Vaginal Discharge: Normal or Not?

With so many women wondering if their vaginal discharge is normal, it seemed time to review the basics of "vaginal ecology". We’ll be examining the following questions:

1. What is normal?


2. How often does it change?


3. Do hormones make a difference?


4. What about douching or washing?


5. Does my choice of birth control have an impact?

What is "normal" vaginal discharge?

A normal discharge is made up from exfoliated vaginal skin cells, bacteria, and secretions from the cervix and vaginal walls. While as many as 30 types of bacteria can be found in normal vaginal discharge, about 95% of a healthy vaginal bacteria population consists of lactobacilli. There are several subtypes of lactobacilli, but the most important type produces hydrogen peroxide. Just like hydrogen peroxide is used to clean cuts and scrapes on the surface of external skin, the hydrogen peroxide produced by the lactobacilli helps decrease the numbers of undesirable bacteria such as E. coli, a common bowel bacteria responsible for urinary tract infections. A healthy vaginal pH is relatively acidic (pH 3.8-4.5). An acidic pH also discourages undesirable bacteria.

In one study (Mijac, 2006), women with yeast were found to have almost as many of the beneficial, hydrogen peroxide producing lactobacilli as women without infections (77% vs 80% respectively). By contrast, women with trichomoniasis had 63%, and those with bacterial vaginosis (BV) were found to have only 25.6% ! In all categories, women who smoked had fewer of the beneficial lactobacilli than nonsmokers.

Women have tried various home remedies to increase lactobacilli numbers in their vagina. Use of natural yogurt as a douche or on a tampon has been advocated. Yet studies suggest that the type of lactobacilli in yogurt lack both the hydrogen peroxide producing qualities, and an ability to cling to vaginal membranes. In a recent experiment (Larsson, 2008) women treated for BV were given 10 days of freeze dried human lactobacilli, or a placebo, as a vaginal capsule. After three months of this treatment the researchers found that the lactobacilli treatment was most effective in preventing relapse of BV in women who were initially cured using antibiotics.

Group B strep, E. Coli, and Staph aureus (normal skin bacteria) were frequently cultured in a group of 631 women, many of whom had no symptoms (Donder, 2002). In a study of 141 GYN surgical patients, Group B strep was found in the vaginal secretions of 20% (Song, 1999). This suggests that many types of bacteria can be a part of the vaginal ecology.

To summarize, normal discharge has a pH of less than 4.5, no overt malodor, a thick or clumpy appearance, and white color. These characteristics can vary over a menstrual month depending upon hormones, changes in pH, brief overgrowths of different species of normal vaginal bacteria, and exposure to semen or menstrual flow.

How often does discharge change?

Among 26 women followed for two months, only four maintained "normal" vaginal conditions. Eight had intermittent yeast ("candida") overgrowths. Nine had intermittent overgrowth of BV linked bacterias, while one other had BV all month long. Interestingly, many women complained of abnormal discharge or other signs of vaginitis, but symptoms did not correlate to lab testing (Priestly, 1997). Among a different group of 51 women, 22% maintained a "normal" vaginal environment with high levels of lactobacilli. The other 78% had significant but transient changes in their vaginal ecosystem (Schwebke, 1999).

A much larger study of 1,193 women was conducted over three years. About 20% of those women developed BV after 6-12 months. Surprisingly about 20% who had BV at the beginning of the study had no evidence of BV infection at the next follow up exam.

Such studies suggest that many bacterias and fungi (yeast) found in normal vaginal secretions can either overgrow and provoke symptoms - or can return to very low levels where they do not produce ill effects.

Do hormones make a difference in vaginal discharge?

Hormones are one variable which can change over the course of a month. We know that estrogen improves vaginal pH by increasing lactic acid production by vaginal cells. Increased levels of estrogen are also responsible for the increased amount of clear, stretchy cervical secretions seen around ovulation. After ovulation, discharge tends to become less watery and may look more like library paste in its consistency.

Conversely, in a post-menopausal woman who has low levels of estrogen, her vagina is more likely to contain gram positive cocci (e.g. staph aureus, staph epidermis, group A strep) and gram negative rods (e.g. proteus, E Coli). Her vaginal pH will be more alkaline, and there will be fewer of the beneficial lactobacilli bacteria. There will be diminished vaginal secretions, and decreased vaginal lubrication during sex. One innovative study (Gorodeski, 2005), determined that the effects of estrogen on the vaginal ecology differed depending upon the age of the vaginal tissues. This suggests that estrogen's effects work directly on vaginal cells, not just by encouraging beneficial bacteria and inducing an acidic pH.

What about douching or washing?

Douching has been linked to increased incidence of BV in many, but not all studies. One of the better studies also examined the reason for douching. It would make sense that if one had the malodorous BV discharge that douching might be tried to temporarily get rid of the smell. Of the 1200 women studied, douching for hygiene, as well as for symptoms, both shared an increased incidence of BV. While douching once a month incurred an increased risk of having BV, those who had douched within the past week had the highest risk of all. Women who douched also had decreased concentrations of the beneficial lactobacilli bacteria (Ness, 2002). More recently (Brotman, 2008), it was determined that incidence of BV could be decreased if women refrained from douching for hygiene purposes after menstruation.

