Gynecology


 
Menopause and Hormone Replacement Therapy

Menopause and Hormone Replacement Therapy

Stephen E. Lamb, M.D.

Menopause is a life event that is common to all women. It is something that every woman will go through. The primary signal that menopause has arrived is the absence of menstruation, but there are many other physical and emotional elements that are a part of menopause, especially because it is often a time of life transition for women.

The average age of menopause is 51 years, although some women experience it in their forties. Perimenopause, or what some women call “premenopause,” is a term that identifies the phase just prior to menopause. Usually this is a time of crazy, irregular, and heavy menstrual periods, episodic night sweats, and significant mood swings. The perimenopause, with its troubling symptoms, often lasts for several years. Women often consider the perimenopause to be more difficult than menopause because of how erratic the menstrual periods and mood swings can be during this time.

The major question that must be answered by every menopausal woman is what to do about it. In searching for an answer, women often discover that there is no single solution that applies to everyone. Decisions about menopause management must be individualized and there may be more than one correct answer for a given situation. In fact, many women use a variety of approaches that include lifestyle and activity changes, the use of prescription and nonprescription medications, and the use of hormones. The decision about how to best handle the effects of menopause really depends upon which symptoms are present, a woman’s personal and family history, and individual preferences.

This information sheet is intended to review the use of hormones in the treatment of menopausal symptoms, but before you can think about its management, it is helpful to know what you’re treating–to understand the effects of menopause. These, perhaps, are best considered in terms of their timing in relation to the onset of menopause. For our purposes, they will be called short-term, intermediate-term, and long-term effects.

Short-term effects: The most immediately noticeable short-term effect of menopause is hot flashes. Hot flashes are the abrupt reddening of the head, neck, or chest accompanied by intense feelings of body heat and perspiration. They can occur rarely or as often as every ten minutes. They are more common at night and are not dangerous to your health, although they may make it difficult to function properly at times. Hot flashes are experienced by about 80% of menopausal women, about one-fourth of whom consider them severe enough to be disabling. About 75% of women will stop having hot flashes within 5 years. Other short-term effects of menopause include significant mood swings, especially irritability and easy tearfulness, forgetfulness, difficulty concentrating, difficulty sleeping, and loss of interest in sex.

Intermediate-term effects: The major intermediate effect of menopause is vaginal dryness. This is usually noticed within the first few years of menopause and doesn’t become severe for about 5-10 years. It is caused by atrophy of the skin and support structures of the vagina. At first, dryness can be alleviated with lubricants, but eventually genital atrophy becomes so severe that sex cannot be consummated without extreme discomfort and/or pain and bleeding. Women often stop having sex when this happens. Sexual problems, including decreased interest in sex, dryness, or pain with intercourse are present in 50-80% of menopausal women. Atrophy of the genital and urinary tracts can also result in urinary incontinence with activities such as coughing, sneezing, or jumping.

Long-term effects: Long-term consequences of menopause include osteoporosis and heart disease. Osteoporosis is the loss of calcium in the bones which causes the bone structure to deteriorate. After 20 years of menopause, the average woman has lost 50% of the bone mass in her spine and 30% in her long bones, such as the leg and arm. This makes a woman vulnerable to fractures, especially upon falling. About half of all women in menopause will experience a fractured bone due to osteoporosis. Hip fractures are especially dangerous. Many women can no longer continue independent living after experiencing a hip fracture and over 50,000 women die from hip fracture complications in the U.S. every year. A woman’s risk of bone fracture is dependent upon factors such as the age of menopause, current age, race, family history, body structure, smoking, the use of certain medications, and the presence of certain other medical conditions. Osteoporosis can be detected with a painless bone scan called a Dexa test.

Another long-term consequence of menopause is heart disease. Heart attacks are the number one cause of death in women. Over 400,000 women die of heart attacks each year, representing 44% of all deaths in women. Deaths due to heart attacks are ten times more than deaths due to breast, ovarian, and uterine cancer combined. Heart attacks occur because of the presence of atherosclerotic plaques in the arteries that supply blood to the heart. Plaques develop more commonly in the absence of estrogen (that is, once menopause starts). Other risks for plaque formation and, therefore, heart attacks include high cholesterol level, high blood pressure, smoking, obesity, lack of exercise, and diabetes.

