Reproductive and Pelvic Health

Reproductive and Pelvic Health

No matter your age, the health of your reproductive and urinary organs—your pelvic organs—is important. If something goes wrong "down there," it affects your overall health and quality of life. Get answers to all of your most pressing questions and put an end to embarrassing symptoms.

What is it?

Overview

What Is It?
A fibroid is a mass of muscle tissue, typically noncancerous, that develops within the wall of the uterus.

Fibroids are masses of muscular tissue that can develop within the wall of the uterus. They are the most common noncancerous tumor in premenopausal women. You may hear your health care professional call fibroids by other terms, including uterine leiomyomas, fibromyomas, fibromas, myofibromas and myomas. They can be small or quite large.

Symptoms of Fibroids
While fibroids can cause a variety of symptoms, they may not cause any symptoms at all—so you may not even know you have one. Heavy bleeding is the most common symptom associated with fibroids and the one that usually prompts a woman to make an appointment with her health care professional. You may learn you have one or more fibroids after having a pelvic exam.

Fibroids may cause a range of other symptoms, too, including pain, pressure in the pelvic region, abnormal bleeding, painful intercourse, frequent urination or infertility.

Causes & Characteristics of Fibroids
What actually causes fibroids to form isn't clear, but genetics and hormones are thought to play a big role. Your body may be predisposed to developing fibroids. They seem to grow or shrink depending on estrogen levels in your body, but researchers don't know why some women develop them while others don't.

Fibroids usually grow slowly during your reproductive years, but may increase in size with pregnancy. At menopause fibroids shrink because estrogen levels decline. Using menopausal hormone therapy containing estrogen after menopause may cause fibroids to continue to grow and cause symptoms.

Progesterone, growth hormone and prolactin are other hormones that may stimulate a fibroid's growth once it has already formed.

A variety of treatments exist to remove fibroids and relieve symptoms. If you learn you have fibroids but aren't experiencing symptoms, you usually won't need treatment.

Who Is at Risk for Fibroids?
Your risk for developing fibroids increases with age. African-American women are more likely than Caucasian women to have them, and they are more likely to develop fibroids at a younger age. If women in your family have already been diagnosed with fibroids, you have an increased risk of developing them. You may also be at an increased risk if you are obese or have high blood pressure.

Types of Fibroids
Fibroids form in different parts of the uterus:

  • Intramural fibroids are confined within the muscle wall of the uterus and are the most common fibroid type. They expand, which makes the uterus feel larger than normal. Symptoms of intramural fibroids include heavy menstrual bleeding, pelvic pain, back pain, frequent urination and pressure in the pelvic region.
  • Submucosal fibroids grow from the uterine wall into the uterine cavity. They can cause pain, abnormal bleeding and infertility.
  • Subserosal fibroids grow from the uterine wall to the outside of the uterus. They can push on the bladder, bowel or intestine causing bloating, abdominal pressure, cramping and pain.
  • Pedunculated fibroids grow on stalks out from the uterus or into the uterine cavity, like mushrooms. If these stalks twist, they can cause pain, nausea or fever, or can become infected.

Diagnosis

Diagnosis

More than half of women who have fibroids never experience symptoms. When fibroids are symptom-free, they generally don't require treatment. But even small fibroids can cause heavy or longer-than-normal menstrual bleeding and significant pain. Fibroids may also contribute to infertility.

The three most common symptoms caused by fibroids are:

  • Abnormal uterine bleeding. The most common bleeding abnormality is menorrhagia—menstrual bleeding that is excessively heavy or long. Normal menstrual periods last four to seven days. If you have abnormal bleeding from fibroids, your periods are likely to last longer or may be heavier. Instead of changing a pad or tampon every four to six hours, you may have to change one every hour and find that your periods greatly interfere with your daily activities. You may also experience breakthrough bleeding, or bleeding that occurs between periods.

  • Pelvic pressure. You may experience pressure in the pelvic region. Many women with fibroids have an enlarged uterus. Pelvic pressure may be caused by either the increased size of your uterus or from the location of one fibroid in particular. Health care professionals usually describe the size of a uterus with fibroids in the same terms used for someone who is pregnant, such as a "12-week-size fibroid uterus."

    You may also experience pressure on areas near your pelvis, including your bowel or bladder. Pressure against these structures can lead to difficulty or pain with bowel movements and constipation or increased urinary frequency and incontinence. Conversely, you may experience urinary retention or recurrent urinary tract infections.

  • Reproductive problems. Fibroids also are associated with a handful of reproductive problems depending on the number of fibroids present in the uterus and on their size and specific location. These risks include a higher risk of miscarriage, infertility, premature labor and labor complications. These problems may occur when fibroids physically change the size and shape of the uterine cavity. While having fibroids may cause complications with pregnancy, most do not have any impact. Fibroids in a uterus do not create a high-risk pregnancy.

Symptoms caused by fibroids can be similar to a number of other symptoms caused by a variety of other conditions, including reproductive cancers, sexually transmitted infections and bowel and bladder disorders. So, if you are having any unusual symptoms, be sure to make an appointment to discuss them with your health care professional.

The first step in diagnosing fibroids is usually a pelvic exam and a comprehensive medical history performed by your health care professional. He or she may be able to feel the fibroids in your uterus during the exam, because fibroids can make the uterus feel enlarged or irregular. If the uterus is enlarged enough, it may also be felt abdominally above the pubic bone.

To confirm the diagnosis, even if nothing is felt, your health care professional may recommend one or more diagnostic tests.

Ultrasound is probably the most common option used to confirm the diagnosis. It is important to note that imaging may find very small fibroids that don't pose any medical problems, wouldn't be felt on physical examination and may not be causing symptoms.

If you have heavy or prolonged bleeding or have had multiple miscarriages, your health care professional may recommend a more involved examination of your uterine cavity to see if you have a submucous fibroid, which might go undetected on a regular ultrasound. The assessment can be performed in one of three ways:

  • Hysterosalpingography (HSG). A dye that shows up on an X-ray is injected into your uterus, enabling your health care professional to evaluate the structure of your uterine cavity and look for any abnormalities in the uterus or fallopian tubes. This test may be recommended in women who are trying to get pregnant.

  • Sonohysterography. A saline solution is injected into your uterus, and ultrasound is used to visualize the uterine cavity. Also called hysterosonography, this test is most useful in women who have prolonged or heavy menstrual bleeding but normal ultrasound results.

  • Hysteroscopy. The uterus is expanded with a liquid or gas, and a hysteroscope (a small telescope) is inserted directly into the uterus through the vagina and cervix enabling your health care professional to see your entire uterus. Fibroids within the uterine cavity can also be removed during this surgery.

Imaging tests, such as magnetic resonance imagery (MRI) or computed tomography (CT), may also be ordered but are rarely necessary.

If you are experiencing abnormal vaginal bleeding as a result of fibroids, your health care professional may want to conduct other blood tests, including a complete blood count (CBC), to rule out other conditions.

Treatment

Treatment

If you aren't experiencing symptoms caused by your fibroids, you may not need any treatment. And, if your symptoms aren't severe, you may decide you can put up with them. This may be especially true if you're close to menopause—a time when fibroids shrink and symptoms resolve. It's important to discuss all your options with your health care professional and consider his or her recommendations when weighing your treatment options.

You may want to try the "watch and wait approach," where your health care professional periodically evaluates the size of your fibroids during routine pelvic exams and discusses how much discomfort you're feeling or how the symptoms may be disrupting your lifestyle.

Fibroids that don't cause symptoms rarely need therapy unless they get big enough to affect other structures in the pelvic area, such as the kidneys or the ureter (the tube that drains the kidney to the bladder).

The need for treatment and the type of treatment you choose depends on the size and position of the fibroids, as well as any symptoms they're causing, your age and whether or not you want to have children in the future. Even with a variety of treatment options available, new fibroids may grow back to some degree in the years following most treatments. No treatment—except hysterectomy—can guarantee that fibroids won't recur. The more fibroids you have, the more likely they are to recur after treatment.

If bleeding is your major symptom, some women opt for managing this symptom with medication before surgery or as a way to delay surgery if they're close to menopause (because fibroids generally shrink and cause few or no problems after menopause).

Medical Treatment Options for Fibroids

  • Oral contraceptives (OCs). While OCs do not treat fibroids, they may be recommended to manage heavy bleeding caused by fibroids or for women who experience irregular ovulation in addition to fibroids. OCs are the first treatment option for many women, often combined with a nonsteroidal anti-inflammatory such as ibuprofen.

  • Intrauterine device (IUD). The levonorgestrel intrauterine device (Mirena), which is usually prescribed for birth control, can help ease the heavy bleeding that accompanies some fibroids. The device won't shrink the fibroids, however, and depending on whether or not the fibroids have distorted the inside of the uterus, it may or may not provide effective birth control. Although the levonorgestrel IUD is FDA-approved for heavy menstrual bleeding, it isn't approved specifically for the treatment of fibroids, so if you are interested in this option, discuss it with your doctor.

  • GnRH agonists Gonadotropin-releasing hormone (GnRH) agonists, including leuprolide (Lupron), nafarelin nasal (Synarel) and goserelin (Zoladex), temporarily shrink fibroids by blocking estrogen and progesterone production; estrogen is thought to stimulate their growth. They are mainly used in women close to menopause or to shrink fibroids before removing them surgically or to correct anemia caused by heavy bleeding associated with fibroids. GnRH agonists are considered a short-term treatment because they block hormone production by the ovaries, thus triggering menopausal symptoms caused by estrogen depletion, such as hot flashes, vaginal dryness and bone loss. The usual course of treatment is three to six months, and it may be combined with estrogen and/or progesterone hormones to minimize menopausal symptoms. Once this medication is stopped, fibroids usually grow back to near pretreatment size or larger within several months.

  • Antifibrinolytic medicines. Antifibrinolytic medicines are drugs that help slow menstrual bleeding by helping blood to clot. The drug tranexamic acid (Lysteda) is FDA-approved for heavy menstrual bleeding. Side effects include headaches, muscle cramps, or pain. Antifibrinolytic medicines do not affect your chances of becoming pregnant. They should not be taken with hormonal birth control without prior approval from a health care professional as the combination can cause blood clots. Antifibrinolytic therapies are relatively new and expensive—and often not covered by insurance. Check with your insurer if that is a concern.

Minimally Invasive Treatment Options

  • Uterine artery embolization (UAE). UAE is a radiological procedure that involves placing a small catheter (a thin tube) into an artery in the leg and guiding it via X-rays to the arteries in the uterus. Then, tiny particles similar in size to grains of sand are injected through the catheter and into the artery. As they move toward the uterus, they obstruct the blood supply to the fibroids. Without an adequate blood supply, the fibroids shrink. The uterus is spared, however, because an alternate blood supply develops to support it.

    UAE takes about one hour to perform and is typically performed by an interventional radiologist. It usually requires a one-night hospital stay. Most women are back to their normal activities in seven to 10 days.

    While this treatment option leaves your uterus intact, it's not recommended for women who wish to become pregnant in the future.

    Potential complications include fever, passage of small pieces of fibroid tissue through the vagina after the procedure, allergic reaction and hemorrhage. Complications can also occur if blood supply to the ovaries or other organs becomes compromised.

  • Endometrial ablation. While this technique is not indicated for treating fibroids, it is used to reduce or eliminate heavy periods that may be caused by fibroids. Endometrial ablation uses electrical energy, heat or cold to destroy the lining of the uterus. It is performed on an outpatient basis and is only offered as a treatment option to women who have finished childbearing. It is not recommended for women who wish to preserve fertility. However, using a reliable form of contraception after having ablation is important.

Surgical Options for Fibroids

  • Hysterectomy. A hysterectomy offers the only real cure because it completely removes the uterus.

    However, hysterectomy is major surgery, requiring between two and eight weeks of recovery, depending on the type of surgery performed. Hospital stays and recovery times can vary based on the type of procedure used and the extent of the surgery performed. Because your uterus and, sometimes, your ovaries, are removed, it is not an option if you want to become pregnant. If your ovaries do not need to be removed, you may want to keep your ovaries to maintain estrogen production.

    If you and your health care professional decide that a hysterectomy is the best choice for you, you may have several options about how the procedure is performed:

    • Abdominal hysterectomy, in which the uterus is removed through an incision in the abdomen. It is generally used for large pelvic tumors or suspected cancer because this procedure allows the surgeon to see and manipulate the pelvic organs more easily.

    • Vaginal hysterectomy, in which the uterus is removed through the vagina.

    • Laparoscopically hysterectomy, in which a surgeon uses a laparoscope (a small telescope) inserted through the abdomen to see inside your pelvis. Laparoscopic hysterectomy is less invasive than an abdominal hysterectomy, but more invasive than a vaginal hysterectomy.

    • Robotic-assisted laparoscopic hysterectomy, in which a robotic system assists in removal of the uterus in a laparoscopic hysterectomy. It may be helpful with some patients because of the flexibility it allows, but it also adds to the time and cost of the procedure.

  • Myomectomy. This procedure removes only the fibroids, leaving the uterus intact, which can preserve fertility. The procedure is performed through an incision in the abdomen (a laparotomy), which requires general anesthesia, or by laparoscopy, which uses a small incision to insert an operative camera (similar to a laparotomy but using a smaller incision). Robotic myomectomy is a variation of laparoscopic myomectomy during which the surgical procedure is aided with a surgical robot. A full recovery from laparotomy can take up to six weeks and two weeks from laparoscopy. Your health care professional will decide which procedure to use based on the size of the fibroids as well as whether they are superficial or deep (which is too difficult for laparoscopy).

    A hysteroscopic myomectomy is performed through the vagina and requires no incision. It is appropriate only for women whose fibroids are in the endometrial canal. With this procedure, fibroids are removed using an instrument called a hysteroscopic resectoscope, which is passed through the vagina into the uterine cavity. A wire loop carrying electrical current is then used to shave off the fibroid.

    Myomectomy can be more complicated than hysterectomy. Risks include:

    • Greater blood loss and need for transfusion

    • Risk of damage to the uterus and other pelvic structures

    • Scarring of the uterus that may affect fertility

  • Myolysis. This procedure involves using an electric current or laser to destroy the fibroids and shrink the blood vessels that feed them. A similar procedure called cryomyolisis freezes fibroids. The safety and effectiveness and risk of fibroid recurrence with both myolysis and cryomyolisis have not yet been determined.

Prevention

Prevention

Fibroids can't be prevented. If you are experiencing symptoms, such as heavy bleeding and pelvic pressure, contact your health care professional for an evaluation. If you have a family history of fibroids or have been treated for them in the past, you may want to be examined more frequently or investigate the various management strategies available to treat fibroids.

Facts to Know

Facts to Know

  1. Fibroids are rarely cancerous. They are balls of muscular tissue that grow inside the uterus, on the surface of the uterus or in the muscular wall of the uterus.

  2. An estimated 80 percent of women have fibroids, but not all of these women have symptoms. They are most commonly found in women in their 30s and 40s.

  3. African-American women are more likely to have fibroids than Caucasian women.

  4. If there are women in your family who already have been diagnosed with fibroids, you have an increased risk for developing them.

  5. Fibroid growth is believed to be related to estrogen levels. They usually grow slowly during the reproductive years, but may increase in size with pregnancy. At menopause, fibroids usually shrink, because estrogen levels decline. Estrogen replacement therapy may interfere with this shrinkage after menopause.

  6. More than half of the women who have fibroids never experience symptoms and require no treatment. In general, the severity of symptoms varies based on the number, size and location of the fibroids.

  7. The two most common symptoms of fibroids are heavy menstrual bleeding and pelvic pressure. Normal menstrual periods last four to seven days, but if you have fibroids, your periods are likely to last longer. The bleeding might be so heavy that you may need to change your sanitary pads or tampons as often as every hour.

  8. Fibroids may be associated with a handful of reproductive problems, such as miscarriage, infertility, premature labor and labor complications. These problems may occur when fibroids physically alter the uterine cavity. But having fibroids doesn't necessarily mean you'll have problems during a pregnancy.

  9. Oral contraceptives (estrogen and progestin and progestin-only) are sometimes recommended to manage heavy bleeding caused by fibroids, but they aren't used to treat fibroids.

  10. There are several treatment options available for fibroids, including medication, minimally invasive options and surgical options.

Questions to Ask

Questions to Ask

Review the following Questions to Ask about fibroids so you're prepared to discuss this important health issue with your health care professional:

  1. How do I know if I have abnormal or excessive menstrual bleeding?

  2. What tests are needed to determine if I have fibroids?

  3. What are my treatment options?

  4. I want to get the best treatment possible to get rid of my fibroids, but I want to have children as well. What are the best treatment options for me?

  5. When should hysterectomy be considered?

  6. What's uterine artery embolization and how is it performed?

  7. What type of doctors perform the treatment options for fibroids?

  8. How can I get a second opinion?

  9. Does my insurance cover all the options we're discussing?

  10. Will my fibroids recur after any of these treatments?

Key Q&A

Key Q&A

  1. How do I know I have fibroids?

    More than half of all women who have fibroids have no symptoms. If you aren't experiencing any problems, there's usually no reason to treat the fibroids. The two most common symptoms of fibroids are heavy menstrual bleeding and pelvic pressure. Normal menstrual periods usually last four to seven days, but if you have fibroids, your periods are likely to last longer.

    If you have fibroids, the bleeding might be so heavy that you may need to change your sanitary pad or tampons as often as every hour. Bleeding between periods isn't usually associated with fibroids, but it may occur in rare situations.

    You may also experience pressure in the pelvic region from an increase in the size of your uterus or from the location of one fibroid in particular. If you notice these symptoms, you should definitely seek a diagnosis from your health care professional.

  2. Are fibroids hard to diagnose?

    Not usually. A health care professional should be able to feel some kind of irregularity in your pelvic region during a regular office pelvic exam. If fibroids are suspected, more detailed tests may be conducted to confirm the initial diagnosis. These may include ultrasound (or ultrasonography), MRI (magnetic resonance imagery), CT (computed tomography), X-ray or hysterosalpingogram (HSG), a test that involves injecting a special dye into the uterus and then taking an X-ray of the area. Ultrasound is the most common option used to confirm the diagnosis.

  3. Does the location of my fibroids really make a difference in how they're treated?

    The symptoms you experience may vary depending on where the fibroids are located. However, the ultimate course of treatment for your fibroids will likely depend more on other factors, such as whether you plan to have children or how close to menopause you are. If preserving your fertility is a priority, several options won't be recommended.

  4. Is a hysterectomy really the only way I can get rid of my fibroids forever, or at least before I reach menopause?

    Yes. While other procedures are helpful because the existing fibroids are removed surgically or shrink with drug therapies, there is no guarantee that new fibroids won't develop.

  5. Is there anything I can do to protect myself from developing fibroids?

    Unfortunately, there isn't. Fibroids appear to affect women mostly in their 30s and 40s. Genetics and hormones appear to play a role in who develops fibroids.

  6. I've heard that estrogen and other hormones can make fibroids grow. Should I avoid taking birth control pills that contain estrogen?

    No, there is no evidence that oral contraceptives have any effect on fibroid size. In fact, health care professionals prescribe oral contraceptive pills for some women with fibroids to help control the prolonged or excessively heavy blood flow during menstruation.

  7. Do I need to see a specialist other than my gynecologist to diagnose and treat fibroids?

    Your gynecologist should have adequate experience in diagnosing fibroids because they are so common. However, some gynecologists may have more experience or better success at treating fibroids. If you're considering any of the more innovative treatments, whether surgical or medical, make sure you see a practitioner with a strong track record in treating fibroids, and ask about their success rates.

  8. Are hormone therapy treatments for fibroids dangerous?

    GnRH agonists are one treatment option for fibroids. This treatment shrinks fibroids by blocking hormone production by the ovaries. Because estrogen production is suppressed temporarily, you will experience menopausal symptoms such as hot flashes and vaginal dryness. Treatment is usually limited to three to six months.

    To offset hot flashes and other uncomfortable menopausal symptoms caused by GnRH agonists, your doctor may add estrogen and/or progesterone therapy.

    Ask your health care professional to review the risks associated with menopausal hormone therapy and how they may or may not be relevant to your treatment needs for fibroids.

Lifestyle Tips

Lifestyle Tips

  1. Regularly track your menstrual cycle

    If you have fibroids, your bleeding may last longer than normal and be heavier than normal. If you already know you have fibroids, you should have regular pelvic examinations and ultrasounds. This monitoring enables you to keep tabs on the size of the fibroid and determine if any additional treatments are necessary.