Among sex workers in Kenya, women who used any type of vaginal washing (as compared to no washing) had an increased risk for HIV was present after ten years of follow up. The greatest risk was to women who used soap or other substances for cleaning the inside of the vagina rather than plain water (McClelland, 2006).

Type of external cleansing techniques (e.g. soap vs water vs antiseptics) did not predict incidence of candida (yeast) infections in 1004 women cultured for yeast (Oliveira, 1993). This suggests that external cleaning choices do not impact vaginal ecology.

Does my choice of birth control have an impact?

It should come as no surprise that the answer to this question is, "Yes, probably so." Birth control pills do not change the numbers of beneficial lactobacilli, keep the pH at about 4.4, and do not change the thickness of protective vaginal skin cells (Eschenbach, 2000). Over all the risk for BV is about 50% less in birth control pill users (Calzolari, 2000). Yet the risk for yeast infections is increased when birth control pills are used (Baeten 2001, Fosch 2006)).

Women who wear the NuvaRing have the same healthy vaginal pH as Pill users, but they may have 2-3 times more hydrogen peroxide producing lactobacilli (Vernes, 2004). One study has shown that several subtypes of vaginal yeast can adhere to the NuvaRing (Camacho, 2007), but an increased risk for yeast infections has not been reported. Should a Ring user develop yeast, use of either a cream or suppository antifungal medication does not decrease the Ring's effectiveness as a birth control method (Verhoeven, 2004).

By contrast, DepoProvera can decrease hydrogen peroxide producing bacteria within six months of use. There can also be a slight thinning of the tissues which keep vaginal pH acidic (Miller, 2000). These effects are likely related to the degree in which DepoProvera decreases estrogen levels. In some women blood estrogen levels can be depressed enough to impact bone density and vaginal symptoms - while in others blood estrogen levels remain well within the usual range.

The use of a copper IUD has been linked to increased BV in four studies. One study (Avonts, 1990), which followed women for two years, found that 50% of IUD users developed BV as compared to 20% of birth control pill users. More recently Ocak and colleagues (2007), followed IUD wearing women for three years. Similarly, it was shown that BV was more common in IUD wearers (11.7%), than in birth control pill consumers (5.9%) or women using neither method (2.9%).

When barrier methods of birth control are utilized there is a spectrum of effects on vaginal ecology. Condoms without spermicide do not change vaginal pH or bacterial parameters. Condoms may protect the vagina from any bacteria present in the ejaculate. However, use of the common spermicide nonoxynol 9 may predispose a woman to abnormal bacterial changes. When used with a diaphragm or cervical cap, this spermicide can transiently decrease lactobacilli, and increase the proportion of E. Coli, enteroccoccus, and anaerobic gram negative bacteria (Gupta, 2000).

You should now be able to make more informed choices about your own vaginal health. As always, seeing a GYN or family planning clinic will yield the most accurate diagnosis and advice.

Related Topics:

• WebMD Video: What Is Normal Vaginal Discharge?
• WebMD Video: Diagnosing Yeast Infections
• WebMD Video: Understand Douching

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My Ultrasound Found An Ovarian Cyst!

There are two types of small ovarian cysts which can be considered "normal". During the first half of the menstrual month ("follicular phase") estrogen stimulates the growth of a dominant follicle. This follicle fills with fluid which is spilled out when the ready egg ("oocyte") is ejected ("ovulation"). After the egg is released, its former follicle closes off and becomes the "corpus luteum" which produces progesterone during the following two weeks ("luteal phase").

If, in either of these phases, larger than normal amounts of fluid collect, one can develop ovarian cysts that will cause pain or menstrual bleeding changes. A normal ovary is about 2 x 3 cm (almond sized). A follicular ovarian cyst, if the egg is not ejected and the amount of fluid continues to increase, can reach sizes of up to 10 cm. Fortunately most follicular cysts are smaller and will resolve within one to three months. If the size is large (eg greater than 8 cm) the heavy cyst can prompt the ovary to twist on itself like a heavy flower on a too fragile stalk. This twisting ("ovarian torsion") causes intense pain as it cuts off the blood supply to the ovary. While follicular cysts are the most common type of ovarian cysts, torsion is uncommon.

In another condition, polycystic ovaries ("polycystic ovarian syndrome/PCOS"), the ovary will contain multiple small follicular cysts. Unlike the cysts described above, PCOS cysts will usually stay small. Yet, like other follicular cysts the egg is not ejected. This lack of ovulations contributes to the fertility problems seen in PCOS.

Normally after ovulation a corpus luteum of less than 3 cm resolves within two weeks. This type of cyst will be maintained, if conception occurs, to produce hormones needed in early pregnancy. If excessive amounts of fluid collect, a corpus luteum cyst can also get large enough to cause pain—or very rarely, ovarian torsion. Occasionally, this type of cyst will have a small blood vessel which continues to bleed into a corpus luteum cyst. This is called a "hemorrhagic ovarian cyst". A cyst of this type can either leak small amounts of blood, or it can rupture, spilling blood into the abdomen. This hemorrhagic ovarian cyst can be linked to prolonged pain, and merits closer follow up.

