All About Breasts

My Breasts Don't Look Normal. Is Something Wrong?

Given the breast centered focus of western civilization it's no surprise that many women are critical of the size and shape of their breasts. But what if something is truly abnormal about a young woman's breasts - would she know it? The purpose of this post is to try and address what is within the range of normal for breast appearance - and what may not be.

Age Matters
What is too early for the beginnings of breast development? Many mothers would be surprised to hear that breast development is not considered premature if it appears in African American girls by age of seven, or in other girls by age eight! Mothers then worry about the development of premature/precocious puberty (full breast development, menstrual periods, etc). Fortunately 80% of early-developing girls will not come fully into puberty. In fact, breast development may halt, only to reappear at the more usual time.

So what is the usual time to be "developed"? Lack of any breast development by age thirteen merits some monitoring. The small, firm breast buds usually appear about age eleven. By age thirteen a majority of girls have the beginnings of a mound-shape of breast tissue. Unless there is an overt reason for lack of development such as illness, radiation exposure, or hormonal problems there is evidence that breast development can continue until one's early 20's.

Size Might Matter
While most all of us have at least some difference in size between our two breasts, there are situations where the size difference is very apparent. Size differences which onset in teen years will likely equalize for about 75% of women.

Very large breasts can develop in teen women. This can occur on just one side or be bilateral. In this instance normalization of size is unlikely to happen. While a tumor can prompt a very large breast, most enlargement is related to a robust tissue response to normal hormonal influences. According to DeSilva (2006) there is no increased risk for breast cancer among young women with an extremely enlarged breast. Cosmetic surgery, if indicated, can be done. Reduction of a very large breast(s) is called reduction mammoplasty. Unlike breast augmentation (i.e. breast implants) there is usually more apparent scarring.

Conversely, there can be insufficient breast development on one or both breasts. One type that seems to cause particular distress creates a tall tube shaped breast. There is tissue growth under the nipple, but no rounded breast mound. Again, plastic surgery is the usual treatment.

Extra Nipples?
Having extra nipples has been reported in 1-2% of women. The line along which extra nipples are usually found extends from the armpit to the groin. Extra nipples do not usually have associated breast tissue so they may go unnoticed. A woman may think that the "accessory nipple" is a mole or other skin lesion. These do not have to be surgically removed unless, like a mole, they become inflamed by restrictive underwear or clothes.

Hormonal Medications
It has been noted that women using birth control pills may experience bilateral breast enlargement. This has been attributed to the hormone estrogen. A similar effect can occur in older women using post-menopausal hormonal therapy. Usually this is not a lasting effect, and size goes back down when the medication is stopped.

Previously, medications which block estrogen effects were tried as a treatment for too early or excessive breast development (Bloom 2008). This is not a standard treatment, however.

Breast Enlargement Options?
There are breast enlarging creams and herbal products advertised on the internet. As new products are touted, our Women's Health Board gets a spate of questions about the effectiveness of such products. The array of products includes pills, creams, devices, and even a chewing gum! I would concur with the review article written by Dr. A. Fugh-Berman (2003) published in the journal Obstetrics/Gynecology. She investigated many of the herbal ingredients touted to increase breast size. A few ingredients have the possibility of producing weak estrogen-like hormones. Yet most have no data to support their use for breast enlargement. Perhaps most concerning is there are no long term safety studies. In the real world, women may not use such products for very long when the promised 3-5 cup size increase does not appear.

Honestly, the most reliable way to get a larger breast size (short of weight gain or pregnancy) is breast augmentation done by surgically inserting a saline or silicone implant. The American Society of Plastic Surgeons reports an increase for cosmetic surgery from 14,000 in 1996 to 333,000 in 2005 for patients under age eighteen. At least 90% of those were females. Breast augmentation is one of the two most frequent plastic surgery procedures performed on teens (Zuckerman, 2008).

Since most health insurance will not cover breast augmentation, the costs have to be borne by the young woman, or her family. While the decision to do augmentation is a very personal decision it is worth understanding some of the risks. The FDA has not approved the use of saline implants in women under age 18, nor the use of silicone implants in women age 21 and younger. Surgeons can still do the procedure, but the benefits have not been demonstrated to out weigh the risks to the satisfaction of the FDA. Currently breast implants have a limited life expectancy. According to Zuckerman breast implants typically last about 10 years, and there is an increased of scar tissue formation the longer the implant is in place.