  2. Manage pain with over-the-counter drugs

    Nonsteroidal anti-inflammatory drugs such as aspirin, ibuprofen and naproxen can help ease menstrual pain. Along with helping with the pain, these drugs can also reduce inflammation. However, long-term use of such drugs can increase the risk of gastrointestinal bleeding and ulcers.

  3. Think about adding iron to your diet

    You can develop anemia from iron deficiency if fibroids cause excessively heavy bleeding. Sometimes the smaller fibroids, usually the submucosal ones, are more likely to cause heavy bleeding than the larger ones. Some of the best foods for increasing or maintaining iron levels include clams, oysters, beef, pork, poultry and fish.

Organizations and Support

Organizations and Support

For information and support on coping with Fibroids, please see the recommended organizations, books and Spanish-language resources listed below.

American Association of Gynecologic Laparoscopists (AAGL)
Website: http://www.aagl.org
Address: 6757 Katella Avenue
Cypress, CA 90630
Hotline: 1-800-554-AAGL (1-800-554-2245)
Phone: 714-503-6200

American College of Obstetricians and Gynecologists (ACOG)
Website: http://www.acog.org
Address: 409 12th Street, SW
P.O. Box 96920
Washington, DC 20090
Phone: 202-638-5577
Email: resources@acog.org

American Society for Reproductive Medicine (ASRM)
Website: http://www.asrm.org
Address: 1209 Montgomery Highway
Birmingham, AL 35216
Phone: 205-978-5000
Email: asrm@asrm.org

Association of Reproductive Health Professionals (ARHP)
Website: http://www.arhp.org
Address: 1901 L Street, NW, Suite 300
Washington, DC 20036
Phone: 202-466-3825
Email: arhp@arhp.org

Center for Uterine Fibroids at Harvard Medical School
Website: http://www.fibroids.net
Address: Brigham and Women's Hospital
77 Avenue Louis Pasteur, 160, New Research Building
Boston, MA 02115
Hotline: 1-800-722-5520 (ask operator for 525-4434)

National Family Planning and Reproductive Health Association (NFPRHA)
Website: http://www.nfprha.org
Address: 1627 K Street, NW, 12th Floor
Washington, DC 20006
Phone: 202-293-3114
Email: info@nfprha.org

National Uterine Fibroids Foundation
Website: http://www.nuff.org
Address: P.O. Box 9688
Colorado Springs, CO 80932
Hotline: 1-800-874-7247
Phone: 719-633-3454
Email: info@nuff.org

Society of Interventional Radiology
Website: http://www.sirweb.org
Address: 3975 Fair Ridge Drive, Suite 400 North
Fairfax, VA 22033
Hotline: 1-800-488-7284
Phone: 703-691-1805
Email: info@sirweb.org

A Gynecologist's Second Opinion
by William H. Parker, Rachel L. Parker

Fibroid Tumors & Endometriosis
by Susan M. Lark

Uterine Fibroids: What Every Woman Needs to Know
by Nelson, M.D. Stringer

What Your Doctor May Not Tell You About Fibroids: New Techniques and Therapies--Including Breakthrough Alternatives to Hysterectomy
by Scott C. Goodwin, David Drum, Michael Broder

Yale Guide to Women's Reproductive Health: From Menarche to Menopause
by Mary Jane Minkin, Carol V. Wright

Medline Plus: Uterine Fibroids
Website: http://www.nlm.nih.gov/medlineplus/spanish/uterinefibroids.html
Address: Customer Service
8600 Rockville Pike
Bethesda, MD 20894
Email: custserv@nlm.nih.gov

Center for Uterine Fibroid
Website: http://www.fibroids.net/aboutfibroids-spanish.html
Address: Brigham and Women's Hospital
77 Avenue Louis Pasteur - 160, New Research Building
Boston, MA 02115
Hotline: 1-800-722-552

Last date updated: 
Tue, 2011-08-09

What is it?

Overview

What Is It?
Estrogen refers to a group of hormones that play an essential role in the growth and development of female sexual characteristics and the reproductive process.

Estrogen is probably the most widely known and discussed of all hormones. The term "estrogen" actually refers to any of a group of chemically similar hormones; estrogenic hormones are sometimes mistakenly referred to as exclusively female hormones when in fact both men and women produce them. However, the role estrogen plays in men is not entirely clear.

To understand the roles estrogens play in women, it is important to understand something about hormones in general. Hormones are vital chemical substances in humans and animals. Often referred to as "chemical messengers," hormones carry information and instructions from one group of cells to another. In the human body, hormones influence almost every cell, organ and function. They regulate our growth, development, metabolism, tissue function, sexual function, reproduction, the way our bodies use food, the reaction of our bodies to emergencies and even our moods.

The Role of Estrogen in Women
The estrogenic hormones are uniquely responsible for the growth and development of female sexual characteristics and reproduction in both humans and animals. The term "estrogen" includes a group of chemically similar hormones: estrone, estradiol (the most abundant in women of reproductive age) and estriol. Overall, estrogen is produced in the ovaries, adrenal glands and fat tissues. More specifically, the estradiol and estrone forms are produced primarily in the ovaries in premenopausal women, while estriol is produced by the placenta during pregnancy.

In women, estrogen circulates in the bloodstream and binds to estrogen receptors on cells in targeted tissues, affecting not only the breasts and uterus, but also the brain, bone, liver, heart and other tissues.

Estrogen controls growth of the uterine lining during the first part of the menstrual cycle, causes changes in the breasts during adolescence and pregnancy and regulates various other metabolic processes, including bone growth and cholesterol levels.

Estrogen & Pregnancy
During the reproductive years, the pituitary gland in the brain generates hormones that cause a new egg to be released from its follicle each month. As the follicle develops, it produces estrogen, which causes the lining of the uterus to thicken.

Progesterone production increases after ovulation in the middle of a woman's cycle to prepare the lining to receive and nourish a fertilized egg so it can develop into a fetus. If fertilization does not occur, estrogen and progesterone levels drop sharply, the lining of the uterus breaks down and menstruation occurs.

If fertilization does occur, estrogen and progesterone work together to prevent additional ovulation during pregnancy. Birth control pills (oral contraceptives) take advantage of this effect by regulating hormone levels. They also result in the production of a very thin uterine lining, called the endometrium, which is unreceptive to a fertilized egg. Plus, they thicken the cervical mucus to prevent sperm from entering the cervix and fertilizing an egg.

Oral contraceptives containing estrogen may also relieve menstrual cramps and some perimenopausal symptoms and regulate menstrual cycles in women with polycystic ovarian syndrome (PCOS). Furthermore, research indicates that birth control pills may reduce the risk of ovarian, uterine and colorectal cancer.

Other Roles of Estrogen

Bone

Estrogen produced by the ovaries helps prevent bone loss and works together with calcium, vitamin D and other hormones and minerals to build bones. Osteoporosis occurs when bones become too weak and brittle to support normal activities.

Your body constantly builds and remodels bone through a process called resorption and deposition. Up until around age 30, your body makes more new bone than it breaks down. But once estrogen levels start to decline, this process slows.

Thus, after menopause your body breaks down more bone than it rebuilds. In the years immediately after menopause, women may lose as much as 20 percent of their bone mass. Although the rate of bone loss eventually levels off after menopause, keeping bone structures strong and healthy to prevent osteoporosis becomes more of a challenge.

Vagina and Urinary Tract

When estrogen levels are low, as in menopause, the vagina can become drier and the vaginal walls thinner, making sex painful.

Additionally, the lining of the urethra, the tube that brings urine from the bladder to the outside of the body, thins. A small number of women may experience an increase in urinary tract infections (UTIs) that can be improved with the use of vaginal estrogen therapy.

Perimenopause: The Menopause Transition

Other physical and emotional changes are associated with fluctuating estrogen levels during the transition to menopause, called perimenopause. This phase typically lasts two to eight years. Estrogen levels may continue to fluctuate in the year after menopause. Symptoms include:

  • Hot flashes—a sudden sensation of heat in your face, neck and chest that may cause you to sweat profusely, increase your pulse rate and make you feel dizzy or nauseous. A hot flash typically lasts about three to six minutes, although the sensation can last longer and may disrupt sleep when it occurs at night.
  • Irregular menstrual cycles
  • Breast tenderness
  • Exacerbation of migraines
  • Mood swings

Estrogen Therapy

Estrogen therapy is used to treat certain conditions, such as delayed onset of puberty and menopausal symptoms such as hot flashes and symptomatic vaginal atrophy. Vaginal atrophy is a condition in which low estrogen levels cause a woman's vagina to narrow, lose flexibility and take longer to lubricate. Female hypogonadism, a condition in which the ovaries produce little or no hormones, as well as premature ovarian failure, can also cause vaginal dryness, breast atrophy and lower sex drive and is also treated with estrogen.

For many years, estrogen therapy and estrogen-progestin therapy were prescribed to treat menopausal symptoms, to prevent osteoporosis and to improve women's overall health. However, after publication of results from the Women's Health Initiative (WHI) in 2002 and March 2004, the U.S. Food and Drug Administration (FDA) now advises health care professionals to prescribe menopausal hormone therapies at the lowest possible dose and for the shortest possible length of time to achieve treatment goals. Treatment is generally reserved for management of menopausal symptoms rather than prevention of chronic disease.

The WHI was a study of 27,347 women aged 50 to 79 (mean age, 63) taking estrogen therapy or estrogen/progestin therapy. They were followed for an average of five and a half to seven years. The study was unable to document that benefits outweighed risks when hormone therapy was used as preventive therapy, and it found that risk due to hormones may differ depending on a woman''s age or years since menopause.

The National Cancer Institute found a very significant drop in the rate of hormone-dependent breast cancers among women, the most common breast cancer, in 2003. In a study published in the New England Journal of Medicine in April 2007, researchers speculated that the drop was directly related to the fact that millions of women stopped taking hormone therapy in 2002 after the results of a major government study found the treatment slightly increased a woman's risk for breast cancer, heart disease and stroke. The researchers found that the decrease in breast cancer began in mid-2002 and leveled off after 2003. The decrease occurred in women over 50 and was marked in women with tumors that were estrogen receptor (ER) positive—cancers that require estrogen to grow. The researchers speculate that stopping the treatment prevented very tiny ER positive cancers from growing (and in some cases, possibly helped them to regress) because they didn't have the additional estrogen required to fuel their growth.

However, for symptomatic menopausal women or for women with premature menopause, hormone therapy remains the most effective therapy for hot flashes. For more on the WHI study, guidelines for considering menopausal hormone therapy and its potential risks and benefits, visit http://www.nhlbi.nih.gov/whi/.

In addition to treating menopause-related symptoms, estrogen and other hormones are prescribed to treat reproductive health and endocrine disorders (the endocrine system is the system in the body that regulates hormone production and function).

Some uses of hormone therapy include the following situations:

  • delayed puberty
  • contraception
  • irregular menstrual cycles
  • symptomatic menopause

Diagnosis

Diagnosis

Because hormone disorders can cause a wide variety of symptoms that also are associated with other conditions, a careful evaluation of your symptoms and general health is recommended, especially if you experience any unusual symptoms. To arrive at a diagnosis, your health care professional will want to rule out certain conditions.

Your assessment will include a thorough personal medical history, a family medical history and a physical examination. Blood and other laboratory tests may be ordered to measure hormone levels. Brain scans are sometimes ordered to identify abnormalities that may be affecting the endocrine system, and DNA testing can detect genetic abnormalities.

Estradiol or other hormone levels may be tested in the evaluation of precocious puberty in girls (the onset of signs of puberty before age seven), delayed puberty and in assisted reproductive technology (ART) to monitor ovarian follicle development in the days prior to in-vitro fertilization. Hormone levels are also sometimes used to monitor HT.

Estrone and/or estradiol levels may be tested if you are having hot flashes, night sweats, insomnia and/or amenorrhea (the absence of periods for extended periods of time). However, due to the day-to-day and even hour-to-hour fluctuations in estradiol levels, they are less helpful than follicle stimulating hormone levels (FSH) for these evaluations. Salivary estradiol testing is less reliable still and of no value in diagnosing or treating symptoms. In most cases, a woman's age, symptoms and menstrual irregularity is sufficient for making the diagnosis.

Accurate diagnosis of hormonal disorders is important to determining appropriate treatment, which often includes estrogen therapy.

The following are common reasons estrogen therapy is prescribed:

  • Delayed puberty. Delayed puberty can result from a variety of disruptions to normal hormone production, including central nervous system lesions, pituitary disorders, autoimmune processes involving the ovaries or other endocrine glands, metabolic and infectious diseases, anorexia or malnutrition, exposure to environmental toxins and over-intensive athletic training.

    Signs of delayed puberty include:
    • Lack of breast tissue development by the age of 13

    • No menstrual periods for five years following initial breast growth or by age 16

    • Estrogen treatment for girls with delayed puberty is somewhat controversial; some health care professionals advise treatment, while others prefer close monitoring.

  • Irregular menstrual periods. Once a medical evaluation finds that there is no other serious cause of your irregular cycles, oral contraceptives or cyclic progesterone may be used to regulate your cycle, assuming there is no reason you can't use them. Polycystic ovarian syndrome is a common cause of irregular menstrual cycles.

  • Contraception. Oral contraceptives containing estrogen are one of the most popular methods of fertility control in the United States. Other hormonal methods include some types of intrauterine devices (IUDs), the patch and an intravaginal ring.

  • Menopausal Symptoms. Declining or fluctuating levels of estrogen and other hormones such as testosterone may begin as early as the late 30s. These hormonal changes trigger many of the physical and emotional changes associated with the transition to menopause. Of course, menopause is a life stage, not a disease, but symptoms associated with menopause can be bothersome and concerning for some women.

These changes may include:

  • Irregular menstrual periods
  • Hot flashes (sudden warm feeling, sometimes with blushing or sweating)
  • Night sweats (hot flashes that occur at night, often disrupting sleep)
  • Fatigue (probably from disrupted sleep patterns)
  • Mood swings
  • Early morning awakening
  • Vaginal dryness
  • Fluctuations in sexual desire or response
  • Difficulty sleeping

There is a wide range of possible menopause-related conditions. Ask your health care professional about any changes you notice.

For symptomatic menopausal women or women with premature menopause, HT or estrogen therapy (ET) remains the gold standard for relief of hot flashes and vaginally related symptoms. The estrogen-only therapy may be prescribed for women who have had a hysterectomy and therefore are not at risk of uterine cancer. For perimenopausal women with these symptoms, estrogen is usually given short-term (six months to four or five years), with the goal of tapering and eventually discontinuing it.

If you are experiencing moderate to severe menopausal symptoms or not getting symptom relief from nonhormonal methods, hormone therapy may be an option. (To find out about alternative, nondrug methods of relieving menopausal symptoms, visit the menopause topic at HealthyWomen.org.)

New, lower-dose versions of the hormone therapies used to treat symptoms of menopause are now available. The U.S. Food and Drug Administration (FDA) has approved pills, skin patches, gels, lotions and sprays in lower doses. Delivery of estrogen through the skin may be less likely than pills to cause blood clots in the legs or lungs.

The estrogen dosage used for hormone therapy varies widely depending on the symptoms it's intended to manage, as does dosing schedule. Discuss your symptoms and concerns with your health care professional.

In 2003, the FDA announced that a new warning on all estrogen products for use by postmenopausal women. The so-called "black box" is the strongest step the FDA can take to warn consumers of potential risks from a medication. It advises health care professionals to prescribe estrogen products at the lowest dose and for the shortest possible length of time.

While HT had also until 2002 been widely used to prevent postmenopausal osteoporosis, the health risks of hormone therapy may outweigh this benefit for many women. Other osteoporosis therapies should be considered first.

Although observational studies over many years indicated that HT prevented heart disease in postmenopausal women, recent placebo-controlled studies indicated that hormone therapy may actually increase an older woman's risk for heart disease, heart attack and stroke, and should not be initiated in women of any age solely to prevent heart disease. However, follow-up studies suggest that this heart disease risk occurs in older, but not younger, postmenopausal women. Longer follow-up of the estrogen-alone trial in women with hysterectomy (reported in the Journal of the American Medical Association on April 6, 2011) suggested that estrogen was associated with a reduced risk of heart disease among women aged 50 to 59 years at study enrollment.

Moreover, study findings also indicate that older women (65 and older) who initiate HT have twice the rate of developing dementia, including Alzheimer's disease, compared with women who do not take the medication. The research, part of the Women's Health Initiative Memory Study (WHIMS) and reported in the May 28, 2003, Journal of the American Medical Association, found the heightened risk of developing dementia in a study of women 65 and older taking Prempro.

The study also found that HT did not protect against the development of mild cognitive impairment (MCI), a form of cognitive decline less severe than dementia, in women aged 65 and older. Effects of HT on cognitive function in recently menopausal women remain unknown.

Treatment

Treatment

There are many formulations and dosages of estrogen and estrogen-progestin combinations on the market today for treating conditions that result from estrogen deficiency, for birth control and for regulation of hormone-related processes such as menstruation.

Hormonal contraception

Oral contraceptives

Most combination oral contraceptives contain between 20 to 50 mcg of estrogen, a lower dose (one-fourth or less) than those marketed 20 to 30 years ago.

Oral contraceptives containing estrogen are now prescribed by some health care professionals for health benefits beyond contraception. For instance, they can:

  • Regulate and shorten a woman's menstrual cycle
  • Decrease severe cramping and heavy bleeding
  • Reduce ovarian cancer risk
  • Reduce the development of ovarian cysts
  • Protect against ectopic pregnancy
  • Reduce the risk of uterine (endometrial) cancer
  • Decrease perimenopausal symptoms

Contraceptive patches and vaginal ring

The patch and ring contain hormones similar to oral contraceptives and provide many of the same benefits, although through a different route of administration.

Hormone-containing intrauterine device

The hormone-containing IUDs provide contraception and, in the case of the Mirena IUD, greatly reduce menstrual bleeding.

There are side effects and risks associated with estrogen-containing birth control pills, however, although many have been reduced through the introduction of lower-dosage versions in recent years. These include heart attack, stroke, blood clots, pulmonary embolism, nausea and vomiting, headaches, irregular bleeding, weight gain or weight loss, breast tenderness and increased breast size.

According to a 1997 World Health Organization study, smoking cigarettes while taking birth control pills dramatically increases the risk of heart attack for women over 35. Smoking is far more dangerous to a woman's health than taking birth control pills, but the combination of oral contraceptive pill use and smoking has a greater effect on heart attack risk than the simple addition of the two factors. For women of all ages, smoking raises the risk of blood clots and stroke associated with birth control pills.

If the primary reason you are taking an oral contraceptive is to prevent unwanted pregnancy and you are worried about potential estrogen-related side effects, the "mini-pill," which contains progestin (a synthetic form of the natural hormone progesterone), may be an option.

Hormone Therapy for Menopausal Symptoms

There are two types of therapy used to replace hormones that decline with the onset of menopause or are deficient as a result of medical conditions.

Estrogen-progestin

Postmenopausal hormone therapy, until recently referred to as "hormone replacement therapy," or "HRT," is now also termed "menopausal hormone therapy" (MHT) or simply "hormone therapy" (HT). HT typically refers to a combination of estrogen and either a synthetic form of the hormone progesterone (progestin) or a natural form of the hormone. Progesterone or progestin is necessary in women with an intact uterus to decrease the stimulating effect of estrogen on uterine tissue—a risk factor for uterine cancer.

Estrogen-only

"Estrogen therapy" (ET) refers to the use of estrogen alone. Estrogen therapy may be prescribed for women who have had a hysterectomy (and therefore are not at risk of uterine cancer).

A variety of estrogen medications containing various types of estrogen are available. These include pills, patches, injections, lotions, gels, sprays, vaginal creams, rings or tablets.

Conjugated estrogens. Premarin is the most frequently prescribed conjugated estrogen therapy product. It contains several types of conjugated estrogens derived from the urine of pregnant mares. It is available in oral, intravenous and vaginal cream formulations. Cenestin is a blend of nine plant-derived, synthetic conjugated estrogens and is FDA approved for treating menopausal symptoms.

Esterified estrogens. These estrogens may be made from plant sources or be prepared from the urine of pregnant mares. Brand names are Estratab and Menest. Estratest is a combination of esterified estrogens and methyltestosterone, a male hormone. It is the only testosterone currently FDA approved for women. However, oral testosterone has been associated with decreases in good HDL cholesterol, and it can cause side effects like acne and increased facial hair growth. You shouldn't take these medications if you are pregnant or are planning a pregnancy.