Each of the cysts described above can start with a normal process and become a medically significant cyst. They are all described as benign cysts. By contrast there are ovarian cysts which are not related to variations in normal processes. Endometriomas are cysts filled with old blood. This gave rise to the nickname "chocolate cysts" as the cyst fluid looked like chocolate syrup. Endometriomas can grow to 6-8 cm. They are formed when bits of uterine lining tissue ("endometriosis") attach to pelvic organs such as ovaries. Dermoid cysts ("cystic teratomas") can contain bits of hair, teeth, or other body tissues. It is still not known why demoid cysts form. At an incidence of 66%, dermoids are most common kind of benign tumors of the ovary. Cystadenomas ("serous cystadenomas") are formed from epithelial cells on the covering of the ovary. These cysts are filled with a fluid or a gel like material. Cystadenomas comprise 20% of benign tumors. The concept of benign tumors sounds like a contradiction in terms. It means that there is a very small chance of this type of ovarian cyst to become cancerous. For example, in one study (Scully, 1973) less than 2% of dermoid cysts showed evidence of malignancy.

What If My Ultrasound Does Not Say What Type of Cyst I Have?

Often, when women get copies of their pelvic ultrasounds there is no definite diagnosis. The ovarian mass may only be described by location, size, and other attributes. The importance of size has been discussed above. The descriptors used can give an indication of the type of cyst that might be present. A cyst described as fluid filled with regular borders is often a simple follicular cyst. The ultrasound term anechoic (no echos) may be used to describe fluid, either cyst fluid or fresh blood.

A complex ovarian cyst generates more concern. A cyst that is a mixture of solid and fluid elements, or is solid, is not a simple follicular cyst. The presence of irregular borders, or septations (internal walls dividing the cyst into separate spaces) are more concerning features found in complex cysts. Other terms which may be linked to complex cysts are: mural nodule, fluid-debris level, retracting blood clot, or a mix of anechoic to hyperechoic appearances.

How Reliable is Ultrasound?

While simple ovarian cysts can usually be diagnosed by vaginal ultrasound, the question arises "How reliable is ultrasound when the cyst is complex?" One well done study (Jermy, 2001), looked at the reliability of ultrasound to make a correct diagnosis for possible endometriosis or dermoid types of complex ovarian cysts. After the mass was removed it was found that ultrasound was successful in predicting 96% of endometriosis cysts and 97% of dermoids. There were no ovarian cancers found.

What Should I Expect for Treatment?

If a simple cyst is suspected, the only treatment may be a repeat ultrasound in six to eight weeks to be sure that it is resolving. If the cyst is very large, and ovarian torsion is a concern, then more frequent ultrasounds may be performed.

Previously, birth control pills (BCPs) were commonly prescribed in an attempt to treat simple ovarian cysts. Studies comparing the use of BCPs to "expectant treatment" (Turan, 1994) began to suggest that "watch and wait" was as effective as treating with BCPs. More recently (Sanersak, 2006) found that low dose monophasic pills were not statistically better at treating functional ovarian cysts than following women with routine ultrasound screening.

In terms of prevention of ovarian cysts, several studies have examined the role for birth control pills. In an older study (Vessey, 1987) there was a 78% reduction in corpus luteum cysts and a 49% reduction in follicular cysts among women who had taken high dose birth control pills within the previous six months. A later study (Lanes, 1992) compared older, high dose mono-phasic pills to lower dose mono-phasic pills, and lower dose tri-phasic pills. This group found that the lower dose pills conferred less protection for functional cysts than did the older types of birth control pills.

Related Topics:

• Your Guide to Menstrual Cramps
• Menstrual Problems: Quiz

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If It's Not Menopause, What Is It?

It's hard to believe, but the first landmark study of women's perceptions of menopause (Neugarten, 1965) found that, "Not knowing what to expect" was midlife women's greatest concern. Since that time there has been an explosion in scientific, and popular, publications pertaining to menopause. Women now are well acquainted with menopausal signs and symptoms. They know what to expect. So the question has shifted to "If it's not menopause, then what is the cause of my menopause-like symptoms?" Let's examine some of the more common symptoms and see what else might be at fault.

Irregular or absent menstrual periods

While a few women will suddenly reach menopause, or the last natural period, most will have sign posts for the upcoming change. The most common sign is marked menstrual changes. The official definition of "perimenopause" is the four to five years before last menstrual period. Perimenopause also includes the first year of no periods following the last menstrual flow. Marked menstrual changes are considered to be: cycle length between flows more than seven days different from normal, and/or more than 60 days of no periods.

There can be other reasons for missed, or irregular, periods. It is possible to conceive right up until the last natural period. If birth control is not being used, pregnancy must be ruled out. If pregnancy is not detected then the next most common cause of menstrual changes is missed, or late, ovulations. In a normal cycle, estrogen is produced all month. Estrogen is responsible for building up the lining of your uterus so you have something to shed each month.

In a normal cycle, progesterone production increases following ovulation and release of an egg.. Progesterone "stabilizes" the uterine lining in preparation for possible implantation of a new pregnancy. If you are not pregnant that month, the levels of estrogen and progesterone fall, triggering the release of the uterine lining--your period. So, if you do not ovulate, the estrogen build up of the lining continues, but without the usual ovulation associated progesterone. Thus, the hormone levels don't decline, and the lining stays up inside the uterus--your missed period.

