual pain that is attributed to some underlying disease process or structural abnormality either within or outside the uterus.

Activity of the hormone prostaglandin, produced in the uterus, is thought to be a factor in primary dysmenorrhea. This hormone causes contraction of the uterus and levels tend to be much higher in women with severe menstrual pain than in women who experience mild or no menstrual pain.

*Premenstrual syndrome (PMS)

*Stress and anxiety


*Pelvic inflammatory disease

*Multiple sexual partners

*History of sexual or physical abuse


*Ovarian cysts





*Intrauterine Device (IUD), but usually only for the first three months after insertion




The following steps may allow you to avoid prescription medications:

*Apply a heating pad to your lower abdomen (below your navel). Be careful NOT to fall asleep with it on.

*Take warm showers or baths.

*Drink warm beverages.

*Do light circular massage with your fingertips around your lower abdomen.

*Walk or exercise regularly, including pelvic rocking exercises.

*Follow a diet rich in complex carbohydrates, like whole grains, fruits, and vegetables, but low in salt, sugar, alcohol, and caffeine.

*Eat light but frequent meals.

*Try over-the-counter anti-inflammatory medicine, such as ibuprofen.

*Practice relaxation techniques like meditation or yoga.

*Try vitamin B6, calcium, and magnesium supplements, especially if your pain is from PMS.

*Keep your legs elevated while lying down. Or lie on your side with knees bent.


If these self-care measures do not work, your doctor may prescribe medications like:

*Cox-2 inhibitors such as celecoxib (Celebrex) and valdecoxib (Bextra)

*Stronger anti-inflammatories like diclofenac (Cataflam)


*Birth control pills


*Stronger pain relievers (even narcotics like codeine, for brief periods) Call your doctor right away if:


*You have a fever.

*Vaginal discharge is increased in amount or foul-smelling.

*Your pain is significant, your period is over one week late, and you have been sexually active.


Also call your doctor if:

*Your pain is severe or sudden.

*Self-care measures don’t relieve your pain after 3 months.

*You pass blood clots or have other symptoms with the pain.

*Your pain occurs at times other than menstruation, begins more than 5 days prior to your period, or continues after your period is over.

*You have an IUD that was placed more than 3 months ago.


What to expect at your health care provider’s office Return to top

Your health care provider will obtain your medical history and perform a physical examination, paying close attention to your pelvis and abdomen.


Your doctor will ask questions about your symptoms, such as the following:

*How old were you when your periods started?

*Have they always been painful? If not, when did the pain begin?

*When in your menstrual cycle do you experience the pain?

*Is the pain sharp, dull, intermittent, constant, aching, or cramping?

*Are you sexually active?

*Do you use birth control? What type?

*When was your last menstrual period?

*Was the flow of your last menstrual period a normal amount for you?

*Do your periods tend to be heavy or prolonged (lasting longer than 5 days)?

*Have you passed blood clots?

*Are your periods generally regular and predictable?


*Do you use tampons with menstruation?

*What have you done to try to relieve the discomfort? How effective was it?

*Does anything make the pain worse?

*Do you have any other symptoms?


Diagnostic tests that may be performed include:

*Blood tests including CBC


*Dilation of the cervix


*Cultures (may be taken to rule out sexually transmitted diseases such as gonorrhea, primary syphilis, or chlamydia infections)


Birth control pills may be prescribed to alleviate menstrual pain. If not needed for birth control, they may be discontinued after 6 to 12 months. Many women note continued freedom from symptoms despite stopping the medication.

Surgery may be necessary for women who are unable to obtain adequate pain relief or pain control. Procedures may range from removal of cysts, polyps, adhesions, or fibroids to complete hysterectomy in cases of extreme endometriosis.

Prescription medications may be used for endometriosis. For pain caused by an IUD, removal of the IUD and alternative birth con- trol methods may be needed.

Antibiotics are necessary for pelvic inflammatory disease.