Estradiol. This type of estrogen, normally produced during the reproductive years, is available in many brand-name oral and transdermal preparations. Oral estradiol is available in a number of FDA-approved brand-name products, including Femtrace, Estrace, Gynodiol and generic estradiol. Transdermal patches include Alora, Climara, Esclim, Estraderm and Vivelle. An ultra–low-dose estrogen patch, Menostar, is approved for prevention of osteoporosis. Estradiol gel (EstroGel) is a transdermal gel; Estrasorb is a transdermal estradiol lotion. Femring is a vaginal ring that provides estradiol acetate as full-dose systemic estrogen therapy. Estring is a vaginal ring that releases very low levels of estradiol and is used only for local vaginal therapy. Vagifem vaginal tablets provide extremely low doses of estradiol for local estrogen therapy.

Estrone. This is the predominant natural hormone in menopausal women and is a product of the metabolism of estradiol. Some forms of estrone are present in conjugated and esterified estrogen preparations, as well as in combination with piperazine.

Estropipate (Ogen, Ortho-Est). This natural estrogenic substance is available in a pill.

Ethinyl estradiol (Estinyl). This synthetic estrogen is available in tablet form.

Synthetic conjugated estrogens, B (Enjuvia). This plant-derived, synthetic conjugated estrogen product includes an additional estrogen component in the form of delta 8,9-dehydroestrone sulfate.

Local vaginal estrogen therapy

Several forms of estrogen are available as creams applied vaginally for treating vulvar and vaginal atrophy. They include: conjugated estrogen cream (Premarin), micronized estradiol (Estrace), dienestrol (Ortho dienestrol) and estropipate cream (Ogen).

Estradiol is also available as an inserted vaginal ring (Estring), for treating those conditions as well as urethritis, and in vaginal tablet form (Vagifem).

Combination hormone therapy: estrogen and progestin

Taking estrogen daily and progestin for two weeks every month may result in monthly bleeding similar to menstruation. Many women prefer taking both hormones every day to eliminate bleeding, which usually stops after three to six months of daily combination therapy.

Some examples of combination pills are:

  • 17 beta-estradiol and norgestimate (Prefest) continuous estrogen and pulsed progesterone.
  • Conjugated estrogens and medroxyprogesterone (Prempro, Premphase)
  • 17 beta-estradiol and norethindrone acetate (Activella)
  • Ethinyl estradiol and norethindrone acetate (Femhrt)

Some examples of combination transdermal products are:

  • estradiol and norethindrone acetate patch (CombiPatch)
  • estradiol and levonorgestrel patch (Climara Pro)

Any of these products may be prescribed for menopausal symptoms, including vulvar or vaginal atrophy.

Bioidentical, natural or compounded estrogen

The term "bioidentical hormones" is used to refer to hormones that are identical to the form of hormone made in the body. They may also be called "natural." Sometimes hormones sold in a compounding pharmacy are called "natural" or "bioidentical." All of these estrogen or progesterone products are made in a laboratory and then mixed with a cream or put into a pill form.

There is no evidence that compounded hormones are safer or more effective than FDA-approved hormones. There are many FDA-approved bioidentical estrogens and progesterones on the market and a wide range of dosing options. FDA-approved products have stricter oversight in terms of product purity and dose consistency than compounded products.

You should not take any form of estrogen if you are pregnant or have had:

  • Breast, uterine or ovarian cancer
  • Abnormal uterine bleeding of an unknown cause (until the cause has been determined)
  • A very high triglyceride level (in this case, some women can take estrogen via a patch, lotion or gel)
  • Active liver disease
  • Blood clots or pulmonary embolism

Women taking either estrogen alone or estrogen plus progestin are advised to have yearly breast exams and receive annual mammograms. Potential side effects of taking ET or HT include increased risk for blood clots, heart disease, heart attacks, stroke and breast cancer (the risks of breast cancer are greater with estrogen plus progestin than with estrogen alone). Other possible side effects include:

  • vaginal bleeding (starting or returning)
  • breast tenderness (which often goes away after three months)
  • nausea (which often goes away after your body adjusts)
  • fluid retention (bloating)
  • headache
  • dizziness
  • depression
  • increased risk of ovarian cancer and gallbladder disease
  • change in vision, including intolerance to contact lenses

Estrogen can interact with a variety of other commonly prescribed medications, including thyroid hormone, so be sure to tell your health care professional about all medicines you are taking, including alternative/complementary products and supplements.

In making the decision about whether to use estrogen to treat your condition, you and your health care professional will discuss your personal health history. This discussion will include considering if you are at increased risk for one or more of the conditions with which estrogen is associated.

Facts to Know

Facts to Know

  1. Estrogen is produced in the ovaries, adrenal glands and fat tissues. It prepares the reproductive organs for conception and pregnancy. Estriol, a form of estrogen, is produced by the placenta during pregnancy.

  2. The function of estrogen in the body is complex. We have learned a lot, but there is still much more to learn.

  3. Declining or low levels of estrogen can cause physical symptoms including hot flashes, night sweats and vaginal dryness.

  4. By the time you reach menopause, you will produce only about one-third the amount of estrogen you produced during your childbearing years.

  5. Supplemental estrogen taken after menopause does not appear to prevent heart disease when initiated in older women several years past menopause.

  6. The term "hormone replacement therapy (HRT)" has been largely replaced by other names, including post-menopausal hormone therapy (PHT), hormone therapy (HT), or menopausal hormone therapy (MHT). Estrogen-alone therapy, previously referred to as estrogen replacement therapy (ERT), has been largely replaced by the term estrogen therapy (ET).

  7. The term "estrogen" includes a group of closely related compounds, including estradiol, estrone and estriol.

  8. Estrogen therapy may be prescribed for conditions such as delayed onset of puberty, genital atrophy or female hypogonadism (incomplete functioning of the ovaries, creating symptoms such as vaginal dryness, breast atrophy and lower sex drive).

  9. There is new evidence that long-term use of hormone therapy may increase a women's risk of ovarian cancer and that estrogen plus progestin may possibly increase lung cancer mortality.

  10. Findings from a memory sub-study of the Women's Health Initiative (WHI) indicate that women who are older than 65 when they start taking combination hormone therapy have an increased risk of developing dementia, including Alzheimer's disease, compared with women who do not take the medication. Effects in younger women remain unknown and require further study.

Questions to Ask

Questions to Ask

Review the following Questions to Ask about estrogen so you're prepared to discuss this important health issue with your health care professional.

  1. Am I experiencing the onset of menopause?

  2. What treatment options are available to me for perimenopausal and postmenopausal health concerns, including hormone therapy and other medical therapies?

  3. What can I do to protect my heart and bones?

  4. I seem to have less interest in sex. Is that just to be expected and accepted with age?

  5. Am I at high risk for breast cancer, and how does estrogen affect it?

  6. How do I know if my on-again, off-again menstrual bleeding is caused by perimenopause or another problem?

  7. What kinds of side effects can I expect when taking estrogen?

  8. How long should I take hormones?

  9. Will my urinary incontinence stop after menopause, and what can I do about it now?

  10. What options are available besides estrogen for my condition? What are the side effects of those products?

Key Q&A

Key Q&A

  1. The menopausal symptoms I'm experiencing since my ovaries were removed are worse than expected. Why?

    The abrupt decrease in hormone levels for women who have surgical menopause can cause more severe symptoms than natural menopause. Talk to your health care professional about medications and lifestyle changes that can ease those symptoms.

  2. Should I have my ovaries removed if I have a hysterectomy for benign disease?

    Increasing evidence suggests that, unless a woman is at elevated risk of ovarian or breast cancer, the benefits of keeping the ovaries may outweigh the risks. This is especially true for women who have not yet reached menopause at the time of hysterectomy. A recent study published in Obstetrics & Gynecology reported that removing both ovaries during a hysterectomy is associated with a decreased risk of ovarian and breast cancer but an increased risk of lung cancer, coronary artery disease and death from other causes, even in postmenopausal women. Talk to your health care professional about your surgical options and the best plan for you.

  3. I've heard that estrogen can affect my chances of getting osteoporosis. How?

    Estrogen helps reduce the rate of bone loss that occurs during normal bone remodeling. Normally there is a balance in the activity of the cells that break down bone and the cells that build it back up. By decreasing the activity of the cells that break down bone, estrogen allows the cells that build bone to have a greater overall effect. Once estrogen levels drop, this balance shifts.

    While hormone therapy has been shown to decrease hip and vertebral fractures, it may also increase your risk of other health conditions, such as invasive breast cancer, stroke and blood clots. Discuss the risks and benefits of available treatments with your health care professional.

  4. What sort of side effects can I expect when taking estrogen?

    The most common side effects are breast tenderness, water retention and uterine bleeding.

  5. How does hormone therapy affect breast cancer risk?

    Some studies suggest a slightly increased risk of breast cancer in women using estrogen. The risk appears higher in women taking estrogen-progestin therapy. According to the Women's Health Initiative (WHI), findings from the study on women who took estrogen alone showed that women who had had a hysterectomy who took ET did not have an increased risk of breast cancer for at least seven years after starting ET (and even had evidence of a reduced risk). In contrast, findings from the estrogen and progestin study showed that women who took both estrogen and progestin had an increased risk of breast cancer by five years following when they started therapy. These findings show that taking estrogen alone is safer with respect to breast cancer risk than taking combined estrogen and progestin, at least in the short term for women who have had a hysterectomy and would not be prescribed a progestin.

    HT can also increase breast density and make mammograms less reliable.

  6. How does estrogen affect cardiovascular health?

    Contrary to earlier hormone therapy studies, recent findings from the Women's Health Initiative (WHI) showed that estrogen-progestin therapy initiated in older women does not protect against heart disease; in fact, the WHI showed that one form of hormone, sold as Prempro, when prescribed to healthy older women (average age 65) to prevent heart disease actually increased their risk for the disease.

  7. What is known about the benefits of hormone therapy on bone health?

    Postmenopausal osteoporosis is characterized by decreased bone mass, deterioration of bone architecture and high bone fragility, making bone fractures of great concern. Estrogen deficiency is the most common risk factor for osteoporosis in women.

    Estrogen, with and without progestin, has been shown to be a protective and effective prevention measure against osteoporosis and the risk of clinical fractures. However, considering the potential risks of HT uncovered in the WHI, such as increased risk of cardiovascular disease and breast cancer, it is no longer recommended as a first-line therapy for osteoporosis.

    Other ways to reduce the risk of osteoporosis include avoiding tobacco, increasing weight-bearing exercise and resistance training and having adequate intake of calcium and vitamin D.

Organizations and Support

Organizations and Support

For information and support on Estrogen, please see the recommended organizations, books and Spanish-language resources listed below.

American College of Obstetricians and Gynecologists (ACOG)
Website: http://www.acog.org
Address: 409 12th Street, SW
P.O. Box 96920
Washington, DC 20090
Phone: 202-638-5577
Email: resources@acog.org

American Menopause Foundation (AMF)
Website: http://www.americanmenopause.org
Address: 350 Fifth Avenue, Suite 2822
New York, NY 10118
Email: menopause@earthlink.net

Association of Reproductive Health Professionals (ARHP)
Website: http://www.arhp.org
Address: 1901 L Street, NW, Suite 300
Washington, DC 20036
Phone: 202-466-3825
Email: arhp@arhp.org

Hormone Foundation
Website: http://www.hormone.org
Address: 8401 Connecticut Avenue, Suite 900
Chevy Chase, MD 20815
Hotline: 1-800-HORMONE (1-800-467-6663)
Email: hormone@endo-society.org

National Family Planning and Reproductive Health Association (NFPRHA)
Website: http://www.nfprha.org
Address: 1627 K Street, NW, 12th Floor
Washington, DC 20006
Phone: 202-293-3114
Email: info@nfprha.org

Sexuality Information and Education Council of the United States (SIECUS)
Website: http://www.siecus.org
Address: 90 John Street, Suite 704
New York, NY 10038
Phone: 212-819-9770

100 Questions & Answers About Menopause
by Ivy M. Alexander, Karla A. Knight

Dr. Susan Love's Menopause and Hormone Book: Making Informed Choices
by Susan M. Love, Karen Lindsey

Hot Flashes, Hormones, and Your Health: Breakthrough Findings to Help You Sail Through Menopause
by JoAnn Manson, Shari Bassuk

Is It Hot In Here? Or Is It Me? The Complete Guide to Menopause
by Barbara Kantrowitz, Pat Wingert Kelly

Making Love the Way We Used to ... or Better: Nine Secrets to Satisfying Midlife Sexuality
by Alan M. M. Altman, Laurie Ashner

Mind over Menopause: The Complete Mind-Body Approach to Coping With Menopause
by Leslee Kagan, Herbert Benson, Bruce Kessel

Medline Plus: Estrogen
Website: http://www.nlm.nih.gov/medlineplus/spanish/druginfo/meds/a682922-es.html
Address: Customer Service
8600 Rockville Pike
Bethesda, MD 20894
Email: custserv@nlm.nih.gov

Last date updated: 
Mon, 2011-07-18

What is it?

Overview

What Is It?
Endometriosis is a condition in which tissue similar to your uterine lining grows outside your uterus and gets stuck to other organs or structures, often resulting in pain or infertility.
Endometriosis is a noncancerous condition in which tissue similar to the endometrium (uterine lining) grows outside your uterus and adheres to other pelvic structures, most commonly the ovaries, bowel, fallopian tubes or bladder. It is a common cause of pelvic pain and infertility.

It affects at least 5 percent of premenopausal women, and at least 5.5 million women in North America alone have endometriosis.

Historically thought of as a disease that affects adult women, endometriosis is increasingly being diagnosed in adolescents, as well.

Symptoms of Endometriosis
The most common symptoms are painful menstrual periods and/or pelvic pain.

Others include:

  • Diarrhea and painful bowel movements, especially during menstruation
  • Intestinal pain
  • Painful intercourse
  • Abdominal tenderness
  • Backache
  • Severe menstrual cramps
  • Excessive menstrual bleeding
  • Painful urination
  • Pain in the pelvic region with exercise
  • Painful pelvic examinations
  • Infertility

It is important to understand that other conditions aside from endometriosis can cause any or all of these symptoms and other causes may need to be ruled out. These include, but are not limited to, interstitial cystitis, irritable bowel syndrome, inflammatory bowel disease, pelvic adhesions (scar tissue), ovarian masses, uterine abnormalities, fibromyalgia, malabsorption syndromes and, very rarely, malignancies.

Characteristics of Endometriosis
Endometrial tissue also may grow in the abdominal area or, more rarely, travel far from the pelvic region into the lungs, skin and other regions of the body. No matter where it goes, however, endometrial tissue continues to respond to hormonal signals—specifically estrogen—from the ovaries telling it to grow. Estrogen is the hormone that causes your uterine lining to thicken each month. When estrogen levels drop, the lining is expelled from the uterus, resulting in menstrual flow (you get your period). But unlike the tissue lining the uterus, which leaves your body during menstruation, endometriosis tissue is trapped in the pelvic cavity. With no place to go, the tissue bleeds internally. Your body reacts to the internal bleeding with inflammation, a process that can lead to the formation of scar tissue, also called adhesions. This inflammation and the resulting scar tissue may cause pain and other symptoms.

Recent research also finds that this misplaced endometrial tissue may develop its own blood supply to help it proliferate and nerve supply to communicate with the brain, one reason for the condition's severe pain and the other chronic pain conditions so many women with endometriosis suffer from.

The type and intensity of symptoms range from completely disabling to mild. Sometimes, there aren't any symptoms at all, particularly in women with so-called "unexplained infertility."

Risks of Endometriosis
If your endometriosis results in scarring of the reproductive organs, it may affect your ability to get pregnant. In fact, 30 to 40 percent of women with endometriosis are infertile. Even mild endometriosis can result in infertility.

Causes of Endometriosis
Researchers don't know what causes endometriosis, but many theories exist. One suggests that retrograde menstruation—or "reverse menstruation"—may be the main cause. In this condition, menstrual blood doesn't flow out of the cervix (the opening of the uterus to the vagina), but, instead, is pushed backward out of the uterus through the fallopian tubes into the pelvic cavity.

But because most women experience some amount of retrograde menstruation without developing endometriosis, researchers believe something else may contribute to its development.

For example, endometriosis could be an immune system problem or hormonal imbalance that enables the endometrial tissue to take root and grow after it is pushed out of the uterus.

Other researchers believe that in some women, certain abdominal cells mistakenly turn into endometrial cells. These same cells are the ones responsible for the growth of a woman's reproductive organs in the embryonic stage. It's believed that something in the woman's genetic makeup or something she's exposed to in the environment in later life changes those cells so they turn into endometrial tissue outside the uterus. There's also some thinking that damage to cells that line the pelvis from a previous infection can lead to endometriosis.

Some studies show that environmental factors may play a role in the development of endometriosis. Toxins in the environment such as dioxin seem to affect reproductive hormones and immune system responses, but this theory has not been proven and is controversial in the medical community.

Other researchers believe the endometrium itself is abnormal, which allows the tissue to break away and attach elsewhere in the body.

Endometriosis may have a genetic link, with studies finding an increase in risk if your mother or sister had the disorder. No specific genetic mutation has been clearly linked with the disease.

Diagnosis

Diagnosis

Gynecologists and reproductive endocrinologists, gynecologists who specialize in infertility and hormonal conditions, have the most experience in evaluating and treating endometriosis.

The condition can be very difficult to diagnose, however, because symptoms vary so widely and may be caused by other conditions.

Among the ways doctors diagnosis the disease are:

Laparoscopy. Currently, laparoscopy is the gold standard for the diagnosis of endometriosis and is commonly used for both diagnosis and treatment. Performed under general anesthesia, the surgeon inserts a miniature telescope called a laparoscope through a small incision in the navel to view the location, size and extent of abnormalities (such as adhesions) in the pelvic region.

However, merely looking through the laparoscope can't diagnose deep endometriosis disease, in which the endometrial tissue is hidden inside adhesions or underneath the lining of the abdominal cavity. More extensive dissection is needed to diagnose and treat this type of disease.

Many women have a combination of both deep and superficial (in which the endometrial tissue can be easily seen) endometrial disease.

Peritoneal tissue biopsy. During the laparoscopy, the doctor may remove a tiny piece of peritoneal tissue (the inner layer of the lining of the abdominal cavity) or other suspicious areas to help establish the diagnosis of endometriosis. This is recommended by the American College of Obstetricians and Gynecologists (ACOG), which notes that only an experienced surgeon familiar with the appearance of endometriosis should rely on visual inspection alone to make the diagnosis. A biopsy, however, is not mandatory to diagnose endometriosis, and a negative biopsy does not rule out the presence of this disease in other areas within the abdomen.

Ultrasonography, MRI and CT scan. An ultrasound uses sound waves to visualize the inside of your pelvic region, while an MRI uses magnets and a CT scan uses radiation. While these tests can suggest endometriosis or rule out other conditions, none can definitively confirm the condition.

At this point, there is no noninvasive method to diagnosis endometriosis, which is frustrating for both women and their health care providers.

Pelvic exam. Your doctor will perform a physical examination, including a pelvic exam, to aid in the evaluation. The examination will not diagnose endometriosis but may allow your doctor to feel nodules, areas of tenderness or masses on the ovaries that may suggest endometriosis.

Medical history. A detailed medical history may offer your health care professional the earliest clues in making the correct diagnosis. According to the Endometriosis Association, clues you may be at risk for endometriosis include pelvic pain; fatigue, exhaustion or low energy; diarrhea, painful bowel movements or other stomach upset around the time of your period; stomach bloating or swelling; or heavy or irregular periods. A simple five-question test about these conditions can quickly determine if you are at risk, but will not diagnose the disease.

Treatment

Treatment

There is no universal cure for endometriosis. However, there are a number of options available for treating and managing the disease after diagnosis. They fall into four categories: medical, surgical, alternative treatments and pregnancy.

  1. Medical. The most common medical therapies for endometriosis are nonsteroidal anti-inflammatories (NSAIDs), hormonal contraceptives (in oral, patch or injectable applications) and other hormonal regimens, such as GnRH agonists (gonadotropin-releasing hormone drugs).

    • Non-steroidal anti-inflammatories (NSAIDs). These drugs, such as ibuprofen, naproxen and aspirin, are often the first step in controlling endometriosis-related symptoms. They may be used long-term in a non-pregnant patient to manage symptoms, in part because they are effective at reducing implantation, are cheaper and easier to use than other options and have fewer side effects than hormonal treatments. However, some patients may experience severe gastrointestinal upset from these agents, particularly if they are administered for prolonged periods and at high doses. They are more effective when taken before pain starts.