One can enter a pattern of non-ovulation at any time after menstrual periods first begin. Causes for not ovulating are multifold: thyroid problems, pituitary problems, ovarian cysts, physical stressors (eg sudden increases in exercise, crash dieting), emotional stressors (problems with parents or boyfriends/girlfriends, exams), increased body weight, anorexia, rotating shifts at work, etc. Yet as women move into their 40's one of the most common causes for not ovulating regularly is "old eggs"--the aging of the remaining follicles in their ovaries. This possibility for erratic ovulations can make the diagnosis of menopause more difficult. If one is experiencing irregular or missed periods at any age it is important to check with a GYN, or other healthcare provider, to help make a correct diagnosis.

Hot flashes

Flashes are the second most often reported symptom by perimenopausal women. Hot flashes and night sweats can onset during perimenopause, and generally peak during the first two years after the last menstrual period.

Hot flashes have been linked to abrupt changes in estrogen levels. Typically they are seen during the hormone swings of perimenopause. Yet other medical conditions can prompt flashes and/or night sweats. These include: hyperthyroidism, infections (eg HIV/AIDS, TB, malaria), some types of cancers (eg pancreas, adrenal gland, leukemia), generalized anxiety/panic, and autoimmune disorders. Many women have noted a sensation of flushing when the sympathetic nervous system ("fight or flight" response) is activated. Even being a heavy cigarette smoker can be linked to more hot flash activity as smoking decreases blood estrogen levels. Lastly, some medications (eg serotonin [SSRI]antidepressants, raloxifene, and others) have been noted to prompt flashes. If your flashes appeared after starting a new medication be sure to ask your pharmacist if flashes are noted as a possible side effect.

Sleep disturbances

One study (National Sleep Foundation, 2002) confirmed what many midlife women have suspected. Perimenopausal and postmenopausal women do have less sleep, marred by shortened sleep hours, and more problems with either difficulty initiating sleep or remaining asleep. While night sweats are a prime suspect in the problem of poor sleep, sleep disturbances can arise from other sources.

Physical causes of poor sleep include sleep apnea and other problems with breathing, digestive problems such as gastro-esophageal reflex disorder ("GERD"), painful conditions such as arthritis or diabetic neuropathy, and hyperthyroidism. Some medications (eg asthma drugs, steroids such as prednisone, Dilantin, and stimulants) have side effects which alter sleep architecture. Psychological causes for insomnia can comprise high stress life events, and/or depression, anxiety, or psychosis.

Mood swings

Longitudinal studies, where a large group of women is followed through the transition into menopause, have contributed the best information about mood swings. The women in such studies are not presenting at their doctor's office with specific complaints of mood problems. Rather they are living their daily routines and are surveyed using questionnaires, or interviews. Earlier studies (Kaufert 1992, McKinley 1992, and Woods 1997) found that a prior history of mood disorders, including PMS/PMDD, helped predict who was likely to become depressed during perimenopause. As might be expected, poor health, and increased levels of life stressors, made depression more likely to occur.

Interestingly, when the presence of severe hot flashes/poor sleep, and a history of prior depression were controlled for when analyzing the women's data an interesting fact was found. The greatest incidence of down moods was in the perimenopause, not in pre-menopause (Bromberger 2003) or post-menopause (Freeman 2004). It would seem that there is a time of increased vulnerability to mood swings as one approaches menopause.

Other causes of mood swings can include: unrecognized clinical depression or anxiety, life stressors unique to midlife (eg new medical problems, changes in relationship or parental dynamics, one's aging parents needs, etc.), low thyroid, and endocrine disorders. If one is experiencing mood swings which are impacting her quality of life, it is important to see a healthcare provider for an assessment of physical and psychological causes.

Vaginal dryness

Vaginal dryness can arise at any age. Frequently it is seen in breastfeeding women as low estrogen levels are triggered by the hormone of lactation, prolactin. Some young women using DepoProvera as a contraceptive can also develop lowered estrogen levels and experience vaginal dryness. The sensation of vaginal dryness, when due to lowered estrogen level is marked by both decreased lubrication, and thinner, more fragile vaginal tissues. The vaginal pH will be more alkaline. Fewer of the beneficial, hydrogen peroxide producing lactobacilli will be present.

Other medical conditions which can create vaginal dryness include: benign pituitary mass, diabetes, and Sjogren's syndrome. Medications such as Lupron, antihistamines, diuretics, or drugs which create dry mouth (eg tricyclic antidepressants) have the potential to create vaginal dryness as well. Radiation therapy may prompt vaginal dryness and tissue fragility. Yeast infections, or vulvar dermatology problems (eg lichen planus, or lichen sclerosus), can be interpreted as a dry, uncomfortable feeling in the vagina. Even poor lubrication due to genital pain, or inadequate sexual arousal, can create a subjective sensation of vaginal dryness.

Heart palpitations

It is common with hot flashes to experience an increase in heart rate during the flash. Increased heart rates can also arise when one is stressed, anxious, or having a panic attack. There are cardiac conditions where heart rate can dramatically speed up or actually become quite irregular. If one is experiencing irregular or very elevated heart rates it may necessitate an electrocardiogram (ECG), a treadmill ECG, or a monitor to be worn for 24 hours to detect the arrhythmia.

Is There a "False Negative" on a Test for Menopause?