                            ORAL CONTRACEPTIVES             





Oral contraceptives (OCs) are available only by prescription and come in two forms: the combined pill (which contains both estrogen and progestin) or the progestin-only pill. Although both are equally effective with typical use, the combined pill is more effective with perfect use and most women choose this form. Some women, however, experience severe headaches or high blood pressure from the estrogen in the combined pill and must take the progestin-only pill. Not all combined pills or progestin-only pills are alike and brands differ in the amount of estrogen or progestin they contain. For all OC users, a check-up at least once a year is essential. It is also important for their blood pressure to be checked three months after beginning the pill. Former pill users who want to bear children usually regain fertility in three to six months.




Combination pills are sold in 21-day or 28-day packs. Each pill in the 21-day pack contains the necessary estrogen and proges- tin. Typically, the user takes the first pill either on the Sunday after her period starts or during the first 24 hours of her period. The remaining pills are taken once a day — ideally at the same time of day — until the pack is used up. The user then waits seven days before starting a new pack. The 28-day combination pill adds seven differently colored “reminder” pills; they are inactive and do not contain hormones but help the user maintain her daily routine during seven days between active pill use. Women continue to menstruate, but their periods are lighter, shorter, more regular, and less painful. If a woman taking the combination regimen misses a pill two days in a row, she should take two pills as soon as she remembers and then two more the following day. She should also use back-up barrier contraception until she starts her next pill cycle. If she misses more than two, she should discard the pack, use a back-up birth control method and begin a new cycle on the following Sunday, even if she has started bleeding. (A recent study found that women who miss three pills will probably still not ovulate, but nevertheless, they should take precautions to prevent pregnancy).




Progestin-only pills, which only contain progestins, are always sold in 28-day packs and all the pills are active. Progestin-only pills must be taken at precisely the same time each day to maintain top effectiveness. If a woman deviates from her pill schedule for even three hours, she must use back-up contraception for the next two days. Progestin-only pill users will experience lighter peri- ods than those taking combination pills; some may not have periods at all.




Oral contraceptives are the most popular reversible contraceptives in the United States and are highly effective if used properly. OCs do not interfere with intercourse, and in fact, many women report that sex is more pleasurable because they no longer have to worry about pregnancy. Oral contraceptives are often used to regulate periods in women with menstrual disorders, including dysmenorrhea (severe pain), amenorrhea (absence of periods), and menorrhagia (heavy bleeding). Oral contraceptives are also used for treating endometriosis, and they may reduce the risk of ovarian, endometrial and possibly colorectal cancers. OCs also provide some protection against ectopic pregnancy, ovarian cysts, pelvic inflammatory disease, benign breast lumps, and rheuma- toid arthritis.




Although OCs pose some risks, serious health problems are unusual. Estrogen and progesterone have different side effects and women on the combined pill may experience different effects from those on the progestin-only pill. Symptoms of serious problems include severe abdominal pain, chest pain, unusual headaches, visual disturbances, or severe pain or swelling in the legs.




During the first two or three months of use, side effects from estrogen in the combined pill includes nausea, vomiting, headaches, dizziness, breast tenderness and enlargement, and weight gain. Nausea and vomiting can often be controlled by taking the pill during a meal or at bedtime. Spotting and bleeding between periods (break-through bleeding) are side effects of progestin. This hormone may also produce fatigue, decreased sex drive, acne, and depression.


Serious Effects on Heart and Circulation


Uncommon but more dangerous complications of OCs include high blood pressure and blood clots, which can sometimes lead to heart attacks or strokes. Newer oral contraceptives containing desogestrel may even pose a slightly higher risk for blood clots than older ones containing nevonorgestrel. High blood pressure that occurs after a woman begins taking OCs can usually be cor- rected by discontinuing the medication. Some studies have found an association between oral contraceptives and risks for stroke and heart attack. These risks, however, appear to be small and occur mainly in women who smoke or have high blood pressure. Low-dose contraceptives do not appear to pose any higher risk for heart attacks. Other factors associated with oral contraceptive use and stroke include being African-American or having a history of migraines or clotting disorders. It is important to note that women should not be unduly alarmed by such reports. For example one study indicated that the higher risk for stroke meant that only 3 more women out of 100,000 would suffer a stroke because of OCs.




Studies have been conflicting about whether estrogen in oral contraception increases the risk for breast cancer. One recent study indicated that there is a small increased risk for breast cancer in women while taking combined oral contraceptives and for up to 10 years after stopping OCs. There is a twofold increased risk for cervical cancer independent of other risk factors for this malig- nancy.