Interestingly, a study of women planning to get breast implants because of dissatisfaction with being too small, found that there was no difference in bra sizes compared to a group of women who were satisfied with their breast sizes (Didie, 2003).

Jane's Economy Breast Lift
Thus far we have moved from discussing medically focused breast issues through more self-concept, or cosmetic, concerns. Most women can think of a change in breast size, or firmness which they would prefer if the Fairy Godmother of Breast Structure was to grant them a wish. Would you be willing to develop a firmer breast profile without drugs, surgery, or any cost? OK, I was skeptical, too. But here it is-free to my readers:

Chest Exercises to Help Tone and More

If you do a few simple exercises, especially if combined with a balanced body work out, you will get better contours. As a bonus, saggy underarms (triceps flop) can improve. It will not increase or decrease your cup size by three to five sizes, but it will make what you have look better. And after all, isn't enhancing what we have been given what it's all about?

Related Topics:

• WebMD Video: Lollipop Breast Reduction
• WebMD Video: Breast Implants - Size Matters
• A Lifetime of Healthy Breasts
• Mastopexy or Breast Lifting Procedures
• GYN Issues with Jane Harrison-Hohner, RN, RNP
• Get the Women's Health newsletter in your inbox weekly

Can A Vagina Be Too Big?

Faithful readers of this blog may remember that Masters and Johnson examined the vaginal sizes of 100 women who had never been pregnant. These women showed an un-stimulated vaginal length of 2 ¾-3 ¼ inches , with a ¾ inch width at the back of the vagina. During the sexual excitement phase the vaginal lengths increased to 3 ¾- 5 ¾ inches, with the width at the back of the vagina being 2 ¼-2 ½ inches. This correlates with our most common diaphragm sizes which are between 2 ½ -3 ½ inches in length.

"But I'm not worried about vaginal length," you might be thinking. "My problem is that I think my vagina is too loose - or too wide. Is that possible? If so what can I do?" Let's examine some of the medical data available to answer these questions.

Is my vagina too loose?
The vagina is like a collapsed, expandable tube lined with skin; the tissue below the skin is loose and contains large veins. Next are smaller circular muscles surrounded by stronger bands of muscle which run the length of the vagina. In addition, the lower third of the vagina is surrounded by a ring of muscles. This is covered by more connective tissue and blood vessels. Damage to these muscles, or if they become thin and weak, can allow the bladder ("cytocele") or rectum ("rectocele") to pouch into the vagina. Thus you can understand the importance of strong vaginal muscles. The ring of muscles around the vaginal opening contract during orgasm and may contribute to the intensity of an orgasm.

So what is too loose? This can be a matter of opinion based upon the input of a sexual partner, or one's observations of vaginal tone. Researchers have devised some ways to measure vaginal tone such as a pressure sensitive intravaginal balloon device, and ultrasound measurements of vaginal area ("pelvic floor") muscle thickness. A study of 30 women aged 20-42 found that better developed vaginal muscles were linked to having orgasms, and getting physical exercise. Conversely, increased age and having been pregnant were linked to decreased strength of vaginal muscles (McKey and Dougherty 1986).

A more recent study using ultrasound measurements (Bernstein,1997) found similar connections. Muscle thickness decreases with age, especially in women older than 60. Women with urinary incontinence had thinner pelvic floor muscles than women who were not incontinent.

Will exercising the vaginal muscles make my vagina tighter?
Two ultrasound studies of women who exercised their vaginal muscles did find that their muscles were thicker and stronger after pelvic floor muscle training. Among women with urine leakage, their thinner muscles became the thickness of healthy women's pelvic floor muscles. Additionally, they had less urine leakage - whether the problem was from stress or urge types of incontinence. The use of vaginal cones and/or Kegel exercises to increase muscle strength were both found to improve tone and decrease urine loss. While some of these studies did not measure vaginal tightness per se, when muscle bulk is increased, a woman can voluntarily contract those muscles to make the vaginal opening tighter.

Do tighter vaginal muscles really improve sexual response?
Despite the fact that most every discussion of Kegel exercises includes improved sex, there are not many scientific studies to back up this claim. One recent publication (Dean, 2008) reported on sexual function and pelvic muscle factors for some 2,800 women. Women who delivered only by Caesarean section (and their partners) perceived they had better vaginal tone leading to improved sexual satisfaction. Women who were currently doing pelvic muscle exercises scored much better on sexual satisfaction questions than women who did not. Women with incontinence (probably thinner muscles) scored the worst on the sex questions.