One can be in perimenopause and have blood tests which do not confirm that diagnosis. This is the reason many healthcare providers chose not to do such tests routinely. There are blood tests (eg inhibin B) used in research settings which are very sensitive indicators of ovarian aging. But the two most common tests FSH, (follicle stimulating hormone) and estrogen (estradiol), are subject to swings in and out of "normal" range.

With ovarian aging it can take much more FSH to push the ovary to produce normal, "young women" levels of estrogen. In general an FSH level greater than 20 mlU/ml suggests approaching menopause. The problem arises when the increasing FSH levels push the ovary to create more estrogen. The resulting spike in estrogen pushes FSH levels back down. This is similar to a thermostat turning off once the heat in the room has returned to an appropriate temperature. Thus, if your GYN were to draw an FSH or estrogen level they would look normal---whereas several weeks before the FSH would be higher than 20 and the estrogen less than 40. This unpredictable variability makes diagnosis of perimenopause less reliable than, say, a blood sugar to rule out diabetes.

Some GYNs will add an additional blood test called LH (lutenizing hormone) which also becomes higher at menopause. However, this increase in LH happens later in the menopause transition so it is not very helpful in early perimenopause.

Finally, the journey into menopause can take a varying amount of time. One source maintains that the range of years during the transition can be from "zero to ten years". Up to 20% of women will enter menopause without significant symptoms. While I would hope that this would be the case for you, any significant symptoms should be assessed before being reflexively attributed to menopause.

Related Topics:

• Too Young for Menopause
• Your Guide to Menopause

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What ARE Those Little White Bumps?

One of the most frequent concerns expressed on our WebMD GYN message board, and our "Friends Talking" message boards relates to "bumps" or "pimples" on the vulva. Usually these lesions have just been noticed, rather than being present for a long time. So let's consider what some of the causes might be.

Occasionally a woman will refer to the raised lesion as a "cyst". Cysts are a common occurrence, and can arise most any place on the body. In the area of the vulva a cyst is usually created by a blocked sweat ("apocrine") or skin ("sebaceous gland") gland. For example, if a hair follicle gets blocked it can fill with the debris of exfoliated/shed skin cells which causes the lining of the follicle to get distended. This is similar to what happens when one develops a "white head" pimple on the face. On the genitals, such cysts are called "epithelial inclusion cysts".

If the cyst continues to enlarge to a size greater than a half inch, it can incised with a sterile instrument and drained in a sterile fashion. While some women attempt to "squeeze" a cyst to extrude the "cheese-like" skin-cell debris, this is not a good idea. Normal skin bacteria can enter through the break in the skin and set up an infection.

There are some specific genital sites where drainage ducts can get blocked and create cysts. These are named after the area in which they occur:

• Skene's duct cysts are located on either side of the urethra. These may be treated with warm moist soaks--or can require incision and drainage.


• Vaginal cysts of embryonic origin typically are not a recent blocked duct opening. Rather they are a cyst which developed in utero. These are treated with surgical excision if they continue to grow in size over time.
• Bartholin's duct cysts can develop on either side of the lower portion of the labia majora. These can grow to be the size of walnuts and usually are noticed because of a rapid increase in size and tenderness. Three times per day warm soaks or sitz baths are tried first, followed by incision and drainage if needed. Bartholin's cysts tend to reoccur. If this happens the cyst may be surgically opened and the sides sewn open (like keeping a purse permanently open) to be sure no fluid or skin cells accumulate. This procedure is called "marsupialization."

There are two conditions where clogged sweat glands can create bumps on the vulva:

• Fox Fordyce is an itchy type of skin lesion which can range in size from small papules to cyst sized bumps. They may also be found on the lower abdomen and thighs. Keratin or skin debris clogs the apocrine/sweat glands, thus it is not a bacterial infection which requires antibiotics. It may be treated with a steroid cream or phototherapy.


• Hiradenitis suppurativa, by contrast, is a clogged sweat gland which often has a secondary bacterial infection associated with the bumps. This condition does not itch, but can be very painful if deep, infected cysts or nodules form. These areas tend to leave a shiny scar of darkened skin. Somewhat more common in women who have acne, these lesions are often treated with acne-type approaches such as oral or topical antibiotics, or even oral Accutane. Steroids and birth control pills have also been tried. If there are large hardened nodules, or draining fistulas (tracts for pus to travel from one nodule to another), the area can be surgically treated

While on the subject of infections we should mention some of the most common vulvar infections which can create bumps or pimples:

• Folliculitis is the most common cause of irritated or tender, raised lesions. Common skin bacterias such as staph or strep get into a hair follicle through a tiny break in the skin (eg bikini shave nicks). The area of infection can remain a small "folliculitis" or it can increase in size to become a "furuncle." A larger, or deeper, infected skin abscess is called a "carbuncle." Depending upon the size and degree of infection, incision/drainage or antibiotics may be utilized as treatments.


• Skene's duct, or Bartholin's duct, abscesses might require antibiotics if a bacterial infection takes advantage of the cyst formed in the clitoral or labial area.

Sometimes the infection is viral rather than bacterial:

• Molluscum contagiosum is caused by a pox virus. The bumps on the vulva or thighs are small, fleshy, and round often with a small indentation in the middle of the round lesion--like a bellybutton. These bumps tend to regress in time even without treatment. For cosmetic purposes they can be removed by freezing/cryo.