Other Complications


In rare cases, the pill can cause liver tumors, gallstones, or jaundice. Women with a history of liver disease, such as hepatitis, should consider other contraceptive options. Oral contraceptive users may be at higher risk for gum disease, vaginitis, and urinary tract infections. The progestin-only pill significantly increases the risk for type 2 (previously called adult-onset) diabetes in women who develop diabetes during pregnancy (a form called gestational diabetes, which usually resolves after delivery). Although the low-dose combination pill does not appear to pose such a risk, women with gestational diabetes should avoid contraceptives containing progestins.


Well-Connected Board of Editors

Harvey Simon, M.D., Editor-in-Chief Massachusetts Institute of Technology; Physician, Massachusetts General Hospital Masha J. Etkin, M.D., Gynecology Harvard Medical School; Physician, Massachusetts General Hospital

John E. Godine, M.D., Ph.D., Metabolism Harvard Medical School; Associate Physician, Massachusetts General Hospital Daniel Heller, M.D., Pediatrics Harvard Medical School; Associate Pediatrician, Massachusetts General Hospital; Active Staff, Children’s Hospital

Irene Kuter, M.D., D. Phil., Oncology

Harvard Medical School; Assistant Physician, Massachusetts General Hospital Paul C. Shellito, M.D., Surgery

Harvard Medical School; Associate Visiting Surgeon, Massachusetts General Hospital Theodore A. Stern, M.D., Psychiatry

Harvard Medical School; Psychiatrist and Chief, Psychiatric Consultation Service, Massachusetts General Hospital Carol Peckham, Editorial Director

Cynthia Chevins, Publisher

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                            POLYCYSTIC OVARY SYNDROME





Polycystic ovary syndrome (PCOS) is a condition most often characterized by irregular menstrual periods, excess hair growth and obesity, but it can affect women in a variety of ways. Irregular or heavy periods may signal the condition in adolescence, or poly- cystic ovary syndrome may become apparent later when a woman has difficulty becoming pregnant.

The signs and symptoms of polycystic ovary syndrome stem from a disruption in the reproductive cycle, which normally culmi- nates each month with the release of an egg from an ovary (ovulation). The name polycystic ovary syndrome comes from the appearance of the ovaries in some women with the disorder — large and studded with numerous cysts (polycystic). These cysts are follicles, fluid-filled sacs that contain immature eggs.

Polycystic ovary syndrome is the most common hormonal disorder among women of reproductive age in the United States, affecting an estimated 5 percent to 10 percent. Early diagnosis and treatment of polycystic ovary syndrome can help reduce the risk of long-term complications, which include diabetes and heart disease.




Women with polycystic ovary syndrome may have any of several signs of varying severity. Criteria for diagnosing the disorder include having at least two of the following indications:

*Irregular or no menstruation. This is the most common finding in PCOS. Irregular menstruation means having menstrual cycles that occur at intervals longer than 35 days or fewer than eight times a year. The condition may begin in adolescence with the onset of menstruation.

*Excess androgen. Elevated levels of male hormones may result in physical signs such as long, coarse hair on your face, chest, lower abdomen, back, upper arms or upper legs (hirsutism), acne and male-pattern baldness (alopecia). However, not all women who have polycystic ovary syndrome have physical signs of androgen excess.

*Enlarged ovaries with multiple cysts. A doctor may detect ovarian cysts by ultrasound. However, a woman may have ovaries with multiple cysts but still not have polycystic ovary syndrome. And a woman with PCOS may have ovaries that appear normal. You must also have abnormal menstrual cycles or excess androgen levels to be diagnosed with PCOS.


Several other disorders can cause signs and symptoms similar to those of polycystic ovary syndrome:

*Hypothyroidism. In this condition, your body produces too little thyroid hormone, which can lead to an absence of menstruation (amenorrhea).

*Hyperprolactinemia. This condition causes your pituitary gland to produce too much prolactin, a hormone that stimulates the pro- duction of breast milk and suppresses ovulation.

*Certain tumors. Tumors of the ovary or adrenal gland can be responsible for excess androgen levels.