I've tried Kegel exercises but they don't work for me.
Assuming that the Kegel exercises have been done correctly, it may be time to move to other options. One low tech choice is weighted vaginal cones. This is a set of weights, shaped more like a tampon than a cone, where one inserts the lightest version then uses the vaginal muscles to hold it up inside. This is done twice daily. When this is easy the next heaviest cone is used - and so on. This is to be done while going about normal activities so that gravity provides an additional challenge to keeping the weight up inside.

More technology is involved in the electrical stimulator. A tampon shaped probe is inserted in the vagina and small electric shocks cause the muscles to contract then relax. This is done about 20 minutes up to several times a week. One patient of mine who used this device found it sexually pleasurable.

Less commonly used may be the "magnetic chair" ("Neocontrol"). This chair uses magnetic action to stimulate the muscles. I know this sounds very "woo, woo", but there is good data showing its effectiveness. This device is not for home use; treatments are given twice weekly by specially trained health care personnel.

Will plastic surgery make my vagina smaller?
Many genital plastic surgery techniques are based upon GYN surgical procedures used for medical problems such as reconstruction after cancer treatment, gender change, repair of cystocele/rectocele, etc. Unfortunately there are few good studies showing benefit where there is no overt medical problem.

One study of 53 women in Santiago, Chile (Pardo, 2006) was done specifically for complaints of wide vagina and decreased sexual satisfaction. The surgeons did two procedures. The first was inside the vagina where tissue along the roof was stitched tighter. This is similar to the type of repair done for a cystocele. Secondly, tissue around the vaginal opening and between the vagina and anus was stitched tighter. This is similar to the type of repair done for episiotomies after childbirth. Six months after surgery 94% claimed they experienced a tighter vagina, and had regained or improved orgasms. Yet some 4% of the women said they regretted the surgery.

The problem with this type of study is that sexual response can be very subjective. There is no easy way to measure sexual satisfaction in a group of diverse women. Every woman knew she got the surgical treatment so six months may not be a long enough time for any placebo response to wear off.

The American College of Obstetricians and Gynecologists (ACOG, 2007) has noted the lack of both safety and effectiveness data for genital plastic surgery. The possible complications for such surgery might include: infection, changes in sensation, pain with intercourse, and scar tissue. One GYN who has been performing genital plastic surgery for a number of years (Goodman, 2009) concluded that agreed upon terminology and training standards are still lacking.

What are you going to do, Jane?
As a big advocate of resistance/weight training to build muscles, I personally think exercise is a better place to start than surgery. As always, if a woman has concerns about sexual function, vaginal/genital structures, etc she should bring these up to her GYN. A GYN sees the wide range of "normal" in vaginal appearances. Yet, if one is having sexual problems due to genital changes, your GYN needs to know that is an issue.

If you are interested in exercising your vaginal muscles here are some instructions to get your started: Kegel Exercises - Topic Overview.

Related Topics:

• Better Sex for Women?
• GYN Issues with Jane Harrison-Hohner, RN, RNP
• Get the Women's Health newsletter in your inbox weekly

Missed Periods - Premature Menopause?

As a reader of this blog you probably know that missed periods, very late, and erratic periods usually can be attributed to missed ovulations. Yet when hot flashes or night sweats are also present many younger women wonder "Could I have premature menopause?" After reading this post you should have the information needed to work with your GYN to get a definitive answer.

Is there a difference between early menopause, premature menopause, and premature ovarian failure?

Overall, menopause means the failure of ovaries to produce estrogen. Estrogen builds up the lining of the uterus so that there is something to shed as a period. Technically, if your uterus is removed with a hysterectomy you will have no more periods. Yet if the ovaries are still in place and working, a woman is not yet in menopause. If ovaries are taken out that is considered "surgical menopause."

According to the North American Menopause Society, early menopause is when the last, natural menstrual period occurs before age 45, while premature menopause indicates a woman aged 40 or less. Premature ovarian failure (POF), like premature menopause, also is linked to being age 40 or younger. Among researchers who study POF, a term used first by the French "Ovarian Insufficiency" may become the new standard term for POF. I'll explain why that is the most appropriate term in a moment.