• Human papilloma virus (HPV) subtypes 6 and 11 cause the visible genital warts which look like little cauliflowers. These rough to touch, raised growths can expand in size and number--especially in times of a suppressed immune system (eg pregnancy, illness, etc.). HPV lesions can be treated with applications of bi or trichlorocetic acid, freezing/cryo, or an immune system enhancing cream ("Aldara").


• Herpes simplex virus (HSV) is more often linked to an itching, burning area which might be slightly raised. It can look like a bug bite in its early stages, but within several days it becomes an open ulcer or cut in the skin--not a bump.

There are a number of medical conditions which can produce bumps which are not related to clogged ducts or infections:

• Acanthosis nigricans produces velvety, dark raised areas on the vulva, armpits, and neckline. It is linked with insulin resistance, the metabolic change found in polycystic ovarian syndrome ("PCOS").


• Neurofibromatosis creates nodular areas all over the body, not just the vulva. This is an uncommon, genetically transmitted disorder.


• Angiokeratomas as the name implies are created by small blood vessels. When there are dilated capillaries grouped together dark red to purple raised spots are visible. There may not be any symptoms until friction to the capillaries causes bleeding. Treatment is by freezing/cryo or surgical removal.

Lastly there are "normal" findings which a woman may suddenly discover:

• Skin tags, or even remnants of the hymenal ring around the vaginal opening, can be mistaken for bumps. As one might expect these are soft and fleshy with irregular shapes.


• Papillomatosis is frequently mistaken for genital warts, but is a normal variation in the vaginal/vulvar anatomy. If genital warts look like a cauliflower, these look like stalks of asparagus--more fingerlike than raised bumps.

Given the multitude of possible causes of bumps or lesions in the genital area it is important to have them examined by a GYN or other healthcare provider to ensure proper treatment. For more in-depth information you can visit this WebMD site targeted to healthcare personnel.

Related Topics:

• Cysts, Lumps and Bumps
• Get the STD Picture

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Chlamydia: From Whom, How Long Ago, and What About My Fertility?

Given that Chlamydia is the most common of the reportable sexually transmitted infection/sexually transmitted disease (STI or STD) we get many questions here at WebMD from very worried women. The most concerned questions tend to be focused on how/when the infection was acquired, and what impact will it have on future fertility. The following is a summary of the answers to those questions, and some related issues as well.

Who Gave Me Chlamydia?

If you are a sexually active woman aged twenty five years or less--and especially if you are aged less than twenty--you are a part of the largest Chlamydia infection demographic. If you are a female performing receptive oral, anal, or vaginal sex you can get Chlamydia, if secretion contact is present. Thus you need to be honest with your GYN about your sexual practices so you can be screened for possible Chlamydia infections of the pharynx, rectum, or vagina/cervix. Chlamydia can be passed between both heterosexual, and same sex couples-although its incidence is less than 1% in women who are exclusively lesbian.

How Long Ago Did I Get Chlamydia?

The incubation of a Chlamydia infection is reported to be one to three weeks. It can take up to six weeks in some cases. From one perspective it would be great if one could count back a few weeks to find the culprit-partner. But that would require that tell-tale symptoms be present. Alas, up to 75% of women and perhaps 50% of men have no symptoms. This can make it difficult to establish blame for the infection. It also means that infected persons can unknowingly continue to spread Chlamydia for a long time.

Many family planning programs do universal screening for Chlamydia among women aged twenty five or less--or if there is a new sexual partner. Certainly if a woman comes in with symptoms of vaginal discharge, the GYN or clinic would be likely to test for STDs, as well as for other vaginal infections. There is often screening during the initial prenatal visits in an attempt to prevent the infant from becoming infected during delivery with Chlamydial infections of the eyes or lungs.

Other instances when a woman might be tested for Chlamydia would be if she presents for an infertility work up, or with pain from a pelvic infection. These two conditions are linked. If Chlamydia ascends up through the cervix to infect the uterus/tubes/ovaries a woman can develop "Pelvic Inflammatory Disease" ("PID"). Some symptoms of PID include: lower abdominal pain, pain with sex, breakthrough bleeding, fever, or even nausea.

Studies have shown that between 20-40% of women with untreated Chlamydia will go on to develop scarring inside the Fallopian tubes, or bands of scar tissue ("adhesions") inside the pelvis. Inflammation from the untreated infection creates this scarring. This impacts fertility by blocking the tubes so fertilization cannot occur, and by "webbing" the open end of the Fallopian tubes to impair egg "capture" at ovulation. One author (Mardah, 2004 ) posits that the "The tubal infection may become chronic in spite of antibiotic therapy." This would infer that even after treatment a percentage of women may have tubal damage.

How Will Chlamydia Affect MY Fertility?

It has been calculated that perhaps 1,000,000 women per year will get PID of some type. Of those, an estimated 10% will develop infertility. One landmark study (Westrom, 1996) followed almost 1,500 women, of whom about 2/3 had confirmed PID as documented by a laproscope. Among the women with a PID history 7.8% had tubal occlusion where the tube was scarred closed. By contrast, a comparison group without PID had less than 1% tubal occlusions.