Doctors rule out the above conditions before diagnosing PCOS.

Many women with polycystic ovary syndrome are obese. The distribution of fat seems to affect the severity of symptoms. One study found that women who have central obesity — fat in the midsection or trunk of the body — have higher androgen, sugar and lipid levels than do women who have accumulated fat in their limbs.


Other possible conditions associated with polycystic ovary syndrome are:


*Acanthosis nigricans — darkened, velvety skin on the nape of your neck, armpits, inner thighs, vulva or under your breasts

*Chronic pelvic pain



The intricate process of a woman’s reproductive cycle is regulated by fluctuating levels of hormones produced by the pituitary gland in your brain, including luteinizing hormone (LH) and follicle-stimulating hormone (FSH), and by your ovaries.


The ovaries secrete the female hormones estrogen and progesterone and also produce some androgens, the so-called male hor- mones. Androgens include testosterone, androstenedione and dehydroepiandrosterone (DHEA).




In polycystic ovary syndrome, your body produces an excess of androgens, and your ratio of LH to FSH is often abnormally high. The process of ovaries releasing eggs (ovulation) occurs less frequently than normal (oligo-ovulation), or the ovaries don’t release eggs at all (anovulation). In the absence of ovulation, the menstrual cycle is irregular or absent.

Doctors don’t know the cause of polycystic ovary syndrome, but research suggests a link to excess insulin, the hormone pro- duced in the pancreas that allows cells to use sugars (glucose), your body’s primary energy supply. By several mechanisms, excess insulin is thought to boost androgen production by your ovaries. Studies also indicate that genetic factors may play a role in PCOS.

Although polycystic ovary syndrome has been noted since antiquity, it was first described in medical literature in the 1930s when Irving Stein and Michael Leventhal wrote about a group of women without menstrual periods (amenorrhea) who had large ovaries with multiple cysts. Doctors sometimes call the condition Stein-Leventhal syndrome, polycystic ovaries or polycystic ovary dis- ease.




Early diagnosis of polycystic ovary syndrome can help reduce the risk of long-term complications such as diabetes and heart disease. Talk with your doctor if you have irregular, scant or no menstrual periods, are overweight, and have acne or excess facial hair growth. Your doctor may refer you to an endocrinologist, a doctor who specializes in hormonal disorders.




Your doctor may evaluate you for reproductive, hormonal and cardiovascular disorders. He or she will obtain a history of your symptoms and perform a complete physical examination, including a pelvic examination.


Other tests may include:

*Blood tests. Your blood may be drawn for laboratory tests to measure levels of several hormones. These may include testoster- one, DHEA and androstenedione, LH, FSH, progesterone, prolactin, and thyroid-stimulating hormone (TSH), which triggers the release of thyroid hormone from the thyroid gland. Additional blood testing may include fasting glucose, cholesterol and triglycer- ide levels.

*Ultrasound. Your doctor may request a pelvic ultrasound to check your ovaries and the thickness of the lining of your uterus. Ultrasound exams are painless. While you relax on a bed or examining table, a wand-like device (transducer) is placed on your body. It emits inaudible sound waves that are translated into images on a computer.




Women with polycystic ovary syndrome are at increased risk of type 2 diabetes, high blood pressure, increased triglycerides, decreased high-density lipoprotein (HDL) cholesterol and cardiovascular disease. Because PCOS disrupts the reproductive cycle and exposes the uterus to a constant supply of estrogen, women with PCOS are at risk of abnormal uterine bleeding and cancer of the uterine lining (endometrial cancer).

You may need treatment with fertility medications to become pregnant if you have polycystic ovary syndrome. During pregnancy, you may be at increased risk of gestational diabetes and pregnancy-induced high blood pressure.




Management of polycystic ovary syndrome focuses on each woman’s main concerns, such as infertility, hirsutism, acne or obesity. Long term, the most important aspect of treatment is managing cardiovascular risks such as obesity, high blood cholesterol, dia- betes and high blood pressure. To help guide ongoing treatment decisions, your doctor will likely want to see you for regular visits to perform a physical examination, measure your blood pressure and obtain fasting glucose and lipid levels.