Hormone replacement therapy (HRT) can be taken to prevent or to treat menopausal problems. HRT has been around for over 50 years. It includes the use of three different hormones: estrogen, progesterone, and testosterone. These are hormones that are normally manufactured by the ovaries, but which are no longer made once menopause occurs. HRT regimens may include the use of one, two, or all three of these hormones.

Estrogen has the ability to prevent or improve all the effects of menopause, usually with great effectiveness. For example, estrogen will get rid of hot flashes in virtually 100% of cases where the hot flashes are menopause-related. This, in turn, leads to better sleep patterns. Estrogen will prevent or reverse vaginal atrophy (dryness) in 95% of cases. It also helps about 50% of women with other sexual problems, such as a loss of interest in sex. Estrogen helps prevent osteoporosis when taken early in menopause and arrests the loss of bone calcium in women who already have osteoporosis. Ten years of estrogen use results in a 75% reduction in the incidence of spine and long-bone fractures and is FDA-approved for this purpose. Estrogen use improves the lipid (cholesterol) profile in women and long-term use reduces the incidence of heart attacks by 50%. Finally, an added advantage to taking estrogen is that it reduces the chance of getting colon cancer by 55% in long-term users.

Progesterone is a companion hormone to estrogen that is used to prevent uterine cancer in women who still have a uterus. Taking estrogen alone can increase a woman’s chances of getting this kind of cancer, but using progesterone at the same time actually decreases the chances of getting it. We don’t usually prescribe progesterone alone since very few studies have been done on its use, but we know it can help reduce hot flashes and prevent osteoporosis to a small degree. Nonetheless, despite a lack of medical data, many patients swear that progesterone helps their menopausal symptoms.

Testosterone replacement is an increasingly important element in hormone therapy. Women normally make only small amounts of testosterone, but menopause further reduces its production by 50%. This can result in sexual problems, including loss of interest, diminished responsiveness, and the absence of orgasms. Testosterone replacement helps with all these problems. It can be given safely in low doses to women without causing any masculinizing side effect such as increased facial hair, acne, and balding.

Unfortunately, HRT cannot be used by all women. Those with a history of breast cancer, uterine cancer, heart attacks, strokes, vascular disease, and a tendency toward clot formation in their blood vessels are not candidates for HRT.

HRT can be administered in a variety of ways and by utilizing many different doses. Your health care provider will talk to you about different HRT regimens and try to find one that works for you. Sometimes women will have side effects with a particular regimen and it may be necessary to try different routes of therapy and dosage levels to treat your particular issues.

Ultimately, the final decision about whether to use HRT in menopause lies with you. You are the only one who can decide whether the risks of taking hormones, which are relatively small (but not zero), are worth the benefits. This is a discussion your health care provider will enjoy having with you.Factors Affecting the Decision to Travel Although pregnancy is a normal state rather than a disabled condition, pregnant women need to consider the potential problems associated with international travel, as well as the quality of medical care available at the destination and during transit. According to the American College of Obstetricians and Gynecologists, the safest time for a pregnant woman to travel is during the second trimester (18-24 weeks) when she usually feels best and is in least danger of experiencing a spontaneous abortion or premature labor. Women in the third trimester (25-36 weeks) may be asked by their physicians to stay within 300 miles of home because of concerns about access to medical care in case of problems such as hypertension, phlebitis, or false or premature labor. The final decision to travel should be based on consultation with the woman’s health care provider.

General Recommendations for Travel

Once a pregnant woman has decided to travel, a number of issues need clarification prior to departure (see Table 1). It is advisable for pregnant women to travel with a companion; in addition, attention to comfort becomes more important. The checklist (Table 2) provides a guideline for planning with regard to medical considerations.

Motor vehicle accidents are a major cause of morbidity and mortality. When available, seat belts should be fastened at the pelvic area. Lap and shoulder restraints are best; in most accidents, the fetus recovers quickly from the seat belt pressure. However, even after seemingly blunt, mild trauma, a physician should be consulted.