How common is POF?
Overall the incidence in the USA is reported to be 1-4% of women. While POF can be triggered by medical interventions such as chemotherapy, radiation, or surgery, the greatest number of women will not have an observable cause. The majority of woman with POF will have had prior menstrual periods.

The exceptions to these generalizations are in teenagers, who have not yet had a first period. In this specific group there is a 50% incidence of an abnormal, genetic karyotype. If this is suspected specialized testing is done, along with genetic counseling.

Is it true that POF can reverse back to normal?
The answer here is both "yes" and "no". About half of younger women (age less than 40) with a clear diagnosis of POF will experience normal function of the ovary that can come and go. That's why the term "Ovarian Insufficiency" may end up as the new standard name for POF. Insufficiency suggests the status quo might return - it is not permanent as implied by the idea of "menopause."

Does that mean I COULD get pregnant after a diagnosis of POF?
The data suggests that 5-10% of POF women will conceive unexpectedly. That is good news if women are trying to conceive. But the majority of women with POF will usually have a family via donor eggs, or adoption. There have been numerous studies of ovulation induction treatments (eg. Clomid, estrogens, GnRH, FSH, etc.) for women with POF. Alas, the best designed studies have failed to show ovulation rates any better than in untreated POF women (Sinha, 2007).

What if I don't want to get pregnant?
Among women who become menopausal at around age 50, we suggest some type of birth control should be used for one year after the last period. For women with POF, contraception should be used for a minimum of two years. Because of the intermittent, and unpredictable, ovulations in some women there are reports of POF women conceiving 8-15 years after there diagnosis of POF! For birth control, barrier methods (eg condoms/spermicide, diaphragm) or birth control pills (BCPs) can be used. BCPs have the additional benefit of adding needed estrogen if a woman's ovaries are not producing their own estrogen. One study (Buckler, 1993) found that BCP use did not enhance the return of normal ovary function.

What should I ask of my GYN if I want them to check for POF?
There is no completely standardized evaluation for POF. Generally, the following four elements need to be present to make a diagnosis of POF:

• Absent periods for 4, or more, months
• Age 40 or less
• Evidence of low estrogen (eg vaginal dryness, hot flashes, etc)
• FSH blood test results of more than 40mIU on two tests taken a little over a month apart

Probably the most important part of the work up for POF is for the GYN to consider it as a possibility. One study of 48 women with POF found age 25 to be the average age of symptom onset, but it took two years to get the correct diagnosis. Almost two thirds of the women had to see three or more MDs before getting the correct diagnosis (Alzubaidi, 2002).

Where can I learn more?
Of all the internet sites I reviewed, I believe that these two have some of the best information.

• Premature Ovarian Failure Support Group
• National institutes of Health: Premature Ovarian Failure

Related Topics:

• Too Young for Menopause
• Menopause Health Center
• Get the Women's Health newsletter in your inbox weekly

I Have Pelvic Pain: Is It Cancer?

When women post to the Women's Health message board about pelvic pain they can describe symptoms which have recently started, or pain which has been present for six months or more. Despite the difference in duration of pain, everyone wants to know if cancer is a possible cause--and if cancer is not the cause then what is the culprit?

Fortunately cancer is not the usual suspect. Yet the list of possible causes extends beyond uterus, Fallopian tubes, and ovaries. The "female organs" are near the intestines, the bladder sits in front of the uterus, and there are networks of nerves which can conduct pain sensations from the actual site of pain to a more distant location ("referred pain"). The purpose of this post and the ones following is to share with you with some possible causes of pelvic pain. The information will be organized into recent pelvic pain, and pain of longer duration. Within those two categories pain sources from different body systems can be designated.

Acute Pelvic Pain
Acute pelvic pain is the medical term for pain that has recently started. Sometimes the onset can be very abrupt, in other conditions the pain builds slowly. Then too the pain can be present only at one time of the menstrual month. Let's look at true OB/GYN pain first.

Pregnancy caused pain:

• Miscarriage


• Tubal pregnancy ("ectopic") which has ruptured. This usually occurs before 7-10 weeks from the first day of the last period.


• Breakdown ("degeneration") of fibroid whose blood supply has been cut off. This can occur in the later part of pregnancy.