Women with polycystic ovary syndrome may benefit from counseling to help with healthy-eating choices and regular exercise. This is particularly important for overweight women with PCOS. Obesity makes insulin resistance worse. Weight loss can reduce both insulin and androgen levels, and may restore ovulation. However, you may have more difficulty losing weight than other women do. Ask your doctor to recommend a weight-control program, and meet regularly with a dietitian.

Your doctor may prescribe one or more medications to help manage the symptoms and risks associated with PCOS.




If you’re not trying to become pregnant, your doctor may prescribe low-dose oral contraceptives that combine synthetic estrogen and progesterone. They decrease androgen production and give your body a break from the effects of continuous estrogen. This decreases your risk of endometrial cancer and corrects abnormal bleeding.

An alternative approach is taking progesterone for 10 to 14 days each month. This medication regulates your menstrual cycle and offers protection against endometrial cancer, but it doesn’t improve androgen levels.

Your doctor also may prescribe metformin, an oral medication for type 2 diabetes that treats insulin resistance. This drug is still being studied as a treatment for polycystic ovary syndrome, but research has demonstrated that it improves ovulation and may reduce androgen levels. However, doctors don’t yet know if metformin offers the same protection against endometrial cancer as does treatment with oral contraceptives or with progesterone alone.




Your doctor may add a medication specifically targeted at countering the effects of excess androgen. Spironolactone blocks the effects of androgen and reduces new androgen production. Spironolactone is also a diuretic and may cause you to urinate more frequently. Possible side effects include heartburn, headaches and fatigue. Other anti-androgen medications include finasteride and flutamide.

Your doctor might also prescribe eflornithine, a prescription cream that slows facial hair growth in women. You apply it twice daily. Avoid using this medication during pregnancy.




To become pregnant, you may need a medication to trigger ovulation. Clomiphene is an anti-estrogen medication that you take for five days in the first part of your menstrual cycle. If clomiphene alone isn’t effective, your doctor may add metformin to help trigger ovulation.

If you don’t become pregnant using clomiphene and metformin, your doctor may recommend using gonadotropins — FSH and LH medications that are administered by injection. Because many women with PCOS have elevated levels of LH, your doctor may recommend treatment with FSH alone.



If medications don’t help you become pregnant, your doctor may recommend an outpatient surgery called laparoscopic ovarian drilling. In this procedure, a surgeon makes a small incision in your abdomen and inserts a tube attached to a tiny camera (laparo- scope). The camera provides the surgeon with detailed images of your ovaries and neighboring pelvic organs. The surgeon then inserts surgical instruments through other small incisions and uses electrical or laser energy to burn holes in enlarged follicles on the surface of the ovaries.

The goal is to stimulate ovulation by reducing levels of LH and androgen hormones. Doctors aren’t sure how this occurs. One theory is that drilling destroys hormone-producing ovarian cells.




Several options exist for hair removal. They include shaving, plucking and over-the-counter remedies such as waxes, gels, creams and lotions (depilatories). However, depilatories may irritate your skin, so follow package directions and on first use, apply the product to an inconspicuous area to determine if it’s suitable for you. The results last for weeks, then you must repeat treatment.


Options for longer lasting hair removal include:

*Electrolysis. To permanently remove excess hair, some women undergo electrolysis in addition to medical therapy. A fine needle is inserted into the hair follicle and electric current is applied to kill the follicle. Because only one follicle can be treated at a time, this method isn’t useful for large areas of the body. Several treatments are usually necessary. Scarring or, rarely, skin infections may occur. Home electrolysis kits usually are ineffective because the hair follicle is deep in the skin, so seek care with an experi- enced, certified electrologist.

*Laser therapy. Laser hair removal systems use laser light — an intense, pulsating beam of light — to remove unwanted hair. Laser hair removal is effective only on short, visible hair. Two to three days before the procedure, you shave the area to be treated, and allow it to grow to a stubble. Your doctor may use multiple treatments to target the affected areas. After six months, laser proce- dures may remove 70 percent to 90 percent of targeted hair. Even after multiple treatments, however, you may experience some hair regrowth, although the new hair may be finer and lighter in color.