    • Contraceptive hormones (birth control pills). This option also costs less and has fewer side effects than other hormonal treatment options and may be recommended soon after diagnosis. Birth control pills stop ovulation, thus suppressing the effects of estrogen on endometrial tissue. In most cases, women taking hormonal contraceptives have a lighter and shorter period than they did before taking them. Often physicians will recommend using birth control pills continuously as opposed to cyclically to eliminate regular menstrual flow, which can be the cause of increased pain in some women with endometriosis.

    • Medroxyprogesterone (Depo-Provera). This injectable drug, usually used as birth control, effectively halts menstruation and the growth of endometrial tissue, relieving the signs and symptoms of endometriosis. Side effects include weight gain, depressed mood and abnormal uterine bleeding (breakthrough bleeding and spotting), as well as a prolonged delay in returning to regular menstrual cycles, which can be of concern to women who want to conceive.

    • Gonadotropin Releasing Hormone Drugs (GnRH agonists). These drugs block the production of ovarian-stimulating hormones, which prevents menstruation and lowers estrogen levels, thus causing endometrial implants to shrink. GnRH agonists usually lead to endometriosis remission during treatment and sometimes for months or years afterward. However, GnRH agonists have side effects, including menopausal symptoms like hot flashes, vaginal dryness and reversible loss of bone density. Add-back hormone therapy, which typically consists of a synthetic progesterone (progestin) administered alone or in combination with a low-dose estrogen, is typically prescribed along with GnRH agonists to alleviate these side effects.

    • Danazol. This reproductive hormone is a synthetic form of a male hormone (androgen) and is available as Danocrine. It is used to treat endometriosis and works by directly suppressing endometrial tissue and suppressing ovarian hormone production. A woman taking danazol will typically not ovulate or get regular periods. Side effects may include weight gain, hair growth and acne, among others. Some of the side effects are reversible. Danazol is typically given for six to nine months at a time. Danazol is not a contraceptive agent, and it is critical that any woman taking this drug also use a barrier contraceptive (condoms, diaphragm, IUD) if she is sexually active.

    • Aromatase inhibitors. This class of drugs inhibits the actions of the enzyme which forms estrogen in the body and can block the growth of endometriosis. It is important to understand that this class of drugs is not approved for use in the treatment of endometriosis by the U.S. Food and Drug Administration; it is under investigation. Side effects include hot flushes, bone loss and the potential for increased risk of birth defects if a woman conceives while taking these medications and remains on them. Their use should be limited to women participating in research trials or after obtaining written consent from a physician who is thoroughly familiar with this class of drugs.

  2. Surgical. The goal of any surgical procedure should be to remove endometriotic tissue and scar tissue. Hormonal therapies may be prescribed together with the more conservative surgical procedures.

    Surgical treatments range from removing the endometrial tissues via laparoscopy to removing the uterus, called a hysterectomy, often with the ovaries (called an oophorectomy). Surgery classified as "conservative" removes the endometrial growths, adhesions and scar tissue associated with endometriosis without removing any organs. Conservative surgery may be done with a laparoscope or, if necessary, through an abdominal incision.

    • Laparoscopy. During a laparoscopy, an outpatient surgery also referred to as "belly-button surgery," the surgeon views the inside of the abdomen through a tiny lighted telescope inserted through one or more small incisions in the abdomen. From there, the surgeon may destroy endometrial tissue with heat, laser or by cutting it out. There is a risk of scar tissue, which could lead to infertility, making pain worse, or damaging other pelvic structures. Surgery to remove endometriosis involving the ureters and bowel can be especially complex and requires a high degree of surgical skill.

    • Laparotomy. A laparotomy is similar to a laparoscopy but is more extensive, involving a full abdominal incision and a longer recovery period.

    • Hysterectomy. During a hysterectomy, your uterus is removed. This leaves you infertile. Hysterectomy alone may not eliminate all endometrial tissue, however, because it can't remove tissue outside of the uterus or ovaries. Additionally, surgery to remove the uterus may not relieve the pain associated with endometriosis.

    • Oophorectomy. Removing the ovaries with the uterus improves the likelihood of successful treatment with hysterectomy because the ovaries secrete estrogen, which can stimulate growth of endometriosis. It also renders you infertile, however.

    If you wish to preserve your fertility, discuss other treatment options with your health care professional and consider seeking a second opinion.

    There have been no comparative studies of medical and surgical therapies to see which approach is better. Each has advantages and disadvantages. Often, your plan of care will be a combination of treatments.

  3. Alternative treatments. Alternative treatments for relieving the painful symptoms of endometriosis include traditional Chinese medicine, nutritional approaches, exercise, yoga, homeopathy, acupuncture, allergy management and immune therapy.

    While some health care professionals may tell you these alternative paths to seeking pain relief from endometriosis are a waste of time, others may encourage you to try alternative methods of pain relief as long as they are not harmful to your condition. Either way, discuss any options you want to try with your health care professional. Also keep in mind that while these options may help relieve the pain of endometriosis, they won't cure the condition.

  4. Pregnancy. While it can't be considered a "treatment" for endometriosis, pregnancy may relieve endometriosis-related pain, an improvement that may continue after the pregnancy ends.

    Health care professionals attribute this pregnancy-related relief to the hormonal changes of pregnancy. For example, ovulation and menstruation stop during pregnancy, and it's menstruation that triggers the pain of endometriosis.

    Plus, endometrial tissue typically becomes less active during pregnancy and may not be as painful or large without hormonal stimulation. However, in many cases, once the pregnancy and breastfeeding end and menstruation returns, symptoms also return.

If endometriosis has caused infertility, you have several treatment options, including surgery, drugs to stimulate ovulation, typically administered with intrauterine insemination or in vitro fertilization. The appropriate approach would be based on the results of a complete evaluation including an assessment of the male partner. In general, medicines that suppress the painful symptoms of endometriosis, such as GnRH agonists, oral contraceptives and danazol, do not improve the likelihood of pregnancy. The only possible exception would be that the use of a course of GnRH agonists before in vitro fertilization may improve outcomes in certain endometriosis patients, according to several recent studies.

Prevention

Prevention

There is no known way to prevent endometriosis. However, some health care professionals believe there might be a certain level of protection against the disease if you begin having children early in life and have more than one child.

Additionally, you may prevent or delay the development of endometriosis with an early diagnosis and treatment of any menstrual obstruction, a condition in which a vaginal cyst, vaginal tumor or other growth or lesion prevents endometrial tissue from leaving your body during menstruation.

There also is some evidence that long-term birth control pill users are less likely to develop endometriosis.

Facts to Know

Facts to Know

  1. Endometriosis is a noncancerous condition that affects at least 5 percent of reproductive-age women.

  2. About 5.5 million women in the United States and Canada have been diagnosed with endometriosis.

  3. Endometriosis develops when cells from the endometrium—or uterine lining—grow outside the uterus and stick to other structures, most commonly the ovaries, bowel, fallopian tubes or bladder. Endometrial tissue may migrate outside of the pelvic cavity to distant parts of the body. Researchers aren't sure what causes this condition.

  4. Symptoms of endometriosis can range from mild pain to pain severe enough to interfere with a woman's ability to lead a normal life. Other symptoms include heavy menstrual bleeding, cramping, diarrhea and painful bowel movements during menstruation, and painful intercourse. However, you may have the disease and experience none of these symptoms.

  5. A laparoscope is commonly used to diagnose and treat endometriosis. Laparoscopy allows a surgeon to view abnormalities in the pelvic region via a miniature telescope inserted through the abdominal wall, usually through the navel. While this is the best method of diagnosis available, it doesn't rule out endometriosis just because the doctor doesn't see any endometrial tissue.

  6. Hormonal changes that occur during pregnancy can temporarily halt the painful symptoms of endometriosis since menstruation stops and estrogen levels drop.

  7. There is no cure for endometriosis. Treatment options include minor and major surgery and medical therapies, including hormonal contraceptives and other hormonal drugs, such as GnRH (gonadotropin-releasing hormone) agonists, that limit the estrogen release that stimulates endometrial tissue growth.

  8. There is some evidence that a family history of endometriosis may contribute to your likelihood of developing this disease. If you have a mother or sister who is battling endometriosis or has been diagnosed with it, your risk of developing the disease is higher than someone with no family history.

Questions to Ask

Questions to Ask

Review the following Questions to Ask about endometriosis so you're prepared to discuss this important health issue with your health care professional:

  1. How many cases of endometriosis do you treat per month?

  2. How do you make the diagnosis?

  3. How many laparoscopic and/or laparotomy procedures do you perform each month for endometriosis and how do you typically treat the disease during surgery?

  4. Do you always use medical therapy before surgical therapy? If so, what therapies do you use?

  5. Do you use GnRH agonists? If so, when? Before or after surgery?

  6. What kinds of hormonal drug therapies have you used for patients with endometriosis?

  7. Do you prescribe add-back therapy with GnRH agonist therapy? What add-back hormones do you use and why? Are there other options I can consider?

  8. What side effects might I experience with the different hormonal therapies? How long do I have to be on these drugs for them to work effectively? Will my endometriosis come back when drug treatment ends?

  9. Does endometriosis affect my ability to have children?

  10. Do you think that alternative treatments—such as traditional Chinese medicines, changes in diet, homeopathy or allergy management—may help reduce the pain associated with endometriosis? Can you refer me to any practitioners who specialize in these areas and might be helpful to me?

  11. When you perform laparoscopy for endometriosis, are you prepared to treat any disease that you see at that time or do you perform a diagnostic procedure only? What surgical approaches do you typically employ to treat endometriosis (for example, ablation, excision, laser, coagulation)?

  12. If I want to conceive or am having trouble getting pregnant and have a diagnosis of endometriosis, how would this change your treatment plan? What treatments for infertility do you offer and what are the success rates in my circumstance?

Key Q&A



Key Q&A

  1. What causes endometriosis?

    The most widely accepted cause of endometriosis is retrograde menstruation. This occurs when tissue from the uterine lining, called endometrial tissue, flows backward through your fallopian tubes while you're menstruating. The tissue gets trapped and can't leave the body.

    However, no matter where it is in the body, endometrial tissue still responds to your hormones each month. This tissue can become inflamed, bleed and develop into scar tissue. When the tissue is attached to organs in the pelvic and abdominal cavities, it may cause severe pain, infertility and other problems.

    Other theories suggest that alterations in the immune system response, hormonal imbalances or environmental causes may be related to the development of endometriosis. Experts find strong evidence suggesting a genetic link.

  2. What does endometriosis feel like?

    Pain in the pelvic region ranging from very mild to severe is the most common symptom, but you may not experience any symptoms. Some women describe the pain as sharp and burning. It may last all month long, but is usually worse during menstruation, deep penetration during intercourse or bowel movements. Other symptoms may include:

    • Diarrhea and painful bowel movements especially during menstruation

    • Abdominal tenderness

    • Intestinal pain

    • Abnormal menstrual bleeding

    • Severe menstrual cramps

    • Pelvic pain distinct from menstrual cramps

    • Backache

    • Pain during or after sexual penetration

    • Painful bowel movements

    • Pain with exercise

    • Pain with urination

    • Painful pelvic examination

    • Infertility

  3. How can I be sure I'm being diagnosed correctly if pain associated with the disease can often be confused with other medical problems?

    Even without a definitive diagnosis, your health care professional may still prescribe hormonal treatments. If the pain decreases, there is an assumption that endometriosis was the cause of the pain. However, endometriosis cannot be definitively diagnosed without laparoscopy and biopsy.

  4. Can I get pregnant if I have endometriosis?

    Yes, you can. The majority of women who have endometriosis are fertile, and there are many who have the disease and go on to have children. However, the likelihood of infertility does increase in women with endometriosis of all stages.

  5. Is there any way I can prevent endometriosis?

    No. Experts don't know definitively what causes the condition so they don't know how to prevent it. Research suggests that having children early, having more than one child and long-term use of oral contraceptives may reduce the risk. However, many other factors determine if and when a woman should have children.

  6. What options are available to treat endometriosis?

    The most common medical therapies for endometriosis are hormonal contraceptives and other hormonal regimens, such as GnRH agonists (gonadotropin-releasing hormone drugs), which reduce estrogen release, limiting the effects of hormones on the endometrial tissue. Danazol, a synthetic androgen, is also used, but it can cause some undesirable side effects, including weight gain, hirsutism (hair growth) and lowering of the voice. Surgical treatments range from removing only the endometrial implants via laparoscopy to removing the uterus and ovaries.

  7. How do I know which is the best treatment option for my case of endometriosis?

    It's tough to know which treatment is best for you, especially since very few comparative studies have been conducted to determine which approach is better. There are pros and cons for all treatments. Most women with the disease can find relief via medical therapies, and birth control pills may be used indefinitely to manage symptoms. Other women turn to surgery. However, many women try to avoid surgery to remove the uterus because it's a serious procedure that will leave them infertile and carries no guarantee of banishing endometriosis forever.

    Because of the risks associated with surgery, the usual course of treatment is to proceed from the least invasive or risky to the more invasive treatment. That means medical treatment first.

    If that doesn't work, your doctor may recommend laparoscopy, with surgery to remove the uterus as a last resort.

Lifestyle Tips

Lifestyle Tips

  1. Boost intake of omega-3s

    Animal research suggests that the omega-3 fatty acids found in fatty fish like mackerel, salmon, sardines and anchovies may help ease the pain of endometriosis. No research has been done on women with endometriosis to date, but some health care professionals recommend fish oil supplements to their patients with the condition. Fish oil has many other health benefits as well. Talk with your doctor about this option.

  2. Eliminate trans fats

    Recent research shows a link between high dietary intakes of trans fats from hydrogenated oils and increased risk of endometriosis—another good reason to substitute healthful omega-3s for trans fats.

  3. Block prostaglandin to relieve pain

    Over-the-counter nonsteroidal anti-inflammatory drugs (NSAIDs) are enough to benefit many women with pain from endometriosis and may be the most helpful choice for you as well—check with your health care professional. Ibuprofen (Advil, Motrin, Rufen) and naproxen (Aleve, Anaprox, Naprosyn) are all examples. These drugs block prostaglandins. Prostaglandins are natural body substances that promote inflammation, uterine contractions and pain and are thought to be linked to endometriosis.

  4. What to do when pain remedies don't work

    Make sure your body is best able to withstand pain by getting enough sleep at night, eating right and taking recommended doses of vitamins and minerals—some studies suggest good results with magnesium or thiamine. A heating pad or hot bath may help ease painful cramps. Relaxation techniques, meditation and even acupuncture have helped some women—see a pain management specialist or visit a pain center. Other possibilities include prescription pain control drugs, hormone therapy, trancutaneous electrical stimulation (TENS) and surgery to remove endometriosis lesions or to cut nerves transmitting pain.

  5. Get help for painful intercourse

    Tell your health care professional and ask for help, as painful intercourse is a symptom of endometriosis. Women typically feel pain during deep penetration and some feel pain as if something has been "bumped into." Your health care professional will need to ask questions and perform a pelvic examination to find abnormalities and the source of tenderness. Ultimately, you may need a laparoscopy to document the presence of endometriosis lesions, and medication or surgery to relieve pain.

  6. Prepare for Laparoscopy

    Schedule your procedure at the end of the week, to take advantage of the weekend as part of your recovery time. The procedure is typically performed during the first half of the menstrual cycle before ovulation but after the menstrual flow has stopped. Clear your schedule for a few weeks afterward to allow as much time as possible for rest. Clean and take care of errands in advance, and lay in a supply of convenience meals. Arrange with your partner or an adult friend to help you with transportation on the day of surgery. Don't eat anything heavy or fatty the evening before, follow your doctor's preoperative instructions, leave jewelry and valuables at home and arrive early to fill out forms.

Organizations and Support

Organizations and Support

For information and support on coping with Endometriosis, please see the recommended organizations, books and Spanish-language resources listed below.

American Association of Gynecologic Laparoscopists (AAGL)
Website: http://www.aagl.org
Address: 6757 Katella Avenue
Cypress, CA 90630
Hotline: 1-800-554-AAGL (1-800-554-2245)
Phone: 714-503-6200

American College of Obstetricians and Gynecologists (ACOG)
Website: http://www.acog.org
Address: 409 12th Street, SW
P.O. Box 96920
Washington, DC 20090
Phone: 202-638-5577
Email: resources@acog.org

American Society for Reproductive Medicine (ASRM)
Website: http://www.asrm.org
Address: 1209 Montgomery Highway
Birmingham, AL 35216
Phone: 205-978-5000
Email: asrm@asrm.org

Association of Reproductive Health Professionals (ARHP)
Website: http://www.arhp.org
Address: 1901 L Street, NW, Suite 300
Washington, DC 20036
Phone: 202-466-3825
Email: arhp@arhp.org

Center for Endometriosis Care
Website: http://www.centerforendo.com
Address: 1140 Hammond Drive
Building F, Suite 6220
Atlanta, GA 30328
Hotline: 1-866-733-5540

Endometriosis Association (EA)
Website: http://www.endometriosisassn.org
Address: 8585 N. 76th Place
Milwaulkee, WI 53223
Phone: 414-355-2200

Endometriosis Research Center
Website: http://www.endocenter.org
Address: 630 Ibis Drive
Delray Beach, FL 33444
Hotline: 1-800-239-7280
Phone: 561-274-7442

A Gynecologist's Second Opinion: The Questions & Answers You Need to Take Charge of Your Health
by William H. Parker, Rachel L. Parker

Coping With Endometriosis
by Robert Phillips, Glenda Motta

Endometriosis: One Woman's Journey
by Jennifer Marie Lewis

Endometriosis Survival Guide: Your Guide to the Latest Treatment Options and the Best Coping Strategies
by Margot Fromer

Endometriosis: The Complete Reference for Taking Charge of Your Health
by Mary Lou Ballweg

Living Well with Endometriosis: What Your Doctor Doesn't Tell You…That You Need to Know
by Kerry-ann Morris

100 Questions & Answers About Endometriosis
by David B. Redwine

Yale Guide to Women's Reproductive Health: From Menarche to Menopause
by Mary Jane Minkin, Carol V. Wright

American Academy of Family Physicians, Family Doctor: Endometriosis
Website: http://familydoctor.org/online/famdoces/home/women/reproductive/gynecologic/476.html
Email: http://familydoctor.org/online/famdoces/home/about/contact.html

Endometriosis Association On-Line
Website: http://www.endometriosisassn.org/es_index.html
Address: La Endometriosis Association Oficinas Internacionales
8585 N. 76th Place
Milwaukee, WI 53223
Hotline: 1-800-992-3636
Phone: 414-355-2200

Last date updated: 
Mon, 2011-06-20

What is it?

Overview

What Is It?
Genital chlamydia is the most frequently reported bacterial sexually transmitted disease (STD) in the United States today. When diagnosed, chlamydia is easily treated and cured.

Genital chlamydia (pronounced kla-mid-ee-uh), a bacterial sexually transmitted disease (STD) caused by the bacterium Chlamydia trachomatis, is the most frequently reported STD in the United States today.

It occurs most frequently among teenagers and young adults, according to the U.S. Centers for Disease Control and Prevention (CDC). In fact, among females, the highest rates of chlamydia occur in those aged 15 to 24. In 2011, over 1.4 million chlamydia infections were reported to CDC, but an estimated 2.8 million infections occur annually in the United States.

Initially, in females, the bacteria invade cells lining the endocervix (the opening to the uterus). As it spreads into the reproductive tract, it can eventually lead to infertility, ectopic pregnancy and chronic pelvic pain. It has been estimated that chlamydia causes no symptoms in up to 70 percent to 95 percent of females and 90 percent of males. It is sometimes called a "silent" disease. Because chlamydia is usually silent but can lead to serious complications, such as infertility, routine annual screening of all sexually active young females 25 years and younger is recommended.

Chlamydia is very common, particularly in young females. In fact, CDC estimates that 1 in 15 sexually active females aged 14 to 19 years has chlamydia.

When diagnosed, chlamydia is easily treated and cured. Left untreated, it can lead to significant medical problems for females, one of the most serious being pelvic inflammatory disease (PID). PID is a generic term indicating various inflammatory disorders of the upper genital tract, including endometritis and tubo-ovarian abscess. Acute PID can be difficult to diagnose. Its signs and symptoms vary widely, and many females have only subtle symptoms.

In addition to PID, chlamydia can lead to proctitis (inflamed rectum) and conjunctivitis (inflammation of the eye lining). It also increases risk for HIV and other STDs, as well as cervical cancer.