Typical problems of pregnant travelers are the same as those experienced at home: fatigue, heartburn, indigestion, constipation, vaginal discharge, leg cramps, increased frequency of urination and hemorrhoids. Signs and symptoms that indicate the need for immediate medical attention are bleeding, passing tissue or clots, abdominal pain or cramps, contractions, ruptured membranes, excessive leg swelling, headaches or visual problems.

Table 1. Relative Contraindications to International Travel during Pregnancy

Patients with Obstetrical Risk Factors:

History of miscarriage

Incompetent cervix

History of ectopic pregnancy (ectopic with present pregnancy should be ruled out prior to travel)

History of premature labor or premature rupture of membranes

History of or present placental abnormalities

Threatened abortion or vaginal bleeding during present pregnancy

Multiple gestation (more than one fetus) in present pregnancy

History of toxemia, hypertension or diabetes with any pregnancy

History of infertility or difficulty becoming pregnant

Primigravida (woman who is pregnant for the first time) older than 35 years or younger than 15 years

Patients with General Medical Risk Factors:

Valvular heart disease or congestive heart failure

History of thromboembolic disease

Severe anemia

Chronic organ system dysfunction requiring frequent medical interventions

Patients Contemplating Travel to Destinations That May Be Hazardous

High altitudes

Areas endemic for or with ongoing outbreaks of life-threatening food- or insect-borne infections

Areas where chloroquine-resistant Plasmodium falciparum is endemic

Areas where live-virus vaccines are required and recommended

Table 2. Checklist for the Pregnant Traveler

Make sure health insurance is valid while abroad and during pregnancy. Check to see if the policy covers a newborn should delivery take place. Obtain a supplemental travel insurance policy and a prepaid medical evacuation insurance policy.

Check medical facilities at the destination. For women in the last trimester, medical facilities should be able to manage complications of pregnancy, toxemia and cesarean sections.

Determine beforehand whether prenatal care will be required abroad and, if so, who will provide it. Make sure prenatal visits requiring specific timing are not missed.

Check ahead of time whether blood is screened for HIV and hepatitis B at the destination. Pregnant travelers and their companions should know their blood types.

Check facilities at the destination for availability of safe food and beverages, including bottled water and pasteurized milk.

Breast-Feeding and Travel 

The decision to travel internationally while nursing brings another set of challenges. However, breast-feeding has nutritional and anti-infective advantages that serve an infant well while traveling. Supplements usually are not needed by breast-fed infants younger than 6 months, and breast-feeding should be maintained as long as possible. If supplementation is considered necessary, powdered formula that requires reconstitution with boiled water should be carried. For short trips, it may be feasible to carry an adequate supply of pre-prepared canned formula. Exclusive breast-feeding relieves concerns about sterilizing bottles and about availability of clean water.

Nursing women may be immunized for maximum protection, depending on the travel itinerary, but consideration needs to be given to the neonate who cannot be immunized at birth and who would not gain protection against many of these infections (e.g., yellow fever, measles, and meningococcal meningitis) through breast-feeding.

Neither inactivated nor live-virus vaccines affect the safety of breast-feeding for mothers or infants. Breast-feeding does not adversely affect immunization and is not a contraindication to the administration of any vaccines, including live-virus vaccines, to the breast-feeding woman. Although rubella vaccine virus may be transmitted in breast milk, the virus usually does not infect the infant, and if it does, the infection is well tolerated. Breast-fed infants should be vaccinated according to routine recommended schedules.

Nursing women need to realize that their eating and sleeping patterns, as well as stress, will inevitably affect their milk output. They need to increase their fluid intake, avoid excess alcohol and caffeine, and, as much as possible, avoid exposure to smoke.

Specific Recommendations for Pregnancy and Travel

ROUTINE IMMUNIZATIONS

Because of the theoretical risks to the fetus from maternal vaccination, the risks and benefits of each immunization should be carefully reviewed. Ideally, all women who are pregnant should be up to date on their routine immunizations. In general, pregnant women should avoid live vaccines and women should avoid becoming pregnant within three months of having received one; however, no harm to the fetus has been reported from the accidental administration of these vaccines during pregnancy.

DIPHTHERIA/TETANUS

The combination diphtheria/tetanus immunization should be given if the traveler has not been immunized in the past 10 years, although preference would be for its administration during the second or third trimesters.