Gynecologic pain:

• Ruptured ovarian cyst. This can onset very suddenly, and if an ultrasound is done promptly it can image "free fluid in the "cul de sac" or fluid leaked by the cyst now present in the lowest part of the abdominal cavity.


• Large intact ovarian cyst. While this can prompt discomfort, the greatest pain occurs when a large cyst twists the ovary like a too heavy flower on a thin stalk. "Ovarian torsion" creates severe pain as the ovary's blood supply is twisted off leading to the ovary's death.


• Pelvic infection. This can be an infection of the lining of the uterus ("endometritis"), or a generalized infection of the uterus/tubes/ovaries ("pelvic inflammatory disease"/"PID"). If an infection has been present for a while the Fallopian tubes and/or the ovaries can develop an abscess or become fluid filled ("hydrosalpinx").


• Painful ovulation ("Mittelschmertz "). This pain generally occurs around midcycle (eg cycle day 14). It is prompted by the release of the egg/oocycte. As the oocyte is ejected from its follicle, the fluid from the follicle splashes the lining of the abdomen and creates a sharp sudden pain. Mittleschmertz generally resolves on its own after 48-72 hours.


• Cramps of menstruation ("primary dysmenorrhea"). Common menstrual cramps are caused by the release of prostaglandins from the lining of the uterus. Prostaglandins create both the cramps of labor and menstrual cramps by making the uterus contract. Common cramps may start prior to the onset of flow and usually last 72 hours. Cramps that increase in intensity, last increasingly longer over time, and start later in life suggest that endometriosis, not just prostaglandins, may be the villain.

Bladder & kidney sources of pain:

• Bladder infection (Urinary tract infection - UTI). Pain from a sudden bladder infection may be described as cramping, with burning during urination. Frequency, urgency, and small amounts of urine passed are common symptoms.


• Kidney infections ("pyelonephritis") will often start with UTI symptoms and progress to back pain at the level of the lower ribs.


• Kidney stone. Pain from a kidney stone can be sudden and so severe that the woman begins to vomit. There may be blood in the urine.

Bowel caused pain:

• Irritable bowel syndrome ("IBS") can start up after eating, or during stressful events. Bloating, gas, and constipation or diarrhea may be present.


• Infection ("gastroenteritis") of the intestines can be caused by bacteria, viruses, or even parasites. Diarrhea and nausea may accompany the painful cramping.


• Diverticulitis is a localized infection in a pouching out section of the bowel.


• Appendicitis pain may manifest with a fever, loss of appetite, and pain focused in the right lower part of the abdomen.


• Crohns disease or inflammatory bowel syndrome may have bloody diarrhea along with the pain.

Less common sources of acute pain include:

• Abdominal aortic aneurysm


• Blood clot in the large pelvic blood vessels


• Acute intermittent poryphyia

Chronic Pelvic Pain
When used as a medical diagnosis, chronic pelvic pain indicates that the pain has been more or less constant for at least six months. The same general body systems, except for pregnancy, that produce acute pain can be a source of chronic pain. Additionally, problems with muscles and nerves can create pain in the pelvis. Let's look at some of the more common causes.

Gynecologic pain:

• Endometriosis (bits of uterine lining tissue growing on the bowel, bladder, ovaries, etc). The endometriosis implants go through the same cycle as uterine lining--they slough off and bleed monthly. Because there is no outflow for the bleeding, the body creates bands of filmy scar tissue ("adhesions") as a response to the inflammation of monthly bleeding into the abdomen. These adhesions can "glue" together organs in the abdomen.


• Adhesions can also be formed if a woman has had an abdominal surgery or a serious abdominal infection (eg PID or ruptured appendix).


• Ovarian remnant syndrome is an ovarian cyst that occurs after oophorectomy. Despite the removal of an ovary, a small bit of ovarian tissue remains behind. This tissue can still produce ovarian cysts. Ovarian remnants tend to be more common in women who have multiple adhesions which "web together" ovaries to the intestines making it more difficult to be sure that all the ovary was removed.


• Adenomyosis is endometriosis that has grown into the muscular walls of the uterus. In addition to pain it can produce a uterus that is enlarged, tender, and boggy. Unfortunately, adenomyosis is usually diagnosed only after hysterectomy has been performed. One could have a suspicion for adenomyosis if the woman, or her family, has a history of endometriosis.