You may hear conflicting advice from media, support groups and health care professionals on the role of diet in weight manage- ment. Much of the disagreement focuses on carbohydrates.

Carbohydrates are long chains of glucose, a type of sugar. Your digestive system splits these chains into small sugar molecules that enter your bloodstream and trigger the release of insulin.

Low-fat, high-carbohydrate diets that have been popular in recent years may increase insulin levels, so some health and nutri- tion advocates advise women with polycystic ovary syndrome to follow a low-carbohydrate diet. However, a diet that calls for increased protein to compensate for decreased carbohydrates may spike your intake of saturated fats, elevating your blood cholesterol levels and increasing your risk of cardiovascular disease. And research hasn’t demonstrated that a diet high in protein offers more benefit to women with PCOS than does a diet high in carbohydrates.




Carbohydrates provide many important nutrients, so don’t severely restrict them. Instead, choose complex carbohydrates, which are high in fiber. The more fiber in a food, the more slowly it’s digested and the more slowly your blood sugar levels rise. High- fiber carbohydrates include whole-grain breads and cereals, whole-wheat pasta, bulgur, barley, brown rice and beans. Limit less healthy, simple carbohydrates such as soda, excess fruit juice, cake, candy, ice cream, pies, cookies and doughnuts.

Additional research may determine which specific dietary approach is best, but it’s clear that losing weight by reducing total calo- rie intake benefits women with polycystic ovary syndrome. Work with your doctor and registered dietitian to determine the best dietary plan for you.




The importance of exercise is much less controversial. Exercise lowers your blood sugar by promoting the transfer of sugar from your blood to your cells through decreasing insulin resistance. For women with PCOS, an increase in daily physical activity and participation in a regular exercise regimen are essential for treating or preventing insulin resistance and for helping weight-control efforts.


By Mayo Clinic staff DS00423

August 04, 2005

© 1998-2005 Mayo Foundation for Medical Education and Research (MFMER). All rights reserved. A single copy of these mate- rials may be reprinted for noncommercial personal use only. “Mayo,” “Mayo Clinic,” “,” “Mayo Clinic Health Information,” “Reliable information for a healthier life” and the triple-shield Mayo logo are trademarks of Mayo Foundation for Medical Education and Research.






You and your partner have tried for months, perhaps for even more than a year. But despite sexual intercourse without birth con- trol, you’ve been unable to conceive a child.

If you’ve been trying to conceive for more than a year, there’s a good chance that something may be interfering with your efforts to have a child. Infertility, also known as subfertility, is the inability to conceive a child within one year. Infertility may be due to a single cause in either you or your partner, or a combination of factors that may prevent a pregnancy from occurring or continuing. Infertility differs from sterility. Being sterile means you’re unable to conceive a child. With sterility, you or your partner has a physi- cal problem that precludes the ability to conceive. A diagnosis of infertility simply means that becoming pregnant may be a chal- lenge rather than an impossibility.




Infertility in women may be signaled by irregular menstrual periods or associated with conditions that cause pain during menstrua- tion or intercourse.




The most common causes of female infertility include fallopian tube damage or blockage, endometriosis, ovulation disorders, elevated prolactin, polycystic ovary syndrome, early menopause, benign uterine fibroids and pelvic adhesions:


Fallopian tube damage or blockage. This condition usually results from inflammation of the fallopian tube (salpingitis). Chlamydia is the most frequent cause. Tubal inflammation may go unnoticed or cause pain and fever.


Tubal damage with scarring is the major risk factor of a pregnancy in which the fertilized egg is unable to make its way through the fallopian tube to implant in the uterus (ectopic pregnancy). One episode of tubal infection may cause fertility difficulties. The risk of ectopic pregnancy increases with each occurrence of tubal infection.


Endometriosis. Endometriosis occurs when the tissue that makes up the lining of the uterus grows outside of the uterus. This tis- sue most commonly is implanted on the ovaries or the lining of the abdomen near the uterus, fallopian tubes and ovaries. These implants respond to the hormonal cycle and grow, shed and bleed in sync with the lining of the uterus each month, which can lead to scarring and inflammation. Pelvic pain and infertility are common in women with endometriosis.