Chlamydia and PID

The following factors may increase your risk for developing PID:

  • previous episodes of PID or STDs
  • multiple sex partners or a partner with multiple sex partners
  • being under age 25
  • douching

It's a common misconception that the use of an intrauterine device (IUD) increases the risk of developing PID. The risk of developing PID is minimally increased during the first 20 days after insertion of the device, but after that time the risk returns to baseline. This risk can be reduced by testing for STDs before IUD insertion and treating appropriately. IUDs are an extremely safe and effective means of preventing pregnancy, with less than 1 percent unintended pregnancies per year.

Chlamydia infection is one of the most common causes of PID. It has been estimated that up to 10 percent to 20 percent of females with untreated chlamydia will develop PID. Some females with PID will become infertile. Other potential complications include chronic pelvic pain and life-threatening ectopic pregnancy, which is a leading cause of pregnancy-related deaths for American females in the first trimester.

Annual chlamydia screening for sexually active females under 25 years old is cost effective because it can prevent serious reproductive complications, such as infertility, ectopic pregnancy and chronic pelvic pain.

Chlamydia and HIV

Research has shown that females infected with chlamydia are up to five times more likely to acquire HIV if exposed to the virus. The reason for the increased risk may be that chlamydia causes a spike in the number of white blood cells at the site of infection. Some of these immune system cells, while needed to fight the infection, also happen to be the main target for HIV.

Chlamydia and Cervical Cancer

Some studies have shown an increased risk of cervical cancer in females who have had chlamydia. Although infections with cancer-causing strains of human papillomavirus (HPV) remain the prime cause of cervical cancer, infection with certain subtypes of Chlamydia trachomatis may contribute to that risk.

In 1993, Congress set aside funds to begin a national STD-related infertility prevention program that has led to significant increases in chlamydia screening. In addition, all medical professional associations, such as the American College of Obstetricians and Gynecologists, the American Academy of Pediatrics and the American Association of Family Physicians, recommend routine chlamydia screening annually for all females under 25. As a result, more public and private health care professionals have been screening young females. Because most young females still are not tested, health officials estimate that the actual number of infections is much higher than reported.

Reported female cases greatly exceed those for males. The reasons for this are unclear, but it may be that fewer males are screened routinely for chlamydia, often presenting for testing only when they have symptoms.

Fortunately, increased awareness of the seriousness of chlamydia has put pressure on health care professionals to offer regular screening to younger females. In the year 2000, chlamydia was added to the list of performance measures for the Healthcare Effectiveness Data and Information Set. This tool rates how well managed care organizations perform on a variety of clinical measures, including prevention efforts for breast cancer, controlling blood cholesterol levels and childhood immunizations. While this does not make chlamydia screening mandatory, managed care organizations are now evaluated on how well they meet the established guideline of offering yearly chlamydia testing to sexually active females between ages 15 and 25 years.

In addition, the Patient Protection and Affordable Care Act (ACA) requires insurance companies to cover the cost of chlamydia screening, as well as some other STD testing and prevention counseling.

Chlamydia in Pregnancy
A small percentage of pregnant females are infected with chlamydia. In pregnant females, untreated chlamydia has been associated with pre-term delivery Transmission to the newborn results from exposure to the mother's infected cervix during birth. All females should be screened for chlamydia as part of routine prenatal care. Infants with chlamydia may be born prematurely. They also may experience eye inflammation (conjunctivitis) and breathing problems. Chlamydia infection also can involve the oropharynx, genital tract and rectum. Infection sometimes can cause pneumonia during an infant's first months. Recommended treatment for neonatal chlamydia is erythromycin base divided in four daily doses for 14 days.

Diagnosis

Diagnosis

Part of what makes chlamydia so difficult to diagnose is that it is largely asymptomatic; in other words, someone can be infected for months or longer and never know they have the infection. When symptoms do occur, they often are mild—a burning sensation when urinating and/or a discharge from the vagina or penis are typical symptoms. Females may also experience pain in the pelvic area or discomfort or bleeding during sex. Health care professionals may not address these symptoms, possibly leading to the chlamydia infection remaining untreated. If left untreated in females, it may result in PID.

PID can occur within days or several months after being infected with chlamydia. At this point, symptoms still may go unnoticed in some females, yet they do have an active PID infection. Other females, however, may experience bleeding between menstrual periods, lower back pain, pain during sexual penetration, increased vaginal discharge and severe pelvic pain. Treatment for these females may require hospitalization and intravenous antibiotics.

Testing is the only way to know whether you have chlamydia. CDC recommends annual screening for all sexually active females 25 years of age and younger and for older females with risk factors (such as, those who have a new sex partner and those with multiple sex partners). All females with signs of infection of the cervix and all pregnant females should be tested.

The most sensitive chlamydia tests, called nucleic acid amplification tests (NAATs), can be performed on a urine specimen or a self-collected vaginal swab. An invasive genital exam is not always required. However, a chlamydia test can also be performed on a swab of the cervix collected as part of a pelvic exam or a urethral swab collected on males. It may take several days before you can get a test result.

Treatment

Treatment

If you test positive for chlamydia, your infection can be cured with antibiotics. Depending on several factors, your health care professional may prescribe azithromycin, in which case you will take only a single dose of a few pills, or you may be prescribed doxycycline, which requires one pill twice a day for seven days.

If you are pregnant and infected with chlamydia, you still can be treated without harming the fetus. However, doxycycline is not recommended during pregnancy. The recommended regimen for pregnant females is azithromycin pills taken in a single dose. As with any antibiotic treatment, it is important that you take all your pills.

Too often, females become reinfected because their partner has not been treated. Studies have shown that females who are reinfected with chlamydia have a much greater risk of developing PID. Therefore, it is important that you abstain from sexual contact until a week after your partner has been tested and completed treatment, meaning seven days after a single-dose azithromycin regimen or after completion of a seven-day doxycycline regimen. In addition, you should return to your doctor for a repeat test three to six months after you are treated to be sure that you have not been infected again.

In general, treatment is recommended for any partner or partners you had sexual contact with up to 60 days prior to having symptoms or a diagnosis of chlamydia. Some clinics and doctors' offices offer what is called expedited partner therapy (EPT). Patients are given a prescription or the medication that treats chlamydia to give to their partner(s) without the clinician assessing the partner. There are legal and ethical debates about this approach, and it does have some limitations (including loss of screening and counseling opportunities and the potential for adverse reactions to antibiotics), but in some cases it may be the most effective way to stop the spread of chlamydia, because many infected male partners have no symptoms and are reluctant to seek treatment.

EPT is legal in several U.S. states and cities. For more information on its legal status, see: http://www.cdc.gov/STD/EPT/legal/default.htm.

In some cases, people infected with chlamydia are also infected with gonorrhea. Therefore, testing for gonorrhea is often done at the same time as testing for chlamydia. If a person tests positive for both infections, additional treatment is necessary.

PID treatment begins with an antibiotic regimen that provides broad coverage against several bacteria. Treatment should begin as soon as a diagnosis is made, because immediate therapy has been shown to reduce the risk of long-term consequences of PID. Antibiotics may be given by mouth or injection. There are several treatment options recommended by CDC. Regardless of which type of therapy is chosen, hospitalization is no longer recommended, except in certain circumstances including:

  • surgery is needed
  • an oral outpatient regimen cannot be tolerated
  • a patient is pregnant
  • a patient does not respond clinically to oral antimicrobial therapy
  • a patient has severe illness, including high fever and vomiting
  • a patient has tubo-ovarian abscess or a weakened immune system

While medication can stop PID, some females may need surgery to remove scar tissue and blockages caused by long-term infection.

Prevention

Prevention

Protecting yourself from chlamydia requires the same care and attention needed to prevent other sexually transmitted diseases (STDs). If you have already been infected, you should be vigilant in preventing reinfection, which can increase your risk of infertility.

Abstinence is one sure way not to become infected, as the spread of chlamydia is almost always limited to sexual contact. If you have sex, make sure you use a latex condom from the beginning to the end of sexual contact every time you have sex. Latex condoms offer the best available means of reducing your risk of contracting an STD when they are used consistently and correctly.

Also know that your risk for chlamydia infection increases with the more sexual partners you have. If you are sexually active and 25 years of age or younger, or if you are older but have any risk factors for chlamydia, you should ask your provider to test you at least once a year. Risk factors include being young and sexually active, having multiple sex partners, and having previous infection with other STDs.

Women who have sex with women—either exclusively or in addition to male partners—are also at risk for chlamydia. Women who have sex exclusively with women may be at a decreased risk, but they should still take precautions. Lesbians and bisexual females need to consider the following precautions to protect themselves from contracting these diseases.

  • Ask about the sexual history of current and future sex partners.
  • Reduce your number of sex partners.
  • If you have sex with a male partner, always use a condom from start to finish during any type of sex (vaginal, anal and oral). Use latex condoms rather than natural membrane condoms. If used consistently and correctly, latex condoms offer greater protection against STD agents, including HIV.
  • Use only water-based lubricants. Oil-based lubricants such as petroleum jelly and vegetable shortening can destroy condoms. If you decide to use a spermicide along with a condom, it is preferable to use spermicide in the vagina according to manufacturer's instructions. As of December 2007, the U.S. Food and Drug Administration (FDA) mandated a new warning for the labels of over-the-counter vaginal contraceptives that contain the spermicide nonoxynol-9. The warning states that vaginal contraceptives containing nonoxynol-9 do not protect against infection from HIV (human immunodeficiency virus, the AIDS virus) or other STDs. The FDA's warning also advises consumers that the use of vaginal contraceptives containing nonoxynol-9 can increase vaginal irritation, which may increase the possibility of transmitting the AIDS virus and other STDs from infected partners.
  • Get tested for chlamydia once a year if you are 25 years or younger or have other risk factors.

Research

Research

Scientists are looking for better ways to diagnose, treat and prevent chlamydia infections. Researchers supported by the National Institute of Health recently completed sequencing the genome for Chlamydia trachomatis. The sequence represents an encyclopedia of information about the organism. This accomplishment will give scientists important information as they try to develop a safe and effective vaccine. Developing topical microbicides (preparations that can be inserted into the vagina to prevent infection) that are effective and easy for females to use is also a major research focus.

Facts to Know

Facts to Know

1. In 2011, the rate of reported chlamydia infections in females was more than two and a half times the rate among males, likely the result of a larger number of females being screened for the infection.

2. Studies have shown that routine chlamydia screening and treatment can significantly reduce the incidence of lower genital tract chlamydia, as well as pelvic inflammatory disease, ectopic pregnancy, chronic pelvic pain and infertility.

3. Up to 95 percent of infected females and 90 percent of infected males have no symptoms of chlamydia, and the majority of cases go undiagnosed.

4. Rates of positive chlamydia tests in females tested in family planning clinics rose 3.8 percent between 2009 and 2010. Rather than evidence of an escalating epidemic, this trend mostly reflects increased screening of asymptomatic females and improved reporting.

5. Research has shown that females infected with chlamydia are up to five times more at risk of acquiring HIV than females not infected.

6. It is estimated that up to 30 percent of females not treated for chlamydia will develop pelvic inflammatory disease (PID). PID increases a woman's chances of infertility, chronic pelvic pain or life-threatening ectopic pregnancy.

7. Rates of chlamydia rose in all regions of the country between 2002 and 2011. In 2011, rates of the disease were highest in the South (505.3 per 100,000), followed by the Midwest (445.7), the West (424.9) and the Northeast (415.8).

8. The rate of chlamydia among African-American females was more than seven times higher than the rate among Caucasians in 2011, according to the Centers for Disease Control and Prevention.

Questions to Ask

Questions to Ask

Review the following Questions to Ask about chlamydia so you're prepared to discuss this important health issue with your health care professional.

  1. If chlamydia is often without symptoms, how do I know if I have been infected?

  2. If I don't treat chlamydia, what will happen?

  3. What treatments are available?

  4. What should I tell my partner?

  5. How long should I abstain from sex after treatment begins?

  6. What are the symptoms of pelvic inflammatory disease?

  7. Is it possible I am infected with gonorrhea as well?

  8. Is chlamydia transmitted by sexual intercourse only?

  9. Do I need to be retested after treatment to be sure I am cured?

Key Q&A

Key Q&A

1. What is chlamydia?

Chlamydia infection is caused by a bacterium called Chlamydia trachomatis. The bacterium can be transmitted during sexual intercourse or by oral-genital contact with an infected person.

2. If so many people with chlamydia don't have symptoms, why is it necessary to get treated?

Even though infection often is asymptomatic, it can still cause serious consequences for females, and for pregnant females and their infants. Also, the only way to stop the epidemic is by treating everyone infected, whether they have symptoms or not.

3. How will chlamydia infection affect my chances of getting pregnant?

It depends on several factors, such as how long you have been infected and whether the infection has migrated into your upper genital tract. Pelvic inflammatory disease, which is often caused by chlamydia infection, can lead to infertility.

4. Does having chlamydia put me at greater risk for other sexually transmitted diseases (STDs)?

Yes. Chlamydia infection increases your risk of HIV by producing more of the type of white blood cells to which HIV attaches itself. Individuals are also frequently infected with more than one STD at a time. These STDs are often transmitted at the same time, so if you have acquired chlamydia, you may also be at risk for having other STDs.

5. What are the side effects of chlamydia treatment?

Chlamydia can be cured with antibiotics without causing significant side effects. The most common side effects are upset stomach, nausea, vomiting and diarrhea.

6. How is pelvic inflammatory disease treated?

In most cases, the first line of treatment is oral antibiotics. More serious cases or special circumstances may require intravenous drugs and hospitalization.

7. Why are more females diagnosed with chlamydia than males?

One reason is that unless they have symptoms, most males are never tested for chlamydia. Females, on the other hand, although they are more likely not to have symptoms of the disease, do have annual exams and therefore more opportunities to be screened for infection.

8. Can a pregnant females pass chlamydia to her infant?

Yes. The infection can be transmitted during birth and can cause eye and lung infection in a newborn. Fortunately, a pregnant female can take medication that will cure chlamydia without harming her or her child.

Lifestyle Tips

Lifestyle Tips

1. Prevent pelvic inflammatory disease
Pelvic inflammatory disease, or PID, occurs when untreated infection, often a sexually transmitted infection such as chlamydia, spreads to the uterus, fallopian tubes or ovaries. Although many females have mild or nonexistent symptoms, some notice pain in the lower abdomen, vaginal discharge or bleeding, painful intercourse, nausea and vomiting and fever. Untreated PID can lead to tubal infertility, chronic abdominal pain or ectopic pregnancy. To prevent PID, make sure you are screened annually for chlamydia if you are 25 years or younger or have other risk factors. Also, your partners should be screened for STDs, particularly chlamydia and gonorrhea. You should also limit the number of sex partners you have, and use condoms every time you have sex.

2. Practice the best protection
After abstinence, the best protection against any type of sexually transmitted disease is a latex condom. However, it doesn't provide 100 percent protection against STDs—only abstinence does. If you use a condom, make sure you use it properly. Human error causes more condom failures than manufacturing errors. Use a new condom with each sexual act (including oral sex). Carefully handle it so you don't damage it with your fingernails, teeth or other sharp objects. Put the condom on after the penis is erect and before any genital contact. Pinch the tip of the condom to leave room for semen collection. Use only water-based lubricants with latex condoms. Ensure adequate lubrication during intercourse. Hold the condom firmly against the base of the penis during withdrawal, and withdraw while the penis is still erect to prevent slippage.

3. Get tested for STDs
No single test screens for all STDs. Some require a vaginal exam and Pap smear; others a blood or urine test. A negative test does not always ensure you do not have an infection. Still, it's important to ask your health care provider to regularly test you for STDs if you're sexually active in a non-monogamous relationship (or have the slightest concern about your partner's fidelity). You can get tested at your health department, community clinic, private doctor or Planned Parenthood. Or call the CDC at 1-800-CDC-INFO (1-800-232-4636) or log on to http://hivtest.cdc.gov/STDTesting.aspx to find free or low-cost clinics in your area.

5. Know whether you have an STD
While some STDs are accompanied by symptoms such as sores/ulcers or discharge, most, unfortunately, have no symptoms. You can't always tell if you or a partner has an STD just by looking. Don't rely on a partner's self reporting and assume that will prevent you from acquiring an STD; many infected persons do not know they have a problem. They may think symptoms are caused by something else, such as yeast infections, friction from sexual relations or allergies. So educate yourself about your own body and, in turn, learn about your own individual risk for contracting an STD. One way to do this is to schedule an examination with a health care provider who can sit down with you and help you learn the principles for staying safe and sexually healthy. Don't allow fear, embarrassment or ignorance to jeopardize your future.

6. Talk to your children about STDs
Sexually transmitted diseases are particularly common among adolescents. And it's an issue kids are concerned about. As a parent, you can play a large role in an adolescent's behavior, both in terms of the behavior you model yourself and in terms of the communication between you and your teen. Talk to your kids. Study after study proves that when parents talk to their kids about sexual issues, their kids listen. Don't worry that talking about sex is the same as condoning it; numerous studies dispute that theory. In fact, studies show that when parents talk about sex, children are more likely to talk about it themselves, to delay their first sexual experiences and to protect themselves against pregnancy and disease when they do have sex. Also, make sure your daughters or sons see a medical professional who is sensitive to adolescent health issues at least once a year, if for nothing else than to talk about STDs and pregnancy.

Organizations and Support

Organizations and Support

For information and support on coping with Chlamydia, please see the recommended organizations, books and Spanish-language resources listed below.

American College of Obstetricians and Gynecologists (ACOG)
Website: http://www.acog.org
Address: 409 12th Street, SW
P.O. Box 96920
Washington, DC 20090
Phone: 202-638-5577
Email: resources@acog.org

American Social Health Association (ASHA)
Website: http://www.ashastd.org
Address: P.O. Box 13827
Research Triangle Park, NC 27709
Hotline: 1-800-227-8922
Phone: 919-361-8400
Email: info@ashastd.org

ASHA's STI Resource Center Hotline
Website: http://www.ashastd.org/herpes/herpes_hotline.cfm
Address: American Social Health Association
P.O. Box 13827
Research Triangle Park, NC 27709
Hotline: 1-800-227-8922
Phone: 919-361-8400

Association of Reproductive Health Professionals (ARHP)
Website: http://www.arhp.org
Address: 1901 L Street, NW, Suite 300
Washington, DC 20036
Phone: 202-466-3825
Email: arhp@arhp.org

AWARE Foundation
Website: http://www.awarefoundation.org
Address: 834 Chestnut Street, Suite 400
Philadelphia, PA 19107
Phone: 215-955-9847

CDC National Prevention Information Network
Website: http://www.cdcnpin.org
Address: P.O. Box 6003
Rockville, MD 20849
Hotline: 1-800-458-5231
Phone: 404-679-3860
Email: info@cdcnpin.org

Guttmacher Institute
Website: http://www.guttmacher.org
Address: 1301 Connecticut Avenue NW, Suite 700
Washington, DC 20036
Hotline: 1-877-823-0262
Phone: 202-296-4012
Email: info@guttmacher.org

National Center for HIV/AIDS, Viral Hepatitis, STD and TB Prevention
Website: http://www.cdc.gov/nchhstp
Address: Centers for Disease Control and Prevention
1600 Clifton Road
Atlanta, GA 30333
Hotline: 1-800-CDC-INFO (1-800-232-4636)
Email: cdcinfo@cdc.gov

National Family Planning and Reproductive Health Association (NFPRHA)
Website: http://www.nfprha.org
Address: 1627 K Street, NW, 12th Floor
Washington, DC 20006
Phone: 202-293-3114
Email: info@nfprha.org

Planned Parenthood Federation of America
Website: http://www.plannedparenthood.org
Address: 434 West 33rd Street
New York, NY 10001
Hotline: 1-800-230-PLAN (1-800-230-7526)
Phone: 212-541-7800

Sexuality Information and Education Council of the United States (SIECUS)
Website: http://www.siecus.org
Address: 90 John Street, Suite 704
New York, NY 10038
Phone: 212-819-9770

Sexual Health Questions You Have...Answers You Need
by Michael V. Reitano, Charles Ebel

Sex: What You Don't Know Can Kill You
by Joe S. McIlhaney, Marion McIlhaney

Center for Disease Control: Chlamydia Information Sheet
Website: http://www.cdc.gov/std/spanish/STDFact-Chlamydia-s.htm
Address: CDC Info
1600 Clifton Rd
Atlanta, GA 30333
Hotline: 1-800-232-4636
Email: cdcinfo@cdc.gov

Medline Plus: Chlamydia
Website: http://www.nlm.nih.gov/medlineplus/spanish/ency/article/001345.htm
Address: Customer Service
US National Library of Medicine
8600 Rockville Pike
Bethesda, MD 20894
Email: custserv@nlm.nih.gov

Last date updated: 
Tue, 2013-02-12

What is it?