MEASLES/MUMPS/RUBELLA

Immunity to measles is essential for all travelers. Many young adults require immunization (and in some cases, reimmunization) for protection. The specific recommendations for different age groups depend on the traveler’s country of origin, itinerary, and the epidemiology of measles in the country to be visited. The measles vaccine as well as the MMR (measles, mumps, and rubella combination) are live-virus vaccines and are contraindicated in pregnancy. Because of the increased incidence of measles in children in developing countries, its communicability, and its potential for causing serious consequences in adults, some authorities recommend delaying travel for nonimmune women until after delivery, when immunization can be given safely. However, in cases in which the rubella vaccine was accidentally administered, no complications were reported. If a pregnant woman has a documented exposure to measles, immune globulin should be given within a six-day period to prevent illness.

POLIO

It is important for the pregnant traveler to be protected against polio. Paralytic disease may occur with greater frequency when infection develops during pregnancy. Anoxic fetal damage has also been reported, with up to 50 percent mortality in neonatal infection. If not previously immunized, a pregnant woman should have at least two doses of vaccine before travel (day 0 and at one month). Despite being a live-virus vaccine, the oral preparation (OPV) is recommended when immediate protection is needed. The recommendation for the nonimmune pregnant traveler is 1 dose of OPV prior to travel followed by completion of the regimen after delivery. However, for routine boosting or for when immediate protection is not required, the inactivated vaccine (IPV) is preferred. There is no convincing evidence of adverse effects of either OPV or IPV in pregnant women or a developing fetus. However, it is prudent to avoid polio vaccination of pregnant women unless immediate protection is needed. In this case, OPV is the vaccine of choice.

Breast-feeding does not interfere with successful immunization against poliomyelitis with IPV or OPV. IPV may be administered to a child with diarrhea, and OPV may be administered to a child with mild diarrhea. Minor upper respiratory illnesses with or without fever, mild to moderate local reactions to a previous dose of vaccine, current antimicrobial therapy, and the convalescent phase of an acute illness are not contraindications for vaccination.

HEPATITIS B

The hepatitis B vaccine may be administered during pregnancy. For tourists or business travelers, it is not routinely recommended unless the woman will be working in a health care setting, is sexually active with new partners, is planning delivery overseas, or will be a long-term traveler. It is desirable, however, for everyone to be protected against hepatitis B.

PNEUMOCOCCAL/INFLUENZA

The pneumococcal and influenza vaccines should be given to all who would otherwise qualify for special protection against these diseases: pregnant women with chronic diseases or pulmonary problems. In general, women with serious underlying illnesses should not travel to developing countries when pregnant.

Travel-Related Immunizations During Pregnancy

YELLOW FEVER

The yellow fever vaccine should not be given to a pregnant woman unless travel to an endemic or epidemic area is unavoidable. In these instances, the vaccine can be administered. Although concerns exist, no congenital abnormalities have been reported after administration of this vaccine to pregnant women.

If traveling to or transiting regions within a country where the disease is not a current threat but where policy requires a yellow fever certificate, a physician waiver should be carried, along with documentation on the immunization record. In general, travel to areas where yellow fever is a risk should be postponed until after delivery, when the vaccine can be administered without concern of fetal toxicity. A nursing mother should also delay travel, as the neonate cannot be immunized because of the risk of vaccine-associated encephalitis. Breast-feeding is not a contraindication to the vaccine for the mother.

HEPATITIS A

Pegnant women without immunity to hepatitis A need protection before traveling to developing countries. Hepatitis A is usually no more severe during pregnancy than at other times and does not affect the outcome of pregnancy. There have been reports, however, of acute fulminant disease in pregnant women during the third trimester, when there is also an increased risk of premature labor and fetal death. These events have occurred in women from developing countries and may have been related to underlying malnutrition. The hepatitis A virus is rarely transmitted to the fetus, but this can occur during viremia or from fecal contamination at delivery. Immune globulin is a safe and effective means of preventing hepatitis A, but immunization with one of the hepatitis A vaccines gives a more complete and prolonged protection. The effect of these inactivated virus vaccines on fetal development is unknown, but the production methods for the vaccines are similar to that for IPV, which is considered safe during pregnancy.