In this same study it was determined that the risk of PID caused infertility was tied to:

The number of times a woman had PID:
Zero episodes---1%
Two episodes---11.3%
Three episodes--19.8%

The severity of the infection influenced the relative risk (RR) of tubal infertility:

Mild infection-------- RR 1.0
Moderate infection---RR 1.8
Severe infection------RR 5.6

PID can be caused by other organisms (eg gonorrhea, anaerobic bacteria), thus this study attempted to identify the risk of tubal damage from having only Chlamydia :

Nonchlamydial--------RR 1.0
Chlamydia-------------RR 1.7

From this data it can be inferred that the greatest impact of Chlamydia on fertility would arise if a woman had a severe PID and/or repeated infections.

Could I have had a false positive Chlamydia test?

There are a variety of tests for Chlamydia; each has its own specificity and sensitivity which means that each has a different risk of false results. There are three basic types: culture, immunoassay, and nucleic acid amplification (NAAT). For a clear explanation of each, click here.

To summarize the scientific studies comparing the reliability of the various tests, the culture and immunoassay types are between 10-30% less sensitive than the nucleic acid amplification tests (Gaydos, 2004). A few of the immunoassay tests will cross react with the subtypes of Chlamydia which are not implicated in GYN infections. Some labs will do a confirmatory test if the screening test is positive--especially if a non-NAAT variety. It is important to note that false negative tests can occur as well.

 Thus if Chlamydia is suspected a clinician will often "treat first; ask questions later." Given the lack of symptoms in many Chlamydia infections this may be the best way to prevent its GYN outcomes.

Related Topics:

• Chlamydia, STD Rates Soar in US
• Learn about STD Testing

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So You Want to Leave Your Period Behind?

Remember the passage in The Diary of Anne Frank where she talks about the excitement and "sweet secret" of getting her first period? Perhaps many of us felt some excitement, a rite of passage into the world of women, when first visited by "Aunt Flo." But with passing years the perceptions of menstruation might be less kindly. "The Curse" with its pads/tampons/cramps and various inconveniences was not a welcome visitor anymore - unless one was concerned about an unintended pregnancy.

For an excellent read about the cultural history of menstruation I highly recommend that you check out a copy of Delaney, Lupton, and Toth's entertaining discourse The Curse: A Cultural History of Menstruation, first published in 1976. Within that book one can visit "Menstrual Images in Literature," "Menstrual Taboos" and other fascinating topics from a feminist viewpoint.

At the time of the most recent edition of that book (1988), DepoProvera was not yet approved for use in the USA (that happened in October 1992), and all birth control pills were packaged with seven days of milk sugar or iron placebo pills. Women were routinely instructed to start their birth control pills (BCPs) on the first Sunday after the beginning of menses. This would ensure that most women would not be on their "pill periods" during a weekend. More progressive GYNs were suggesting starting BCPs on the first day of flow to decrease the need of a back up method. A few GYNs were advising patients to take only the active pills to try and avoid a scheduled bleed. Usually, this method of pill taking was reserved for medical indications such as menstrual migraines, severe premenstrual symptoms, or endometriosis.

Things have certainly changed. In May of 2007 the Food and Drug Administration approved Lybrel, the first birth control pill approved to be used without any placebo pills. This was the final step that followed the introduction of four days of placebo pills (Yaz), and a week of placebo pills only every third month (Seasonale). What are the pluses or minuses around trying to eliminate menstrual periods? Let's look at things you might want to consider.

"No Period on the Pill" is not the same as "Missed Periods on Your Own"

In a normal menstrual month, estrogen is produced all month long, and the majority of progesterone is produced in the two weeks after ovulation. If your uterine lining could be considered as your grass or lawn—then estrogen is like fertilizer (it stimulates the lining to grow thicker). In this analogy, progesterone is like the lawn mower—it prevents the grass from getting too thick and tall. When progesterone leaves the scene (ie conception does not occur with that ovulation), the grass clippings are dumped—your menstrual flow.

DepoProvera ("the shot") is a very large dose of synthetic progesterone. This is like having heavy duty lawnmower activity everyday. That's why DepoProvera for birth control can prompt women to not have periods. There is not that much lining to shed. All birth control pills (BCPs) contain synthetic progesterone. This is why most women on BCPs will have shorter, lighter periods. Even BCP users can develop such a thin uterine lining that their periods will disappear. So for a woman using hormonal forms of birth control (even the progesterone containing IUD) menstruation can disappear as the uterine lining becomes thin. Generally speaking a thin uterine lining is a good thing. It decreases the risk of the most common form of uterine cancer. Once the hormonal contribution of the birth control is out of the woman's body her original menstruation pattern will return.

By contrast, when a woman misses a period(s), and she is not taking hormonal forms of birth control, that can result in health problems. The most common reason for not having a period (once pregnancy is ruled out) is missed ovulations. In this instance, the uterine lining grows very thick from continued estrogen effects. Without the lawn mower effects of progesterone the lining becomes very thick. When the lining begins to shed, the bleeding can be very heavy and/or prolonged. An overly thickened lining provides a setting for abnormal cells to arise. These can set the stage for cancer of the uterine lining.

What Happens When Continuous Birth Control Pills Are Taken?

Remember in most birth control pills (BCPs) there is both synthetic estrogen and progesterone in each active pill. So everyday the uterine lining gets some fertilizer effects and some lawn mowing effects. During the placebo week of a pill pack, the blood levels of synthetic estrogen and progesterone fall. This causes the lining of the uterus to become destabilized and shed. When pills/patch/ring are used continuously a thick lining is NOT being created, or retained, inside the uterus. If there is no week when the hormones are withdrawn, there is no regular "pill period" ("hormone withdrawal bleed").