Infertility in endometriosis also may be due to:

*Ovarian cysts (endometriomas). Ovarian cysts may indicate advanced endometriosis and often are associated with reduced fertil- ity. Endometriomas can be treated with surgery.

*Scar tissue. Endometriosis may cause rigid webs of scar tissue between the uterus, ovaries and fallopian tubes. This may prevent the transfer of the egg to the fallopian tube.

*Ovulation disorders. Some cases of female infertility are caused by ovulation disorders. Disruption in the part of the brain that regulates ovulation (hypothalamic-pituitary axis) can cause deficiencies in luteinizing hormone (LH) and follicle-stimulating hor- mone (FSH). Even slight irregularities in the hormone system can affect ovulation.


Specific causes of hypothalamic-pituitary disorders include:

*Direct injury to the hypothalamus or pituitary gland

*Pituitary tumors

*Excessive exercise

*Anorexia nervosa


Elevated prolactin (hyperprolactinemia). The hormone prolactin stimulates breast milk production. High levels in women who aren’t pregnant or nursing may affect ovulation. An elevation in prolactin levels may also indicate the presence of a pituitary tumor. In addition, some drugs can elevate levels of prolactin. Milk flow not related to pregnancy or nursing (galactorrhea) can be a sign of high prolactin.

Polycystic ovary syndrome (PCOS). An increase in androgen hormone production causes PCOS. In women with increased body mass, elevated androgen production may come from stimulation by higher levels of insulin. In lean women, the elevated levels of androgen may be stimulated by a higher ratio of luteinizing hormone (LH). Lack of menstruation (amenorrhea) or infrequent men- ses (oligomenorrhea) are common symptoms in women with PCOS.


In PCOS, increased androgen production prevents the follicles of the ovaries from producing a mature egg. Small follicles that start to grow but can’t mature to ovulation remain within the ovary. A persistent lack of ovulation may lead to mild enlargement of the ovaries.

Without ovulation, the hormone progesterone isn’t produced and estrogen levels remain constant. Elevated levels of androgen may cause increased dark or thick hair on the chin, upper lip or lower abdomen as well as acne and oily skin.


Early menopause (premature ovarian failure). Early menopause is the absence of menstruation and the early depletion of ovarian follicles before age 35. Although the cause is often unknown, certain conditions are associated with early menopause, including:

*Autoimmune disease. The body produces antibodies to attack its own tissue, in this case the ovary. This may be associated with hypothyroidism (too little thyroid hormone).

*Radiation or chemotherapy for the treatment of cancer.

*Tobacco smoking.


Benign uterine fibroids. Fibroids are benign tumors in the wall of the uterus and are common in women in their 30s. Occasionally they may cause infertility by interfering with the contour of the uterine cavity, blocking the fallopian tubes.


Pelvic adhesions. Pelvic adhesions are bands of scar tissue that bind organs after pelvic infection, appendicitis, or abdominal or pelvic surgery. They may limit the functioning of the ovaries and fallopian tubes and impair fertility. Scar tissue formation inside the uterine cavity after a surgical procedure may result in a closed uterus and ceased menstruation (Asherman’s syndrome). This is most common following surgery to control uterine bleeding after giving birth.


Other causes. A number of other causes can lead to infertility in women:

*Medications. Temporary infertility may occur with the use of certain medications. In most cases, fertility is restored when the medication is stopped.

*Thyroid problems. Disorders of the thyroid gland, either too much thyroid hormone (hyperthyroidism) or too little (hypothyroidism), can interrupt the menstrual cycle and cause infertility.

*Cancer and its treatment. Certain cancers — particularly female reproductive cancers — often severely impair female fertility. Both radiation and chemotherapy may affect a woman’s ability to reproduce. Chemotherapy may impair reproductive function and fertility more severely in men than in women.

*Other medical conditions. Medical conditions associated with delayed puberty or amenorrhea, such as Cushing’s disease, sickle cell disease, HIV/AIDS, kidney disease and diabetes, can affect a woman’s fertility.




Many of the risk factors for both male and female infertility are the same. They include:

*Age. Age is the strongest predictor of female fertility. After about age 32, a woman’s fertility potential gradually declines. A woman does not renew her oocytes (eggs). Infertility in older women may be due to a higher

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