TYPHOID

The older injectable typhoid vaccine is not recommended during pregnancy because of febrile reactions, which can result in spontaneous abortions. It can be administered intradermally with less risk of systemic symptoms. The safety of the oral typhoid vaccine in pregnancy is not known. Nonetheless, neither of these is absolutely contraindicated during pregnancy, according to the Advisory Committee on Immunization Practices (ACIP). The Vi injectable preparation may be the vaccine of choice because it is inactivated and requires only one injection. With any of these, the vaccine efficacy (about 70 percent) needs to be weighed against the risk of disease.

MENINGOCOCCAL MENINGITIS

The polyvalent meningococcal meningitis vaccine may be administered during pregnancy if the woman is entering an area where the disease is endemic. The vaccine’s safety during pregnancy has not been conclusively determined.

RABIES

The cell-culture rabies vaccines may be given during pregnancy for either pre- or postexposure prophylaxis.

JAPANESE ENCEPHALITIS

No information is available on the safety of Japanese encephalitis vaccine during pregnancy. It should not be routinely administered during pregnancy, except when a woman must stay in a high-risk area. If not mandatory, travel to such areas should be delayed.

MISCELLANEOUS

There are no data available on the use of plague vaccine for pregnant women. BCG (Bacillus Calmette-Gurin) vaccine for the prevention of tuberculosis can theoretically cause disseminated disease and thus affect the fetus; skin testing for tuberculosis exposure before and after travel is preferable when the risk is high. Therefore, neither of these vaccines is recommended.

Malaria During Pregnancy 

Malaria in pregnancy carries significant morbidity and mortality for both the mother and the fetus. Because no antimalarial agent is 100 percent effective, it is imperative that pregnant women use personal protective measures when traveling through a malaria-endemic area. Pregnant women should remain indoors between dusk and dawn, but if outdoors at night, should wear light-colored clothing, long sleeves, long pants, and shoes and socks. Pregnant women should sleep in air-conditioned quarters or use screens and permethrin-impregnated bed nets.

Pyrethrum-containing house sprays or coils also should be used indoors if insects are a problem. Insect repellents containing a low percentage of DEET (recommendations vary from 10 percent to 35 percent) can be used on the skin. Nursing mothers should be careful to wash repellents off hands and breast skin prior to handling infants.

Chloroquine and proguanil have been used by pregnant women for malaria chemoprophylaxis for decades with no documented increase in birth defects. Mefloquine has been recommended for chemoprophylaxis during the second and third trimesters. Women in the first trimester should be discouraged from visiting areas where chloroquine-resistant malaria occurs. However, if they do travel to these areas, experience suggests that mefloquine causes no significant increase in spontaneous abortions (miscarriages) or congenital malformations (birth defects) among women who have inadvertently taken the drug during this period.

Nursing mothers should take the usual adult dose of antimalarial appropriate for the country to be visited. The amount of medication in the breast milk will not be helpful or harmful to the infant. Therefore, the breast-feeding child needs his or her own prophylaxis.

Any pregnant traveler returning with malaria from an area where chloroquine-resistant Plasmodium falciparum is endemic should be treated as a medical emergency and as if she had illness due to chloroquine-resistant organisms. Because of the serious nature of malaria, quinine or intravenous quinidine should be used and should be followed by Fansidar, or even doxycycline, despite concerns regarding potential fetal problems. Frequent glucose levels and careful fluid monitoring often require intensive care supervision.

Travelers’ Diarrhea 

During Pregnancy Dietary vigilance should be adhered to while traveling during pregnancy because dehydration due to travelers’ diarrhea (TD) can lead to inadequate placental blood flow. Potentially contaminated water should be boiled. Iodine-containing purification systems should not be used long term. Iodine tablets can probably be used for short-term travel up to several weeks, but congenital goiters have been reported in association with administration of iodine-containing drugs during pregnancy. Eating only well-cooked meats and pasteurized dairy products, as well as avoiding pre-prepared salads, should help avoid diarrheal disease, as well as infections such as toxoplasmosis and listeria, which can have serious sequelae in pregnancy. It is not recommended that pregnant women use prophylactic antibiotics for the prevention of TD.