In the ideal world this would mean that there is no bleeding until the medication is stopped. However, as many women know from experience, breakthrough bleeding and unscheduled spotting can be common among users of pill/patch/shot/vaginal ring forms of birth control. This is one of the greatest possible drawbacks to "continuous" or "long cycle" regimens of BCPs. In the initial studies on Lybrel, only one third of participants had no bleeding or spotting after about a year's use.

So What Are the Downsides - If Any?

As discussed above, having to deal with some breakthrough bleeding or spotting is a real possibility. Absent menstrual periods can be a big advantage, but if one is worried about an undetected pregnancy, theoretically a woman could be spending more on pregnancy tests. For women who experience decreased sex drive on hormonal birth control (due to loss of pre-ovulatory testosterone, and lower free testosterone levels) increased pill usage would likely not improve the problem. Finally, there is no long term data on using BCPs continuously. With intensive scrutiny for almost fifty years, the largest studies have not suggested a link between BCP use and development of breast cancer.

For some women there is a strong symbolic link between regular menstruation and their concept of femininity. There is a subculture of menstrual rituals including the use of washable menstrual pads, then using the soaking water to water plants. The loss of the cyclic rituals, shared or private, might be mourned with the absence of regular flows.

Am I a Good Candidate to Try and Eliminate My Periods?

Only your own GYN or clinic can give you a conclusive answer. Yet, if you are a successful and satisfied user of hormonal forms of birth control you could easily try an extended use regimen. Your own GYN can discuss the various options such as the FDA approved Lybrel or even using your current method without a hormone free week. Whatever you try, just remember you can always decide to bail out and try something else.

Related Topics:

• Birth Control Health Center
• Choosing a Birth Control Method

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Feel Pregnant but the Pregnancy Test is Negative?

I frequently see posts on my message board which state, "My pregnancy test is negative, but I feel pregnant" or "What about common symptoms of pregnancy; if I’m not pregnant what could be causing them?" Let's look at some of the most common signs of pregnancy:

Nausea and vomiting. Generally speaking the nausea and vomiting of pregnancy are presumed to start about four weeks from conception. Some other causes of nausea and vomiting are viral, or bacterial, infections in the bowel. Appendicitis, or problems with the gall bladder or pancreas, can provoke nausea. Neurologic conditions such as migraine headaches or increased intracranial pressure can induce nausea. Even severe emotional or physical stressors can make one queasy. Less common are the psychiatric causes including anorexia, bulimia, and anxiety disorders.

Breast tenderness/sensitivity. Bilateral breast tenderness can be a very early sign of pregnancy, appearing as early as two weeks after conception. This is thought to be related to increasing levels of hormones such as estrogen. In a month without an ovulation, not only can a menstrual period be missed, but there can be breast tenderness as well. This is similar to the increased breast tenderness experienced by some women when first taking postmenopausal hormone therapy. There are many other causes of breast pain (e.g., infections, herpes zoster) but most often these occur on one breast - not both.

Enlarging abdomen. It is not until the second trimester that most women can begin to feel an enlarging uterus by pressing on the abdomen. Sometimes a large fibroid can feel and look like a pregnancy, but this is not very common. Overall abdominal distension can arise from fluid shifts in the bowel (cause of premenstrual bloating), air in the bowel, or food intolerances (lactose, gluten, etc). Much more remotely, fluid in the abdominal cavity ("ascites") can be a product of ovarian cancer or liver disease.

Fatigue. While many women complain of fatigue in their premenstrual week, early pregnancy can produce profound tiredness. Fatigue in the first trimester has been attributed to the rapid rise in progesterone. One of the metabolites of natural progesterone uses the same brain binding sites as the "Valium-type" drugs. Fatigue is also one of the most common symptoms for a myriad of medical conditions as well. Infections, anemia, electrolyte imbalances, low thyroid, diabetes, MS, cortisol abnormalities, cancer, depression, stress, and a variety of medications have all been linked to the symptom of fatigue.

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Is your pregnancy test giving you a "false negative" result when you are in fact very early pregnant? In this instance the false negative can arise from three problems.

• First of all check the box to be sure that the product has not expired or shows visible signs of damage.
  
• Second, check to see if the sensitivity of the test purchased is 20 international units of pregnancy hormone (HCG). If it is more than that, it could be less sensitive to low levels of HCG. In this instance you might wish to wait until at least a week after the missed period so that HCG levels are high enough to trigger a "true positive".
  
• Third, and the least common problem, would be a missed miscarriage. If there was an early pregnancy, which was then lost but has not yet produced bleeding, the pregnancy test would return as "not pregnant". This is a difficult diagnosis to make. The most conclusive way to confirm a miscarriage is to have sequential blood pregnancy tests which show dropping HCG levels in amount which may be too low for a standard urine test to detect.

To summarize, there are many conditions which can produce "pregnancy symptoms". If one continues to have such symptoms despite a negative pregnancy test, it is best to see your GYN or clinic and get some additional testing.

Related Topics:

• Pregnancy Symptoms: What They Never Told You
• 6 Embarrassing Pregnancy Symptoms

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