• Pelvic congestion syndrome is also more difficult condition to diagnosis. It involves varicose veins of the uterus or ovaries.


• Uterine prolapse can create a dragging, heavy pain. The supportive tissues become relaxed and the uterus drops down into the vaginal canal.


• Large uterine or ovarian masses. Even benign masses such as large external uterine fibroids, or large dermoid cysts, can put pressure on surrounding organs.

Bladder & kidney sources of pain:

• Interstitial cystitis ("IC") can present like a urinary tract infection (UTI) with urgency, frequency, and pain with urination. Unlike a UTI there can be pain in the vagina, urethra, or pelvis; there can be pain with intercourse. Unlike a UTI pain may be less at the end of urination. Urine cultures are negative for bacteria, and antibiotics do not relieve the symptoms.


• Urethral syndrome will also have urinary urgency, frequency, pain with urination, and no evidence of bacteria in the urine. Sometimes women are given a longer than normal duration of broad spectrum antibiotics as a trial treatment. If the woman is postmenopausal she may be prescribed estrogen therapy.


• Problems with the ureters leading from the kidney to the bladder can include obstructions or diverticulum (a pouch in the walls). These are an uncommon source of pain.

Bowel caused pain:

• Irritable bowel syndrome ("IBS") can start up after eating, or during stressful events. Bloating, gas, and constipation or diarrhea may be present. Excluding GYN causes, IBS is the most common cause of chronic pelvic pain.


• Infection ("gastroenteritis") of the intestines can be caused by bacteria, viruses, or even parasites. Diarrhea and nausea may accompany the painful cramping.


• Diverticulitis is a localized infection in a pouching out section of the bowel.


• Appendicitis pain may manifest with a fever, loss of appetite, and pain focused in the right lower part of the abdomen.


• Crohn's disease or inflammatory bowel syndrome may have bloody diarrhea along with the pain.


• Hernias may be evident and uncomfortable when the woman is standing upright, then not apparent when she is lying flat on the exam table.


• Cancer of the bowel, while not a common cause of pelvic pain, needs to be ruled out with a sigmoidoscopy. This is especially important if there are other bowel symptoms such as blood in the stool.

Neurologic sources:

• Myofascial pain creates abdominal wall pain along the lines of major nerve pathways. The area of pain can often be identified very specifically with a finger tip. It is believed that the pain can be instigated by a deeper organ which then refers the pain to the area served by the shared nerve. Performing a straight leg raise (tightens the abdomen) can make the pain worse. Treatment involves injection of the shared nerve with a local anesthetic at the specific site of pain identified by the finger tip.


• Nerve entrapment or injury may follow a GYN surgical incision (eg laparoscope or C-section scar). The pain may be described as burning, or aching and like myofacial pain follows the shared pathway of a nerve ("dermatome"). As noted above abdominal tightening or exercise can make the pain worse, and treatment includes injection with a local anesthetic at the specific site of pain on the outside of the abdomen.


• Neuroma is a mass, or thickening, of nerve tissue. Often these can arise where there has been trauma to a nerve. In pelvic pain a neuroma can occur in the area of a hysterectomy scar (including inside the vagina), or other surgical scars.


• Pudendal neuropathy results from damage to the pudendal nerve. Women may experience vaginal pain with sex, rectal pain with bowel movements, bladder pain with urination, and pain with sitting.

Finally, less common sources of chronic pain can include:

• Systemic lupus erythematosis


• Low back injury with pain referred to the abdomen


• Acute intermittent porphyria

Given this long list of reasons to have pelvic or lower abdominal pain, one can see why it may take more than a single office visit to get an accurate diagnosis. It may take more than one type of imaging technique. If a GYN cause is strongly suspected, an ultrasound is usually performed first. If the ultrasound results are equivocal then either a CT or MRI scan may be ordered. More than one specialist may be needed to examine specific organs in the abdomen--for example a gastroenterologist, or urologist.

WebMD has an extensive library of information here. If you are interested in more information consider visiting these sites. The International Pelvic Pain Society has a list of pelvic pain specialists indexed by geographic location. One can also review the lectures from past conferences on a variety of pelvic pain issues. Also, the NIH has an extensive list of resources.

Related Topics:

• WebMD Video: Spectrometry to Diagnose Tumors
• What's Causing Your Pelvic Pain? Avoid Misdiagnosis

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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