Oral rehydration is the mainstay of TD therapy. Bismuth subsalicylate compounds are contraindicated due to the theoretical risks of fetal bleeding from salicylates and teratogenicity from the bismuth. The combination of kaolin-pectin may be used, and loperamide should be used only when necessary. The antibiotic treatment of TD during pregnancy can be complicated. An oral third-generation cephalosporin may be the best option for treatment if an antibiotic is needed.

Breast-feeding is desirable during travel and should be continued as long as possible because of its safety and its lower incidence of infant diarrhea. A nursing mother with TD should not stop breast-feeding but should increase her fluid intake.

Air Travel During Pregnancy 

Commercial air travel poses no special risks to a healthy pregnant woman or her fetus. The lowered cabin pressures (kept at the equivalent of 5,000 to 8,000 feet or 1,524 to 2,438 meters) affect fetal oxygenation minimally because of the fetal hemoglobin dissociation curve. Severe anemia (Hgb 0.5 g/dL), sickle-cell disease or trait, a history of thrombophlebitis, or placental problems are relative contraindications to flying; however, supplemental oxygen may be ordered in advance. Each airline has policies regarding pregnancy and flying; it is always safest to check with the airline when booking reservations, as some will require medical forms to be completed. Domestic travel is usually permitted until 36 weeks gestation, and international travel may be curtailed after the 32nd week. Pregnant women should always carry documentation stating their expected date of delivery.

An aisle seat at the bulkhead will provide the most space and comfort, but a seat over the wing in the midplane region will give the smoothest ride. A pregnant woman should walk every half hour during a smooth flight and flex and extend the ankles frequently to prevent phlebitis. The seat belt should always be fastened at the pelvic level. Fluids should be taken liberally because of the dehydrating effect of the low humidity in aircraft cabins.

Women traveling with infants should keep in mind that newborns (younger than 6 weeks old) should not fly because their alveoli are not completely functional. Infants are particularly susceptible to pain with eustachian tube collapse during pressure changes, and breast-feeding during ascent and descent relieves this discomfort.

The Travel Health Kit 

During Pregnancy Additions and substitutions to the usual travel health kit need to be made during pregnancy and nursing. Talcum powder, a thermometer, oral rehydration packets, multivitamins, an antifungal agent for vaginal yeast, acetaminophen, insect repellent containing a low percentage of DEET, and sunscreen with a high SPF (sun protection factor) should be carried. Women in their third trimester may want to carry a blood pressure cuff and urine dipsticks to check for proteinuria and glucosuria, both of which would require attention. Antimalarial and antidiarrheal self-treatment medications should be evaluated individually, depending on the traveler, her trimester, the itinerary, and her health history. Most medications should be avoided, if possible.

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Source: National Center for Infectious Diseases, Centers for Disease Control and Prevention

This page last reviewed July 10, 2000

Cancer of the Uterus

Cancer of the uterus most often affects the lining of the uterus (endometrium). If it is found and treated early, the cure rate is very good.

What Is Cancer? 

Sometimes, certain cells develop abnormally and begin to grow out of control. Too much tissue is made, and growths or tumors begin to form. Tumors can be benign (not cancer) or malignant (cancer).

Malignant tumors can invade and destroy nearby healthy tissues and organs. Cancer cells also can spread (or metastasize) to other parts of the body and form new tumors.

Most types of uterine cancer are adenocarcinomas. Adenocarcinomas involve cells in the lining of the uterus.

Who Is at Risk? 

Cancer of the uterus is rare in women under 40 years of age. It most often occurs in women between the ages of 60 to 75 years.

Symptoms 

At present, there is no simple way to detect uterine cancer at an early stage in women with no symptoms. The key to finding the disease early is being alert to its symptoms.

The main symptoms of uterine cancer are abnormal bleeding, spotting or discharge from your vagina.

Ask your doctor about any bleeding or spotting you have after menopause.

Diagnosis 

Most of the methods used to diagnose cancer of the uterus can be done in the doctor’s office. Methods that may be used include ultrasound or endometrial biopsy. Sometimes hysteroscopy may be done in the doctor’s office with local anesthesia. The patient may have dilation and curettage (D&C) done in the hospital.

Although the Pap test should be part of a regular checkup, it is not a good test for uterine cancer.

Treatment 

If cancer of the uterus is found, surgery will be done to decide the stage of the disease and how it should be treated. Staging helps your doctor decide what treatment has the best chance for success.