Overview

What Is It?
Cervical cancer is a disease in which cancer cells develop in the tissues of the cervix. The cervix, the lower part of the uterus which protrudes into the vagina, connects the body of the uterus to the vagina.

Cancer of the cervix is second only to breast cancer as the most common type of cancer found in women worldwide. It affects an estimated 500,000 women each year. In the United States and other developed countries, the rates of cervical cancer are much lower; in fact, according to the National Cervical Cancer Coalition, more than 80 percent of all cases of cervical cancer occur in developing countries.

The American Cancer Society estimates that about 12,170 cases of invasive cervical cancer will be diagnosed in the United States in 2012, and about 4,220 women will die from the disease.

Cervical cancer is a disease in which cancer cells develop in the tissues of the cervix. The cervix, the lower part of the uterus which protrudes into the vagina, connects the body of the uterus to the vagina. Nearly all cases of cervical cancer can be linked to the human papillomavirus, or HPV, a sexually transmitted virus.

There are more than 100 strains of HPV, and at least 15 high-risk types have been linked to cancer of the cervix. While most women who develop cervical cancer have HPV, only a small proportion of women infected with HPV develop cervical cancer. Only persistent HPV infection leads to cervical cancer. Additionally, some low-risk types of HPV cause vaginal and vulvar warts; other HPV strains cause the warts that sometimes develop on the hands or feet.

The normal cervix is a firm muscle that feels much like the tip of your nose. It is reddish pink, and the outside is covered with scale-like cells called squamous cells. The cervical canal is lined with another kind of cell called columnar cells. Tthe area where the two cell type meet—called the squamocolumnar junction or transformation zone (T-zone)—is the most likely area for abnormal cells to develop. The T-zone is more exposed on the cervix of young women (teens through 20s), making them more susceptible to cervical infections.

Health care professionals use the Pap test to find abnormal cell changes in cervical tissue that are cancerous or may become cancerous. The earlier cervical cancer is diagnosed, the better the chance for a cure. The American Cancer Society reports that both incidence and deaths from cervical cancer have declined markedly over the last several decades, due to more frequent detection and treatment of preinvasive and cancerous lesions of the cervix from increased Pap test screening.

Because persistent infection with high-risk strains of HPV can be a predictor of the presence or future development of preinvasive and cervical cancer, many medical professionals now also test for this virus as an adjunct to the Pap test. The U.S. Food and Drug Administration (FDA) has approved use of an HPV test for screening women ages 30 and older. When combined with a Pap test in women of this age group, the HPV test is better at identifying women at risk for developing cervical cancer than the Pap test alone.

Additionally, the FDA has approved two HPV vaccines, called Gardasil and Cervarix. Gardasil protects women against four HPV types—the two most common high-risk (cancer-causing) types of HPV, strains 16 and 18, and also the two most common low-risk types of HPV, 6 and 11, which cause 90 percent of genital warts. Cervarix protects against HPV 16 and 18. Both vaccines should be given before an infection occurs, ideally, before a girl becomes sexually active. Gardasil is approved for girls as young as nine and is routinely recommended for girls 11 and 12 years of age. It may also be given to women ages 13 to 26 who did not receive it when they were younger as well as males ages nine to 26. Cervarix is approved for use in girls and women ages nine through 25. If a woman is already infected with one of the four HPV types in one of the vaccines, the vaccine will not work against that particular HPV type. (It will still work against the remaining types she has not been exposed to.)

Clinical trials have shown that both Gardasil and Cervarix are safe and 100 percent effective in preventing HPV strains 16 and 18, which cause 70 percent of cervical cancers. Gardasil is also 99 percent effective in preventing HPV strains 6 and 11, which cause about 90 percent of genital wart cases. Both vaccines are given in three injections over six months. Although both Gardasil and Cervarix prevent two of the most serious high-risk HPV strains in women not previously exposed to them, they do not protect against all cancer-causing strains, so the FDA recommends continued screening with regular Pap tests.

The reason screening is so important in preventing cervical cancer is because the disease usually causes no symptoms in its earliest stages. Irregular bleeding, bleeding or pain during sex or vaginal discharge may be symptoms of more advanced disease. These symptoms should always be discussed with a health care professional.

All women are at risk for developing the disease, but several factors can increase a woman's risk of developing cervical cancer, according to the American Cancer Society:

  • Persistent infection with high-risk strains of the human papillomavirus (HPV), a common sexually transmitted disease. (Most women and men who have been sexually active have been exposed to the HPV virus, which is spread through skin-to-skin contact with an HPV-infected area. However, certain types of sexual behavior increase a woman's risk of getting an HPV infection, such as having sex at an early age, having many sexual partners and having unprotected sex at any age.)

    Recent studies find that using condoms cannot completely protect against HPV because the virus is passed through skin-to-skin contact, including the skin in the genital area that may not be covered by a condom. Correct and consistent condom use is still important, however, to protect against AIDS and other sexually transmitted diseases.
  • A compromised immune system related to certain illnesses such as human immunodeficiency virus (HIV) infection. Being HIV positive makes a woman's immune system less able to fight cancers such as cervical cancer.
  • Smoking cigarettes, which exposes the body to cancer-causing chemicals absorbed initially by the lungs but then carried in the bloodstream throughout the body. Women who smoke are about twice as likely to develop cervical cancer. The chemicals produced by tobacco smoke may damage the DNA in cells of the cervix and make cancer more likely to occur there.
  • Infection with chlamydia bacteria, which is spread by sexual contact and may or may not cause symptoms. Researchers don't know exactly why chlamydia infection increases cervical cancer risk, but they think it might be because active immune system cells at the site of a chlamydia infection might damage normal cells and cause them to turn cancerous.
  • A diet low in fruits and vegetables. Women who don't eat many fruits and vegetables miss out on the protective antioxidants and phytochemicals such as vitamins A, C, E and beta-carotene, which have all been shown to help prevent cervical cancer and other forms of cancer. Overweight women are also more likely to develop cervical cancer.
  • A family history of cervical cancer—if your mother or sister had cervical cancer—may mean you have a genetic tendency for the disease. This could be because such women are genetically less able to fight off HPV infection than other women.
  • Exposure in utero to diethylstilbestrol (DES), a synthetic hormone that was prescribed to pregnant women between 1940 and 1971 to prevent miscarriages. For every 1,000 women whose mother took DES when she was pregnant, about one develops clear-cell adenocarcinoma (cancer) of the vagina or cervix. For more information on DES exposure, contact the U.S. Centers for Disease Control and Prevention (CDC), toll-free: 1-800-CDC-INFO (232-4636), or online at www.cdc.gov.
  • Long-term oral contraceptive use (five or more years) may very slightly increase a woman's risk of cancer of the cervix, according to some statistical evidence. However, this risk appears to go back to normal after a woman has been off birth control pills for 10 years. The American Cancer Society advises women to discuss the benefits of oral contraceptive use versus this very slight potential risk with their health care professionals.

The death rate from cervical cancer in African-American women is nearly double that of the death rate in Caucasian women. Additionally, Hispanic women develop this cancer nearly twice as often as non-Hispanic Caucasian women. Lack of access to health services (and therefore, less screening), cultural influences and diagnosis of cancer at more advanced stages are all possible reasons for these differences.

Women of all ages are at risk of cervical cancer, but it occurs most often in women 30 and over because they are more likely to have persistent HPV infections. Regardless, it is important that even postmenopausal women continue having regular Pap tests if they still have a cervix. If a woman's cervix was removed during a hysterectomy because of cervical cancer or pre-cancer, she should continue screening with Pap tests and HPV tests. If her cervix was removed during a hysterectomy and there were no signs of cancer and no suspicious Pap tests before the surgery, then she may not need to continue screening. Women over age 65 should stop getting Pap tests if they have had adequate prior screenings and are not at high risk for cervical cancer. Always discuss screening needs with your primary care physician.

The benefits of the Pap test are clear: Once one of the most common causes of cancer death for American women, cervical cancer has caused 70 percent fewer deaths per year since the introduction of the Pap test in the 1950s.

Although both the incidence and death rates of cervical cancer are going down, it is still a fairly common cancer in U.S. women, which may be related to the prevalence of infection with HPV. According to the CDC, approximately 20 million people are currently infected with HPV. At least 50 percent of the reproductive-age population has been infected with one or more types of HPV, and up to 6 million new infections occur each year.

Diagnosis

Diagnosis

In its earliest stages, cervical cancer usually causes no symptoms. Irregular bleeding, bleeding or pain during sex or vaginal discharge may be symptoms of more advanced disease. These symptoms don't necessarily mean you have cancer, but they should always be discussed with a health care professional.

Despite the Pap test's 60-year record as a safe and highly accurate screening tool for cervical cancer and precancerous abnormalities of the cervix, many women do not have regular Pap tests. Most invasive cervical cancers occur in women who have not had regular Pap tests. Many other cases of cervical cancer are attributed to failure to follow up on screening results.

A Pap test is a simple procedure: After a speculum (the standard device used to examine the cervix) is placed in the vagina, cells are taken from the surface of the cervix with a cotton swab then smeared onto a glass slide or in a liquid solution. Another sample is taken from the T-zone (or the transition-zone, the area of transition between cervical cells and uterus cells) with a tiny wooden or plastic spatula, or a tiny brush. The "liquid-based" Pap tests may provide a higher degree of accuracy and reliability.

For women who have had total hysterectomies, in which the cervix is removed, cells are taken from the walls of the vagina.

The slide or vial is delivered to a laboratory where a cytotechnologist (a lab professional who reviews your tissue sample) and, when necessary, a pathologist (a health care professional who examines bodily tissue samples) examines the sample for any abnormalities. Each smear contains roughly 50,000 to 300,000 cells.

Though not infallible, when performed regularly, the Pap smear detects a significant majority of cervical cancers.

New Technology for Cervical Cancer Screening and Diagnosis

Because the Pap test can be associated with sampling and interpretation errors, research and development strategies are focused, to a large degree, on fine-tuning Pap test interpretation, visualization and tissue retrieval. The U.S. Food and Drug Administration has approved a number of devices to enhance the Pap test, including the following:

  • Liquid-based Pap tests: These tests use a solution that helps preserve the cells scraped from the cervix (the Pap smear), as well as remove mucus, bacteria and other cells from the specimen that may interfere with examining the cervical cells. Test vials preserve specimens for up to three weeks from the date of collection, giving the physician an opportunity to request HPV testing on a patient for screening women ages 30 and over if a borderline Pap test results.

  • Computerized instruments that help to more accurately identify abnormal cells on slides: Unfortunately, studies so far have not found a real advantage for this kind of automated testing.

Additional new technologies that enable health care professionals to more accurately interpret Pap smear slides and get a better view of abnormal tissue include larger photographs of the cervix used along with Pap test results and improved lighting devices.

In addition, the FDA has approved the HPV DNA test to be used together with the Pap test to screen for cervical cancer in women age 30 and over. The HPV DNA test may also be used for women of any age who have slightly abnormal Pap test results to see if additional testing or treatment is necessary. The HPV DNA test is designed to be used in conjunction with—not in place of—the Pap test. Health care professionals can use the HPV DNA test to look for the presence of high-risk types of HPV that are most likely to cause cervical cancer by looking for pieces of their DNA in cervical cells. The sample is collected similarly to the Pap test.

To help improve the reliability of your Pap test, schedule your appointment two weeks after your last menstrual period and refrain from doing the following for at least 48 hours before the test:

  • having sex

  • douching

  • using tampons

  • using vaginal creams, suppositories, medicines, sprays or powders

Pap Test Results

An abnormal Pap test result does not mean you have cervical cancer. It indicates some degree of change or abnormality in the cells that cover the surface (lining or epithelium) of the cervix.

While the Pap test cannot confirm an HPV infection, it can show cell changes that suggest infection with HPV.

Pap test classifications include:

  • Negative for intraepithelial lesion or malignancy. This classification means that no signs of pre-cancerous changes, cancer or other significant abnormalities were detected. Some specimens under this classification are completely normal, and others may have changes unrelated to cervical cancer, such as signs of yeast infection, herpes or Trichomonas. Other specimens may show what are known as "reactive cellular changes," which is how cervical cells react to infection and other irritations.

  • Atypical squamous cells of undetermined significance, or ASCUS. These cellular changes appear abnormal for unknown reasons. It isn't possible to determine if the abnormality is caused by inflammation, infection, low estrogen after menopause or by precancerous changes. These types of cellular changes usually return to normal without intervention or after treatment of an infection. Follow-up for this Pap test result is usually a repeat Pap test in three to six months. Some doctors will use the HPV DNA test to help them decide the best course of action. And if a woman with ASCUS has a high-risk type of HPV, doctors will usually do a colposcopy.

  • Squamous intraepithelial lesion (SIL). This change is considered precancerous. SIL changes are divided into two categories: low-grade SIL and high-grade SIL.

    • Low-grade SIL refers to early changes in the size, shape and number of cells on the surface of the cervix. These changes may also be referred to as mild dysplasia or cervical intraepithelial neoplasia 1 (CIN 1). Most of these lesions are caused by an active HPV infection and return to normal on their own without treatment. Others, however, may continue to grow or become increasingly abnormal in other ways and develop into a high-grade lesion.

      According to the National Cancer Institute, these cell changes occur most often in women ages 25 to 35, but can appear in other age groups.

      Because a Pap test cannot tell for sure whether a woman has high- or low-grade SIL, any patient with an SIL should have a colposcopy.

    • High-grade SIL. Cells in this category look very different from normal cells and are less likely to return to normal without treatment and are more likely to develop into cancer. These abnormal cellular changes are considered precancerous changes. High-grade SIL is most common in women age 30 to 40, but can occur in other age groups.

      Other terms for high-grade SIL are moderate or severe dysplasia (CIN 2 or CIN 3) carcinoma in situ.

      Follow-up for high-grade SIL (CIN 2 or CIN 3 are the usual pathologic results after biopsy) depends on the results of the colposcopy. In most cases, it involves additional procedures, including biopsy, endocervical curettage or both to determine the degree of abnormality and rule out invasive cancer.

Usually, cervical cancer grows slowly. Precancerous changes may not become cancerous for months or years. Once they spread deeper into cervical tissue or to other tissues and organs, the cellular abnormalities are classified as cervical cancer, or invasive cervical cancer. Cervical cancer tends to occur in midlife; about half of women diagnosed with cervical cancer are between the ages of 35 and 55, and it rarely occurs in women younger than 20.

A Pap test is a screening tool; other procedures are necessary to confirm Pap test abnormalities and diagnose conditions. All abnormal Pap tests should have some form of action plan. This may include a "watch and wait" approach with retesting in several months. Or, depending on the degree of abnormality, your health care provider may order other tests, including:

  • Colposcopy: The doctor uses a colposcope to magnify and focus light on the vagina and cervix to view these areas in greater detail. Depending on these findings, your health care professional may then use one or more of the following tests:

    • Biopsy: During this procedure, sample tissue is taken from the cervical surface. Often several areas are biopsied.

    • Endocervical curettage: Cells are scraped from inside the cervical canal using a spoon-shaped instrument called a curette to help make a more precise diagnosis. This procedure evaluates a portion of the cervix that cannot be seen.

    • Cone biopsy: When biopsy or endocervical curettage reveals a problem that requires further investigation, a cone biopsy may be performed. A "cone" of tissue is removed from around the opening of the cervical canal. In addition to diagnosing an abnormality, cone biopsy can be used as a treatment to remove the abnormal tissue. A pathologist examines tissue removed during cone biopsy to be sure all the abnormal cells are removed.

    • Loop Electrocautery Excision Procedure (LEEP): The suspicious area is removed with a loop device and the remaining tissue is electrocoagulated (vaporized with electrical current). LEEP is both a diagnostic test and a treatment. A pathologist examines tissue removed during LEEP to be sure all the abnormal cells are removed.

If cancer of the cervix is diagnosed, more tests will be conducted to learn if cancer cells have spread to other parts of the body. These tests may include:

  • Cystoscopy: This test is performed to see if the cancer has spread to the bladder. The doctor examines the inside of the bladder using a lighted tube.

  • Proctoscopy: Similar to a cystoscopy, this test is performed to see if the cancer has spread to the rectum.

  • Examination of the pelvis under anesthesia to check for further spread.

  • Chest x-ray to see if the cancer has spread to the lungs.

  • Other imaging tests such as CT (computed tomography) scans or magnetic resonance imaging (MRI) to see if the cancer has spread to lymph nodes or other organs.

In some cases, a Pap test may report that abnormal cells are present in a sample when, in fact, the cells in question are normal. This type of abnormal report is known as a false positive.

When a Pap test fails to detect an abnormality that is present, the result is called a "false negative." Even under the best of conditions, there is always a small false negative rate. Several factors may contribute to a false negative Pap test:

  • When irregular cells are located high in the cervical canal they are difficult to get to or scrape under normal Pap test procedures.

  • Menstrual blood and inflammatory cells can mask abnormal cells; these cells would not be visible to the cytotechnologist.

  • An inadequate sample—not enough cells were collected during the Pap test.

  • Human error, in which the person reviewing the slide misinterpreted abnormal cells as normal.

Screening Guidelines for Cervical Cancer

The American Cancer Society (ACS), the American College of Obstetricians and Gynecologists (ACOG) and the U.S. Preventive Services Task Force (USPSTF) recommend:

  • All women should begin screening at age 21.

  • Women ages 21 to 29 should have a Pap test every three years. They should not have an HPV test unless it is needed because of an abnormal Pap test result.

  • Women ages 30 to 65 should have both a Pap test and an HPV test every five years or a Pap test alone every three years. (The ACS and ACOG prefer the two tests together every five years but say either method is acceptable; the USPSTF recommends either schedule.)

  • Women over age 65 who have been screened previously with normal results and are not at high risk for cervical cancer should stop getting screened. Women with cervical precancer should continue to be screened.

  • Women who have had a total hysterectomy, with removal of their uterus and cervix, and have no history of cervical cancer or precancer should not be screened.

  • Women who have received the HPV vaccine should still follow the screening guidelines for their age group.
  • Women who are at high risk for cervical cancer may need more frequent screening. Talk to your health care professional about what's right for you.

Talk to your health care provider about what is best for you, based on your medical history.

Treatment

Treatment

To plan your treatment, your health care professional needs to know the stage of the disease. The following stages are used for cervical cancer:

  • Stage 0 or carcinoma in situ. This is very early cancer. The abnormal cells are found only in the first layer of cells of the lining of the cervix and do not invade the deeper tissues of the cervix.

  • Stage I cancer involves the cervix but has not spread.

  • Stage IA indicates a very small amount of cancer that is only visible under a microscope and is found in the deeper tissues of the cervix.

  • Stage IB indicates a larger amount of cancer is found in the tissues of the cervix that can usually be seen without a microscope.

  • Stage II cancer has spread to nearby areas but is still inside the pelvic area.

  • Stage IIA cancer has not spread into the tissues next to the cervix, called the parametria. The cancer may have spread to the upper part of the vagina.

  • Stage IIB cancer has spread to the tissue around the cervix.

  • Stage III cancer has spread throughout the pelvic area. Cancer cells may have spread to the lower part of the vagina. The cells also may have spread to block the tubes that connect the kidneys to the bladder (the ureters).

  • Stage IV cancer has spread to other parts of the body.

  • Stage IVA cancer has spread to the bladder or rectum (organs close to the cervix).

  • Stage IVB cancer has spread to other organs such as the lungs.

The best treatment plans for cervical cancer take into account several factors: the location of abnormal cells, the results of colposcopy, your age and whether you want to have children in the future. Basically, treatment involves destroying or removing the abnormal cells. Three basic approaches are used alone or in various combinations:

Surgery is used to remove the cancer. Various surgical techniques may be used, including:

  • excision (cutting out the abnormal cells)

  • electrocautery (electric current is passed through a metal rod that touches, vaporizes and destroys abnormal cells)

  • cryosurgery (abnormal cells are frozen with nitrous oxide)

  • laser vaporization (precise destruction of the small areas of abnormal cells)

  • conization (a biopsy used as a treatment)

  • simple hysterectomy (removal of the cervix and uterus)

  • radical hysterectomy (removal of cervix, upper vagina, uterus and ligaments that support them)

Radiation therapy (using high-dose X-rays or other high-energy rays to kill cancer cells) is used to treat both early and advanced-stage diseases. Sometimes your health care professional will use it alone or in combination with surgery. A common way to receive radiation is externally, just like an X-ray. Another procedure, called brachytherapy, involves having the radioactive source placed inside your body; it continues to emit energy for a specific period of time. In most stages of cervical cancer, radiation should be used with chemotherapy.