To treat uterine cancer, most patients have both hysterectomy and salpingo-oophorectomy. Tissue from lymph nodes in the pelvic region may be tested to find out if the cancer has spread.

If tests show that the cancer has spread or come back after surgery or radiation, your doctor may advise more drug therapy.

Prevention 

There are things you can do to lower your risk of uterine cancer and improve the chance of finding it early:

Report any abnormal vaginal bleeding promptly to your doctor.

Get a yearly pelvic exam.

Eat foods that are low in fat and cholesterol and high in fiber.

Finally… If you think you have a problem, see your doctor at once. When uterine cancer is found early, the outlook is great. This disease is much harder to cure if treatment is delayed.

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This excerpt from ACOG’s Patient Education Pamphlet is provided for your information. It is not medical advice and should not be relied upon as a substitute for visiting your doctor. If you need medical care, have any questions, or wish to receive the full text of this Patient Education Pamphlet, please contact your obstetrician-gynecologist.

To ensure the information is current and accurate, ACOG titles are reviewed every 18 months.

Copyright March 1999 The American College of Obstetricians and Gynecologistsup B streptococcus (GBS) is a type of bacteria that can be found in 10 percent to 30 percent of pregnant women. A woman with GBS can pass it to her baby during delivery. Most babies who get GBS from their mothers do not have any problems. A few, however, will become sick.

What Is GBS?

GBS is one of the many bacteria that usually do not cause serious illness. It may be found in the digestive, urinary, and reproductive tracts of men and women. In women, it is most often found in the vagina and rectum. GBS is not a sexually transmitted disease.

Effects on the Baby

If the bacteria is passed from a woman to her baby, the baby may develop GBS infection. This happens to only one or two of every 100 babies whose mothers have GBS. Babies who do become infected may have early or late infections.

Early infections develop right after delivery when the baby passes through the birth canal colonized with GBS.

Late infections occur after the first seven days of life. About one-half of late infections are passed from the mother to the baby during birth. The other half result from other sources of infection, such as contact with other people who are GBS carriers.

These infections can cause inflammation of the baby’s blood, lungs, brain or spinal cord. Both early and late GBS infections lead to death in about 5 percent of infected babies.

Testing for GBS

A culture is the most accurate way to test for GBS. This is a simple procedure and should not be painful. With cultures, a swab is placed in the woman’s vagina and rectum to obtain a sample.

The results of cultures are most useful between 35 and 37 weeks of pregnancy.

Treatment

To reduce the risk of GBS infection in newborns, all women who test positive for GBS must be treated with antibiotics during labor. Babies of women who are carriers of GBS and do not get treatment have more than 20 times the risk of getting infected than those who do receive treatment.

Penicillin is the antibiotic that is most often given to prevent GBS in newborns. Another antibiotic may be given if you are allergic to penicillin.

In women who have planned a cesarean birth, it is not necessary for them to be given antibiotics during delivery, whether or not they are GBS carriers. However, these women should still be tested for GBS because preterm labor may occur before the planned cesarean birth.

Finally … GBS is fairly common in pregnant women. Yet, very few babies actually become sick from GBS infection. Treatment during labor and delivery may help prevent infection in your baby.

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This excerpt from ACOG’s Patient Education Pamphlet is provided for your information. It is not medical advice and should not be relied upon as a substitute for visiting your doctor. If you need medical care, have any questions, or wish to receive the full text of this Patient Education Pamphlet, please contact your obstetrician-gynecologist.

To ensure the information is current and accurate, ACOG titles are reviewed every 18 months.

Copyright © July 2003 The American College of Obstetricians and Gynecologists

Pelvis Support Problems

Many women’s pelvic organs change as they age. They may have a feeling of pelvic pressure or heaviness. It may feel like “something is falling out of the vagina.” These symptoms may be caused by pelvic support problems. Although these problems may begin with childbirth, women may notice them even more as they age.

The Pelvic Organs 

The parts of the body affected by pelvic support problems include the urethra and bladder, the small intestine, the rectum, the uterus and the vagina.

The pelvic organs are held in place by three types of support:

Layers of connecting tissue called endopelvic fascia

Thickened parts of the fascia called ligaments

A paired group of muscles that lies on either side and around the openings of the urethra, vagina and rectum

When the tissues that support the pelvic organs are stretched and damaged, the organ that they support may drop down and press against the wall of the vagina. This causes a bulge.

Causes 

The main causes of pelvic support problems are pregnancy and childbirth. However, pelvic support problems can occur in women who have never had children.

Symptoms 

The symptoms of pelvic support problems depend on which organs are involved. They can cause minor discomfort or major problems in the way the organs work. Symptoms include:

Feeling of pelvic heaviness or fullness, or as though something is falling out of the vagina

Pulling or aching feeling in the lower abdomen or pelvis

Leakage of urine or problems having a bowel movement

In severe cases, the pelvic organs may bulge into the vagina. This bulge may stick out of the vaginal opening, where it may be seen with a mirror or felt with the fingers.

In some cases, the uterus may stick out through the vaginal opening.

Types of Pelvic Support Problems 

The main types of pelvic support problems and the pelvic organ that can cause bulging are as follows:

Cystocele — bladder

Vaginal vault prolapse with enterocele — vagina and small intestine

Rectocele — rectum

Uterine prolapse — uterus

Cystocele

A cystocele, sometimes called anterior wall prolapse, occurs when the bladder drops from its normal place into the vagina. Some cystoceles cause urine to leak when you cough, sneeze, lift objects or walk.

Small cystoceles are common. In most cases, they do not cause problems with urination and do not need surgery. If a cystocele is causing symptoms, your doctor can suggest ways to relieve them.

Vaginal Vault Prolapse With Enterocele

Sometimes after hysterectomy (removal of the uterus), the top of the vagina loses its support and drops. This is called vaginal vault prolapse. The degree of prolapse varies. The top of the vagina may drop part of the way into the vagina and remain there, or it may extend part or all of the way through the vaginal opening.

Rectocele

When the rectum bulges into or out of the vagina, it is called a rectocele. It is sometimes called a posterior wall prolapse. A large rectocele may make it hard to have a bowel movement, especially if you are constipated.

Uterine Prolapse

When the uterus drops down into the vagina, it is called uterine prolapse. Mild degrees of prolapse are common. They often do not cause symptoms and do not need surgery.

Women with more severe forms of this condition often will have a feeling of pelvic pressure or a pulling feeling in the vagina or lower back. The cervix (the opening of the uterus) may stick out from the vagina. This may cause discomfort or problems with sex.

Diagnosis Proper diagnosis is key to treating pelvic support problems. However, diagnosis is not always simple because the symptoms of pelvic support problems often are the same as those of other conditions. The exact cause of the problem must be found before the best treatment can be given.

Treatment Many women do not need treatment. Some women find symptoms are relieved by exercising, making changes in their diet, keeping their weight under control, not smoking, and avoiding heavy lifting and straining. Medication or use of a device called a pessary also may be helpful. Pelvic support problems sometimes may be treated by surgery.

Special Exercises

Exercises called Kegel exercises, or pelvic muscle exercises, are used to strengthen the muscles that surround the openings of the urethra, vagina and rectum.

Diet

You should cut down on caffeine, which acts as a diuretic. Caffeine can be found in coffee, tea and soft drinks. A high-fiber diet may help bowel function and prevent constipation.

Medicines

There are special medicines that help treat urinary and bowel symptoms.

Vaginal Pessaries

A pessary may be inserted into the vagina to support the pelvic organs. When a pessary is used, it must be removed, cleaned and reinserted on a regular basis.

Surgical Repair

Pelvic support problems may be corrected by surgery. The surgery can be done through the vagina or abdomen based on your type of support problem.

Finally … Many women have pelvic support problems. If you have any symptoms, talk to your doctor about them. The right diagnosis and treatment can offer relief.

________________

This excerpt from ACOG’s Patient Education Pamphlet is provided for your information. It is not medical advice and should not be relied upon as a substitute for visiting your doctor. If you need medical care, have any questions, or wish to receive the full text of this Patient Education Pamphlet, please contact your obstetrician-gynecologist.

To ensure the information is current and accurate, ACOG titles are reviewed every 18 months.

Copyright © April 2004 The American College of Obstetricians and Gynecologists

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