Chemotherapy is the use of drugs to kill cancer cells. Chemotherapy may be taken by pill or infused into the body with a needle inserted into a vein. Chemotherapy is called a systemic treatment because the drugs enter the bloodstream, travel through the body and can kill cancer cells outside the cervix. Combination chemotherapy is constantly evolving, with the goal of improving response to treatment. Chemotherapy with platinum can also make radiation more effective, depending on the stage of the cancer.

Based on the stage of your cancer, treatment regimens usually include the following:

  • Stage 0 cervical cancer is sometimes called carcinoma in situ. Treatment may be one of the following: conization; laser surgery; loop electrocautery excision procedure (LEEP); cryosurgery; and surgery to remove the cancerous area, cervix, and uterus (total abdominal or vaginal hysterectomy) for women who cannot or do not want to have children. The precancerous changes or the stage 0 cancer can recur in the cervix, vagina or, rarely, the anus, so close follow-up is very important.

  • Stage I cervical cancer treatments depend on how deep the tumor cells have invaded the normal tissue.

    • Stage IA cancer is divided into stage 1A1 and stage 1A2.

    • For stage 1A1, there are a few options. If you still want to be able to have children, your doctor will remove the cancer with a cone biopsy and then closely follow you to see if the cancer returns. If you are through having children or the cone biopsy doesn't remove all the cancer, your doctor may remove your uterus (simple hysterectomy). If the cancer has invaded your lymph nodes or blood vessels, treatment will involve a radical hysterectomy and removal of the pelvic lymph nodes. If you still want to have children, you may be able to have a radical trachelectomy (surgery to remove the cervix and pelvic lymph nodes) instead of a radical hysterectomy.

    • Stage 1A2 involves three treatment options: radical hysterectomy and removal of lymph nodes in the pelvis; brachytherapy with or without external beam radiation; or, if you still want to have children, radical trachelectomy combined with removal of pelvic lymph nodes.

      If the cancer has spread to the parametria or to any lymph nodes, your doctor will recommend radiation therapy and possibly chemotherapy. If the pathology report reveals that some of the cancer may have been left behind, you may be treated with pelvic radiation combined with chemotherapy and possibly, brachytherapy.

    • Stage IB cancer is divided into stage 1B1 and 1B2.

    • For pelvic stage 1B1, treatment may involve radical hysterectomy and removal of lymph nodes or para-aortic lymph nodes (lymph nodes higher up in the abdomen), possibly combined with radiation therapy and/or chemotherapy; high dose internal and external radiation; or, if you still want to be able to have children, radical trachelectomy combined with the removal of pelvic and some para-aortic lymph nodes.

    • For stage 1B2, the standard treatment is chemotherapy and radiation therapy to the pelvis combined with brachytherapy. In some cases, treatment may involve a radical hysterectomy combined with removal of pelvic and some para-aortic lymph nodes. If your doctor finds cancer in the removed lymph nodes, he or she may recommend radiation therapy after surgery, possibly with chemotherapy as well. And some doctors recommend starting with a combination of radiation and chemotherapy as a first option, followed by a hysterectomy.

  • Stage IIA cervical cancer treatment depends on the size of the tumor. If the tumor is larger than four centimeters, treatment may include brachytherapy and external radiation. Treatment may also include chemotherapy with cisplatin. Some doctors recommend removing the uterus after radiation. If the cancer is smaller than four centimeters, treatment may involve a radical hysterectomy and removal of pelvic and some para-aortic lymph nodes. If the removed tissue reveals cancer, treatment will also include a combination of radiation and chemotherapy, possibly with brachytherapy as well.

  • For stage IIB cancer, treatment may include internal and external radiation therapy combined with cisplatin chemotherapy and possibly other chemotherapy drugs.

  • Stage III and IVA: Most health care professionals combine these two groups in terms of prognosis and treatment. The treatment for these two groups includes combined internal and external radiation therapy with cisplatin chemotherapy. If the cancer has spread to the lymph nodes, especially if it has spread to lymph nodes in the upper part of the abdomen (para-aortic lymph nodes), the cancer may have spread to other areas of the body. Some doctors will check the lymph nodes with surgery, a CT scan or an MRI. If lymph nodes appear enlarged, they will be biopsied. If the para-aortic lymph nodes are indeed cancerous, the doctor may want to do further tests to see if the cancer has spread to other areas of the body.

  • Stage IVB cancer treatments often include chemotherapy and/or radiation therapy. Cancer at this stage is not usually considered curable, so treatments are more to relieve symptoms caused by the cancer than to treat the cancer itself.

  • Recurrent cervical cancer may require radiation therapy combined with chemotherapy. If the cancer has come back outside of the pelvis, a patient may choose to go into a clinical trial of a new treatment and/or use chemotherapy or radiation therapy to ease symptoms. If the recurrence is limited to the pelvis, radical pelvic surgery may be recommended.

Prevention

Prevention

Detecting precancerous changes in their earliest stages through regular Pap tests is the best way to prevent cervical cancer. Most women who develop invasive cervical cancer have not had regular Pap tests. Reducing or eliminating risk factors associated with the development of cervical cancer can also help prevent it:

  • Don't smoke cigarettes.

  • Use condoms correctly and consistently to protect yourself from sexually transmitted diseases. Note, however, that while condom use will decrease the risk of HPV infection, it can't prevent it entirely because HPV can infect cells anywhere on the skin in the genital area.

Additionally, the FDA has approved two HPV vaccines, called Gardasil and Cervarix. Gardasil protects women against four HPV types—the two most common high-risk (cancer-causing) types of HPV, strains 16 and 18, and also the two most common low-risk types of HPV, 6 and 11, which cause 90 percent of genital warts. Cervarix protects against HPV 16 and 18. Both vaccines should be given before an infection occurs, ideally, before a girl becomes sexually active. Gardasil is approved for girls as young as nine and is routinely recommended for girls 11 and 12 years of age. It may also be given to women ages 13 to 26 who did not receive it when they were younger, as well as males ages nine to 26. Cervarix is approved for use in girls and women ages nine through 25. If a woman is already infected with one of the four HPV types in one of the vaccines, the vaccine will not work against that particular HPV type. (It will still work against the remaining types she has not yet been exposed to.)

Clinical trials have shown that both Gardasil and Cervarix are safe and 100 percent effective in preventing HPV strains 16 and 18, which cause 70 percent of cervical cancers. Gardasil is also 99 percent effective in preventing HPV strains 6 and 11, which cause about 90 percent of genital wart cases. Both vaccines are given in three injections over six months.

Although Gardasil and Cervarix prevent two of the most serious high-risk HPV strains, these vaccines don't protect against all of them so the FDA recommends choosing one of them as a complement to safe sex practices and regular Pap tests.

HPV screening of women ages 30 and over is also an important part of preventing potential complications of cervical cancer. The easiest way to screen for HPV is with the HPV test which checks for the virus itself. The Pap test can identify cervical cancer in its earliest stage but can also find abnormal precancerous cells and signs of an active HPV infection.

In conjunction with the Pap test, the HPV test can be used in women over age 30 to help detect HPV infection. Because it specifically tests for the types of HPV that are most likely to cause cervical cancer, when combined with a Pap test in women of this age group, the HPV test is better at identifying women at risk for developing cervical cancer than the Pap test alone.

The American Cancer Society (ACS) and the U.S. Preventive Services Task Force (USPSTF) recommend the following guidelines for early detection and prevention of cervical cancer:

  • All women should begin screening at age 21.

  • Women ages 21 to 29 should have a Pap test every three years. They should not have an HPV test unless it is needed because of an abnormal Pap test result.

  • Women ages 30 to 65 should have both a Pap test and an HPV test every five years or a Pap test alone every three years. (The ACS prefers the two tests together every five years but says either method is acceptable; the USPSTF recommends either schedule.)

  • Women over age 65 who have been screened previously with normal results and are not at high risk for cervical cancer should stop getting screened. Women with cervical precancer should continue to be screened.

  • Women who have had a total hysterectomy, with removal of their uterus and cervix, and have no history of cervical cancer or precancer should not be screened.
  • Women who have received the HPV vaccine should still follow the screening guidelines for their age group.

  • Women who are at high risk for cervical cancer, such as women with a family history of the disease, a history of treatment for precancer, DES exposure before birth, chlamydia infection or a weakened immune system (from HIV infection, organ transplant, chronic steroid use or chemotherapy), may need more frequent screenings. Talk to your health care professional about what's right for you.

The guidelines from the American College of Obstetricians and Gynecologists (ACOG) differ slightly. ACOG recommends that women between the ages of 21 and 29 get Pap tests every two years, and women 30 years of age and older with three consecutive negative Pap tests be tested every three years.

Talk to your health care provider about what is best for you, based on your medical history.

Facts to Know

Facts to Know

  1. The American Cancer Society estimates that in 2012, about 12,170 cases of invasive cervical cancer will be diagnosed in the United States and about 4,220 women will die from the disease.

  2. The death rate from cervical cancer in African-American women is nearly double that of Caucasian women. Additionally, Hispanic women develop this cancer nearly twice as often as non-Hispanic Caucasian women. The highest rate of cervical cancer is in underdeveloped countries.

  3. Both incidence and deaths from cervical cancer have declined markedly over the last several decades, due to more frequent detection and subsequent treatment of pre-invasive and cancerous lesions of the cervix from increased Pap screening.

  4. The five-year survival rate for early invasive cancer of the cervix is 93 percent. The survival rate falls steadily as the cancer spreads to other areas.

  5. Changes in cervical cells are classified by their degree of abnormality. If your test is abnormal, ask your health care professional to discuss how your abnormalities were described. Many abnormalities return to normal with no treatment, so your health care professional may want to wait and perform another Pap test in several months. Overtreating mild dysplasia can harm the cervix. However, if the Pap results reveal atypical squamous cells of undetermined significance (ASCUS), then HPV testing is routinely done. If no high-risk strains are identified, then no further testing in needed. You should repeat the Pap test in one year. If the Pap reveals ASCUS and the HPV test is positive, a colposcopy will be needed. Colposcopy also is needed if any other more serious changes are shown by the Pap results. Further screening and treatments will depend on the results of the colposcopy. CIN 1 should not be treated, but the Pap will be repeated in 6 to 12 months. For CIN 2-3, further treatment is needed to remove the abnormal cells.

  6. The primary risk factor for cervical cancer is infection with certain types of the human papillomavirus (HPV). Together, HPV 16 and HPV 18 account for about 70 percent of cervical cancer cases. However, it is important to note that not every HPV infection with high-risk strains is destined to become cervical cancer. Only infections that persist are likely to develop precancerous cell changes if untreated.

  7. Rates of low-grade squamous intraepithelial lesion (low-grade SIL), usually caused by an active HPV infection, peak in both black and white women between the ages of 25 and 35. However, the number of cases of invasive cervical cancer increases with age, as does the chance of dying from cervical cancer.

  8. Women who had first sexual intercourse at an early age or who have had many sexual partners or who have partners who have many sexual partners have a higher-than-average risk of developing cervical cancer.

  9. The majority of cervical cancers develop through a series of gradual, well-defined precancerous lesions. During this usually lengthy process, the abnormal cells can usually be detected by the Pap test and treated.

  10. Pap tests, like other early detection tests, are not 100 percent accurate. When performed properly, the Pap smear detects a significant majority of cervical cancers—usually in the early stages when the likelihood of a cure is the greatest.

Questions to Ask

Questions to Ask

Review the following Questions to Ask about cervical cancer so you're prepared to discuss this important health issue with your health care professional.

  1. What is my risk for developing cervical cancer? How can I limit my risks?

  2. What should I do before getting a Pap test to make sure the test is as accurate as possible?

  3. Are you sending my Pap test to a board-certified lab? Does a board-certified pathologist oversee this lab? Do I need the HPV test?

  4. How will I be informed of the results?

  5. If I have abnormal cells on Pap test or a positive HPV test, what next steps are necessary?

  6. I was diagnosed with human papillomavirus (HPV). How often do I need pelvic exams and Pap tests?

  7. I am so afraid to find out I may have cancer that I'm afraid to come in for a Pap test or pelvic exam. What should I do?

  8. What is a colposcopy and why do you recommend it? Will it hurt?

  9. Can cervical cancer be cured? How? Can it come back after it's been treated?

  10. If you are diagnosed with cervical cancer, ask what kind of experience do you have in treating cervical cancer? Have you had specialty training in gynecological oncology?

  11. Will I have to be "checked for cancer" for the rest of my life?

  12. What are the risks that my daughter will have cervical cancer too?

Key Q&A

Key Q&A

  1. My Pap test was abnormal—what should I do?

    Don't panic. There are many things that can produce an abnormal result. To improve the reliability of the test, schedule your appointment two weeks after your menstrual period and refrain from having intercourse or using vaginal contraceptives or douches for at least 48 hours before the test. Return for further testing if your doctor recommends it.

  2. I've already gone through menopause. Should I continue to have Pap tests?

    Current guidelines suggest that if you are age 65 or older and have had adequate prior screening and are not otherwise at high risk for cervical cancer, you can stop having Pap tests. Annual pelvic exams are still recommended.

  3. My health care professional has recommended a hysterectomy for invasive cervical cancer. How do I know if this is the right thing to do?

    There are a number of diagnostic steps your health care professional should take before surgery, including a colposcopy and biopsy. Treatment regimens are always your choice and should be discussed thoroughly with your health care professional. Additionally, you should seek a second opinion from a gynecological oncologist before undergoing any surgical procedure. A gynecological oncologist is an obstetrician-gynecologist who has had special training in the care of women with cancers of the cervix, ovary, uterus and vulva.

  4. Is it true that there are new tests to replace the Pap test?

    There are several new technologies, but most are designed to improve the reliability of the Pap test, which is still the most widely used screening test to detect changes in cervical cells. Pap tests, like other early detection tests, are not 100 percent accurate. Still, when performed properly, the Pap smear detects a significant majority of cervical cancers—usually in the early stages when the likelihood of a cure is the greatest.

  5. How often should I have a Pap test? What about the HPV test?

    The American Cancer Society (ACS) and the U.S. Preventive Services Task Force recommend that screenings begin at age 21. Women ages 21 to 29 should have a Pap test every three years. They should not have an HPV test unless it is needed because of an abnormal Pap test result. Women ages 30 to 65 should have both a Pap test and an HPV test every five years or a Pap test alone every three years.

    The American College of Obstetricians and Gynecologists recommends that women between the ages of 21 and 29 get Pap tests every two years, and women 30 years of age and older with three consecutive negative Pap tests get tested every three years.

    However, women who are at an increased risk for developing cervical cancer (those with new or multiple sexual partners, family history of the disease, or other risk factors) should be screened more frequently. Women who have abnormal Pap test results or a positive HPV test should discuss subsequent tests and follow-up with their health care professionals.

    Women who are 65 or older and have had adequate prior screening and are not at high risk for cervical cancer may stop screening for cervical cancer altogether.

    Women who have had a total hysterectomy (removal of the uterus and cervix) may also stop screening unless the hysterectomy was performed because of cervical cancer or pre-cancer-related reasons, or you have a history of abnormal Pap smears. If the hysterectomy was performed to treat cervical cancer, more frequent Pap screenings may be recommended.

    Talk to your health care provider about what is best for you, based on your medical history.

  6. I've avoided going to the health care professional for years and never even had a Pap test. What can I expect when I have the test?

    A Pap test is a simple procedure: After a speculum (the standard device used to examine the cervix) is placed in your vagina, cells are skimmed from the surface of the cervix then smeared onto a glass slide or placed in a liquid. A sample is taken from the T-zone with a tiny wooden or plastic spatula or a tiny brush. The cervix is the narrow neck of the uterus that opens into the vagina. For women who have had total hysterectomies, in which the cervix is removed, cells are taken from the walls of the vagina. The cell sample is delivered to a laboratory where a cytotechnologist (a lab professional who reviews your Pap test) and, when necessary, a pathologist (a physician who examines bodily tissue samples) examine the sample for any abnormalities.

  7. I have cervical cancer and my health care professional has not recommended chemotherapy. I thought it was used for all cancers?

    Depending on the stage of your cancer, sometimes radiation alone will be recommended as a treatment. However, clinical trials show that the combination of radiation therapy and chemotherapy with cisplatin is more effective than radiation alone for women with stage IB2 cervical cancer. This prompted the National Cancer Institute to recommend that chemotherapy be considered in all patients receiving radiation therapy for cervical cancer larger than four centimeters. If you're unsure of whether chemotherapy is an option for you, talk to your health care professional.

  8. My Pap test was reported as a false negative. What does that mean?

    When a Pap test fails to detect an existing abnormality, the result is referred to as a false negative. Several factors can contribute to a Pap test reporting a false negative:

    • When irregular cells are located high in the cervical canal and are difficult to access under normal Pap test procedures

    • When menstrual blood masks abnormal cells; these cells would not be visible to the cytotechnologist

    • An inadequate sample—when not enough cells were collected during the Pap test

    • Human error, where the person reviewing the slide misinterpreted abnormal cells as normal

  9. I haven't had a Pap test in several years because I don't have health insurance and can't afford it. Are there any options for me?

    The National Breast and Cervical Cancer Early Detection Program provides breast and cervical cancer screening services to underserved women throughout the country, including 12 American Indian/Alaska Native organizations. Services are either free or provided on a sliding scale based on your income. For information about access in your area, call 1 (800) CDC-INFO (232-4636) or log onto www.cdc.gov/cancer/nbccedp.

    The federal Affordable Care Act, approved in 2010, will also make more low-income women eligible for Medicaid coverage, particularly single women who are not currently covered.

    Additionally, Medicare provides 100 percent coverage for a Pap smear and pelvic examination once every 24 months. If you are at high risk for cervical or vaginal cancer, or if you are of childbearing age and have had an abnormal Pap smear in the preceding 36 months, Medicare covers these tests every 12 months.

    For women who do have health insurance but were still concerned about screening costs, the federal Affordable Care Act makes free screenings available to many women. If you have a new health insurance plan beginning on or after September 23, 2010, Pap tests and many other preventive screenings must be covered (when performed by a network provider) without you being required to pay a co-payment or coinsurance or deductible.

Lifestyle Tips

Lifestyle Tips

  1. Give yourself the best odds after treatment for cervical cancer or precancerous conditions

    If you smoke, look seriously for opportunities or resources to quit. Smoking exposes your body to cancer-causing chemicals that promote the growth of cervical cancer. The chemicals produced by tobacco smoke may damage the DNA in cells of the cervix and make cancer more likely to occur there. Also avoid drinking excessive alcohol and follow the dietary recommendations of your cancer care team. Assuming there's no reason for you to avoid these foods, eat plenty of dark green leafy vegetables, red, orange or yellow vegetables and whole grains. This will help you heal faster and give you a better chance of recovering completely. Exercise as soon as your condition permits. Know your recommended medical follow-ups and keep up with them.

  2. Face your fertility issues

    If you're concerned about your ability to have children, make this clear to your cancer care team. Ask how the medical and surgical procedures necessary for your care will affect your fertility. If you have early cervical cancer, it may be possible for you to be treated with a cone biopsy, a surgical procedure that allows most women to remain fertile. If your fertility can't be spared, you're entitled to your feelings and consideration from others. A good counselor or support group may help. You can also consider looking into newer options, such as ovarian tissue banking.

  3. Reclaim your sex life

    During this stressful time, it is normal for you to be less interested in sex than before. Counseling can help you and your partner adjust and stay physically intimate in other ways as you return to intercourse at your own pace. If you are experiencing vaginal dryness, hormone creams and lubricating gels can help. To keep your vagina elastic and flexible after radiotherapy, use a vaginal dilator and talk to your partner about having regular sex. This won't make the cancer worse or hurt your partner. Make sure that penetrative sex is very gentle at first.

  4. If you're going to have a hysterectomy...

    Ask your surgeon whether your ovaries will also be removed and research this decision carefully. It is not always a good idea to remove your ovaries, especially if you are young, because it will cause you to go into sudden menopause. Studies also have shown increased risk of lung cancer, coronary artery disease and even premature death from other causes in young women who have their ovaries removed.

    Also ask whether you'll be having abdominal laparoscopic surgery with or without robotic assistance or surgery through the vagina, since the procedures have different recovery rates. Arrange for help at home; you'll be glad later, even if you don't need it for long. Freeze your favorite meals ahead of time, and prepare the room in which you'll be resting after surgery with reading materials and pictures or posters on the wall. Also have a supply of sanitary pads for post-operative drainage and large-size, comfortable panties.

  5. After your hysterectomy...

    Cooperate when you're asked to get up and walk after surgery. You'll recover faster and won't have as many problems with gas. Once you're home, don't lift heavy objects or walk up stairs too soon after surgery. If you've had an abdominal incision, edema (swelling) may make your abdomen look like it sags; with time, this will subside. Stick to a healthy, nutritious diet, not a weight-loss diet, while recovering from surgery. After your surgeon has cleared you for normal activity, exercise to tighten your muscles, build up strength and endurance and improve sleep.

Organizations and Support

Organizations and Support

For information and support on coping with Cervical Cancer, please see the recommended organizations, books and Spanish-language resources listed below.

American Cancer Society (ACS)
Website: http://www.cancer.org
Address: 250 Williams Street
Atlanta, GA 30303
Hotline: 1-800-ACS-2345 (1-800-227-2345)
Phone: 404-315-1123

American Institute for Cancer Research
Website: http://www.aicr.org
Address: 1759 R Street, NW
Washington, DC 20009
Hotline: 1-800-843-8114
Phone: 202-328-7744
Email: aicrweb@aicr.org

Association of Cancer Online Resources, Inc.
Website: http://www.acor.org
Address: 173 Duane Street, Suite 3A
New York, NY 10013
Phone: 212-226-5525

Cancer Care, Inc.
Website: http://www.cancercare.org
Address: 275 Seventh Ave., Floor 22
New York, NY 10001
Hotline: 1-800-813-HOPE (1-800-813-4673)
Phone: 212-712-8400
Email: info@cancercare.org

Cancer Information and Counseling Line (CICL)
Address: AMC Cancer Research Center
1600 Pierce Street
Denver, CO 80214
Hotline: 1-800-525-3777
Email: contactus@amc.org

Cancer Support Community
Website: http://www.gildasclub.org/
Address: Gilda's Club Worldwide
48 Wall Street, 11th Floor
New York, NY 10005
Phone: 888-GILDA-4-U
Email: info@gildasclub.org

Corporate Angel Network
Website: http://www.corpangelnetwork.org
Address: Westchester County Airport
One Loop Road
White Plains, NY 10604
Hotline: 1-866-328-1313
Phone: 914-328-1313
Email: info@corpangelnetwork.org

Gathering Place
Website: http://www.touchedbycancer.org
Address: The Arnold & Sydell Miller Family Campus 23300 Commerce Park
Beachwood, OH 44122
Phone: 216-595-9546
Email: info@touchedbycancer.org

Gynecologic Cancer Foundation
Website: http://www.thegcf.org
Address: 230 W. Monroe, Suite 2528
Chicago, IL 60606
Hotline: 1-800-444-4441
Phone: 312-578-1439
Email: info@thegcf.org

Mautner Project - The National Lesbian Health Organization
Website: http://www.mautnerproject.org
Address: 1875 Connecticut Ave., NW Suite 710
Washington, DC 20009
Hotline: 1-866-MAUTNER (1-866-628-8637)
Phone: 202-332-5536
Email: info@mautnerproject.org

Memorial Sloan-Kettering Cancer Center, New York
Website: http://www.mskcc.org
Address: 1275 York Ave
New York, NY 10065
Phone: 212-639-2000
Email: publicaffairs@mskcc.org

National Cancer Institute (NCI)
Website: http://www.nci.nih.gov
Address: NCI Public Inquiries Office
6116 Executive Boulevard, Room 3036A
Bethesda, MD 20892
Hotline: 1-800-4-CANCER (1-800-422-6237)
Phone: TTY: 1-800-332-8615

National Cervical Cancer Coalition (NCCC)
Website: http://www.nccc-online.org
Address: 6520 Platt Ave., #693
West Hills, CA 91307
Hotline: 1-800-685-5531
Phone: 818-909-3849
Email: info@nccc-online.org

National Coalition for Cancer Survivorship (NCCS)
Website: http://www.canceradvocacy.org
Address: 1010 Wayne Ave., Suite 770
Silver Spring, MD 20910
Hotline: 1-877-NCCS-YES (1-877-622-7937)
Phone: 301-650-9127
Email: info@canceradvocacy.org

National Comprehensive Cancer Network
Website: http://www.nccn.org
Address: 275 Commerce Dr, Suite 300
Fort Washington, PA 19034
Phone: 215-690-0300

Native American Cancer Research
Website: http://www.natamcancer.org
Address: 3022 South Nova Rd.
Pine, CO 80470-7830
Phone: 303-838-9359
Email: info@natamcancer.net

Prevent Cancer Foundation
Website: http://www.preventcancer.org
Address: 1600 Duke Street, Suite 500
Alexandria, VA 22314
Hotline: 1-800-227-2732
Phone: 703-836-4412

Women's Cancer Resource Center
Website: http://www.wcrc.org
Address: 5741 Telegraph Avenue
Oakland, CA 94609
Hotline: 1-888-421-7900
Phone: 510-420-7900
Email: info@wcrc.org

Johns Hopkins Patients' Guide to Cervical Cancer
by Colleen McCormick, Robert Giuntoli

A Gynecologist's Second Opinion: The Questions & Answers You Need to Take Charge of Your Health
by William H. Parker, Rachel L. Parker

Intimacy After Cancer: A Woman's Guide
by Dr. Sally Kydd, Dana Rowett

The HPV Vaccine Controversy: Sex, Cancer, God, and Politics: A Guide for Parents, Women, Men, and Teenagers
by Shobha S. Krishnan

National Cancer Institute
Website: http://cancernet.nci.nih.gov/sp_menu.htm
Hotline: 1-800-422-6237
Email: nciespanol@mail.nih.gov

H. Lee Moffitt Cancer Center & Research Institute
Website: http://www.moffitt.usf.edu/pated/español.htm
Address: 12902 Magnolia Drive
Tampa, FL 33612
Hotline: 1-888-663-3488
Phone: 813-745-4673

Medline Plus: Cervical Cancer
Website: http://www.nlm.nih.gov/medlineplus/spanish/cervicalcancer.html
Address: Customer Service
US National Library of Medicine
8600 Rockville Pike
Bethesda, MD 20894
Email: custserv@nlm.nih.gov

Last date updated: 
Thu, 2012-03-15

What is it?

Overview

What Is It?
Bacterial vaginosis (BV) is a condition in which the normal balance of bacteria in the vagina is disrupted and replaced by an overgrowth of certain bacteria. Symptoms may include discharge, odor, itching or irritation, but often there are no symptoms.

Bacterial vaginosis (BV) is the most common of three vaginal infections that fall under the category known as vaginitis. The other two infections are trichomoniasis, a sexually transmitted disease, and the fungal infection commonly known as a yeast infection.

BV is the least understood and most often ignored or misdiagnosed of these conditions. However, it is gaining more attention as more research shows that untreated BV can lead to significant health complications, including premature delivery, postpartum infections, clinically apparent and subclinical pelvic inflammatory disease (PID), postsurgical complications (after abortion, hysterectomy, cesarean section and other reproductive procedures), increased vulnerability to HIV infection and, possibly, infertility. As many as one-third of women in the United States have BV.

BV is now considered a sexually transmitted disease. Women who have a new sex partner or multiple sex partners are at an increased risk for getting BV, although it is occasionally diagnosed in women who have never had sex. Douching also appears to increase the risk of developing BV.

BV has gone by different names in the past, including nonspecific vaginitis and Gardnerella vaginalis vaginitis. BV is simpler to remember, but there is nothing simple about this condition, and it is not harmless, as was once believed.

BV is actually a syndrome resulting from an imbalance in the different types of bacteria in the vagina (also called vaginal "flora"). A healthy vagina has numerous organisms that naturally live there. The vast majority—about 95 percent—belong to a type of bacteria called lactobacillus.

There are several kinds of lactobacillus, at least one of which is responsible for keeping the vagina's pH at normal levels. When these levels become unbalanced, certain microorganisms may overtake the normal flora leading to a low-grade infection that often produces an abnormal vaginal discharge.

Diagnosis

Diagnosis

With many negative outcomes now linked to bacterial vaginosis (BV), it is important that women get tested and treated. But surveys find that the majority of health care professionals don't routinely test for or treat BV. And yet an estimated 29 percent of women aged 14 to 49 and 50 percent of African American women have BV.

The most common symptoms include a discharge and an unpleasant vaginal odor. Women may easily mistake BV for a yeast infection, which is caused by the overgrowth of fungi called Candida albicans. However, BV requires a different treatment, so it is important you get an accurate diagnosis. Additionally, you may have more than one type of vaginitis at the same time, so having a yeast infection doesn't mean you can't also have BV.

Fortunately, a trained health care professional can easily diagnose BV. All it takes is a test to check the level of acidity, or pH, in the vagina. A vaginal pH greater than 4.5 is one sign you may have BV.

Your health care professional will also take a vaginal discharge specimen for examination under a microscope to look for "clue cells"—cells from the vaginal lining that are covered with bacteria. It is important not to douche or use deodorant sprays before a medical exam because these products can make it more difficult to diagnose BV.

In addition to checking the vaginal pH and checking for clue cells, your health care professional may place a drop of 10 percent potassium hydroxide on a vaginal fluid specimen and check the odor. Several commercial tests also are available to diagnose BV. Cultures for Gardnerella vaginalis alone and cervical Pap tests are not accurate methods for diagnosing BV.

The most common symptom of BV is a vaginal discharge similar in consistency and appearance to skim milk. The discharge caused by the infection often has a strong "fishy" odor that may become worse after sex because semen changes the acidic level of vaginal fluids. BV also may cause vaginal itching and irritation. About 50 percent to 75 percent of all women with BV experience no symptoms.

Treatment

Treatment

As with other vaginal infections, the primary goal in treating bacterial vaginosis (BV) is to relieve signs and symptoms of infection. All women with symptoms should be treated.

BV is treated with antibiotics. The most common therapies are metronidazole (Flagyl), and clindamycin (Cleocin). Both metronidazole and clindamycin are available by prescription in oral (pill) form, and metronidazole is available in a gel (MetroGel-Vaginal), and clindamycin is available in a cream (Clindesse) that you insert into the vagina. Generic versions of these antibiotics also are available and effective.

If your symptoms disappear with treatment, you don't have to see your health care professional again. One round of treatment usually works in about 75 percent of cases. However, BV frequently recurs and can be chronic in some women.

Don't drink any alcohol while using metronidazole (either oral or vaginal) because it may make you nauseous and/or lead to severe vomiting. Also, if you're using intravaginal forms of clindamycin, the oil-based medication may weaken latex condoms or diaphragms. Clindamycin may also cause colitis, a potentially life-threatening infection of the colon.

Talk to your health care professional about this risk and be sure to alert him or her if you experience severe diarrhea, stomach cramping or blood in your stool while taking clindamycin or within a few weeks of stopping it. Over-the-counter treatments available for some vaginal infections (Candidiasis, or "yeast" infections) are NOT effective for BV.

While you're being treated for BV, you may be advised not to have sex; if you do have sex, your partner should wear condoms. Treating your male partner isn't necessary, however, since studies find it doesn't help prevent another infection. Female partners may need treatment, however.

Treatment is more complicated for pregnant women. If you've previously delivered a premature infant, you may be tested for BV during your first prenatal visit. If you have the infection, you'll be treated in the earliest part of your second trimester of pregnancy.

Regardless of other risk factors for preterm delivery, all symptomatic pregnant women should be tested and treated. However, most studies show no difference in risk of preterm delivery in asymptomatic women who don't get treated versus those who get treated. Thus, pregnant women with asymptomatic BV don't require treatment.

In any case, pregnant women who are going to be screened should have this done during the first prenatal visit. Pregnant women are usually treated with oral rather than topical (intravaginal) medications.

Prevention

Prevention

Numerous factors may be associated with vaginal infections. Although no single factor has emerged as a primary cause, experts say healthy diets and behavior are the best medicine.

One of the more disturbing aspects of bacterial vaginosis (BV) is that the infection frequently returns after treatment. About 30 percent of women have a recurrence within three months of treatment. While the reasons for recurrent BV are not well understood, long-term maintenance treatment may be recommended for women with frequent recurrences of BV.

However, you should take all prescribed medicines as recommended to decrease the likelihood of recurrence. Continue taking the medicine as you've been directed even if your symptoms disappear.

One cause of recurrent BV may be that even after the harmful bacteria that replaced the "good" bacteria is gone, the "good" bacteria have trouble growing back in the vagina.

Most women with recurrent BV infection respond well to therapies that help maintain the ratio of "good" to "bad" bacteria in the vagina. One such therapy is metronidazole gel (0.75 percent) for seven to 10 days followed by an application twice a week for four to six months.

Here are some tips that may decrease the risk of BV or recurrent BV:

  • Don't douche. Douching upsets the normal pH balance of the vagina.
  • Avoid sexual contact with someone who has a sexually transmitted disease; use condoms if you're uncertain.
  • Avoid local irritants such as bubble baths, harsh soaps, feminine hygiene sprays and deodorant tampons, all of which can affect the normal pH of the vagina.
  • Reduce semen exposure (which can affect the vaginal bacteria balance) by using condoms.
  • Don't smoke.
  • If you develop BV three or more times in a year, talk to your health care professional about alternating medications or using intravaginal metronidazole as a prophylactic for three to six months.

Facts to Know

Facts to Know

1. Half of all African-American women aged 14 to 49 in the United States have BV. This may help explain why African-American women have higher rates of problem pregnancies. The reason for increased BV in this population is not clear.

2. BV is widespread but its prevalence varies widely. BV is the most common cause of vaginitis in women of childbearing age—an estimated 29 percent of women aged 14 to 49 and 50 percent of African American women in that age bracket have BV.

3. BV increases a woman's risk of delivering prematurely or delivering a baby with low birthweight. A National Institutes of Health study found that pregnant women with BV were more likely to deliver a baby with low birthweight than those without the infection. The most common cause of premature birth from BV is premature rupture of membranes.

4. A woman with BV may be more likely to become infected with HIV, the sexually transmitted virus that causes AIDS (acquired immunodeficiency syndrome). Recent studies have shown a relationship between BV and HIV, so health officials now consider BV a risk factor for HIV acquisition, particularly in developing countries where BV is often untreated.

5. Bacterial vaginosis infection disrupts the vaginal ecosystem. Some women infected with BV may have up to 1,000 times more anaerobic bacteria (bacteria that require no oxygen to live) than uninfected women. Once this imbalance occurs, the body has difficulty getting back to normal. Consequently, researchers are looking at natural ways to supplement the "good" bacteria needed to protect the genital tract from infection, and thereby reduce recurrences.

6. Because its symptoms mimic other vaginal infections, BV is often mistaken for a common yeast infection.

7. About 50 percent to 75 percent of women with BV have no symptoms. And yet studies find that as many as one-third of women entering obstetric clinics have a BV infection.

8. Despite adequate treatment, BV recurs in 30 percent of women within three months. Researchers are not sure what makes some women more prone to recurrent BV.

9. The greatest risk factors for BV are having a new sex partner or having multiple sex partners.

Questions to Ask

Questions to Ask

Review the following Questions to Ask about bacterial vaginosis (BV) so you're prepared to discuss this important health issue with your health care professional.

  1. Do over-the-counter products work for treating and preventing BV?

  2. Does my male partner need to be treated?

  3. What if I have a female partner? Will she need to be treated?

  4. What difference does it make whether I have BV or a yeast infection?

  5. If I have had BV in the past and am pregnant, should I get tested for BV even if I don't have any symptoms?

  6. How do I identify BV and avoid it in the future?

  7. Do I need to refrain from sexual contact while I am being treated?

  8. How much douching is excessive?

  9. Are the drugs used for treating BV safe for pregnant women?

  10. Is BV considered a sexually transmitted infection?

Key Q&A

Key Q&A

1. How do I know if I need to see my health care professional?

Pay attention to your body. If you experience symptoms, such as a change in the color and consistency of vaginal fluid, genital itching or burning, you may have a vaginal infection, which, if left untreated, can lead to health complications.

2. What makes bacterial vaginosis (BV) serious for women who are pregnant?

Studies have shown that women with untreated BV are at higher risk of delivering prematurely or giving birth to a low-weight baby. Not all vaginal infections cause pregnancy problems, but BV is potentially serious and requires attention. Screening and treatment is appropriate for pregnant women with symptomatic BV. Follow-up may be needed during the pregnancy.

3. Are all pregnant women treated for BV?

No. Regardless of other risk factors for preterm delivery, all pregnant women with BV who have symptoms should be treated. However, treating pregnant women who test positive for BV but who don't have symptoms (asymptomatic) is controversial. Generally, pregnant woman with asymptomatic BV don't require treatment.

4. What are my chances of having BV come back?

As many as 30 percent of women who have been treated for BV experience recurrences within 90 days of treatment. Not finishing your prescribed medicine can lead to a recurrence.

5. Why does excessive douching increase the risk of developing BV?

The healthy vaginal ecosystem requires the right balance of bacteria flora. Nearly 95 percent of the vaginal mucous membrane, which protects against bacteria and other pathogens, is made up of healthy bacteria called lactobacilli. These bacteria make natural acids that keep unhealthy bacteria from getting out of hand. Too much douching can disrupt the bacterial balance and lead to infection.

6. Can I treat BV with over-the-counter yeast infection medications?

No. Vaginal creams and suppositories for treatment of "yeast" (Candida) infections do not treat BV.

7. Why is it important to determine what type of vaginitis I have?

BV, trichomoniasis and candidiasis (yeast infection) are caused by different pathogens and must be treated differently. Each type of infection requires a specific treatment, and some infections have more than one cause.

8. What about diagnosing and treating BV in men?

The organisms that cause BV in women can exist in the male urethra. Clinical studies have shown, however, that treating male partners with antibiotics doesn't affect a woman's risk of recurrence or her response to treatment.

Organizations and Support

Organizations and Support

For information and support on coping with Bacterial Vaginosis, please see the recommended organizations and Spanish-language resources listed below.

American College of Obstetricians and Gynecologists (ACOG)
Website: http://www.acog.org
Address: 409 12th Street, SW
P.O. Box 96920
Washington, DC 20090
Phone: 202-638-5577
Email: resources@acog.org

ASHA's STI Resource Center Hotline
Website: http://www.ashastd.org/herpes/herpes_hotline.cfm
Address: American Social Health Association
P.O. Box 13827
Research Triangle Park, NC 27709
Hotline: 1-800-227-8922
Phone: 919-361-8400

Association of Reproductive Health Professionals (ARHP)
Website: http://www.arhp.org
Address: 1901 L Street, NW, Suite 300
Washington, DC 20036
Phone: 202-466-3825
Email: arhp@arhp.org

CDC National Prevention Information Network
Website: http://www.cdcnpin.org
Address: P.O. Box 6003
Rockville, MD 20849
Hotline: 1-800-458-5231
Phone: 404-679-3860
Email: info@cdcnpin.org

Guttmacher Institute
Website: http://www.guttmacher.org
Address: 1301 Connecticut Avenue NW, Suite 700
Washington, DC 20036
Hotline: 1-877-823-0262
Phone: 202-296-4012
Email: info@guttmacher.org

National Center for HIV/AIDS, Viral Hepatitis, STD and TB Prevention
Website: http://www.cdc.gov/nchhstp
Address: Centers for Disease Control and Prevention
1600 Clifton Road
Atlanta, GA 30333
Hotline: 1-800-CDC-INFO (1-800-232-4636)
Email: cdcinfo@cdc.gov

National Family Planning and Reproductive Health Association (NFPRHA)
Website: http://www.nfprha.org
Address: 1627 K Street, NW, 12th Floor
Washington, DC 20006
Phone: 202-293-3114
Email: info@nfprha.org

Planned Parenthood Federation of America
Website: http://www.plannedparenthood.org
Address: 434 West 33rd Street
New York, NY 10001
Hotline: 1-800-230-PLAN (1-800-230-7526)
Phone: 212-541-7800

Family Doctor
Website: http://familydoctor.org/online/famdoces/home/women/reproductive/vaginal/234.html

Centers for Disease Control and Prevention
Website: http://www.cdc.gov/std/Spanish/STDFact-Bacterial-Vaginosis-s.htm
Address: Centros para el Control y la Prevención de Enfermedades
P.O. Box 6003
Rockville, MD 20849
Hotline: 1-800-458-5231
Phone: 1-800-232-4636
Email: cdinfo@cdc.gov

Last date updated: 
Wed, 2009-10-28

What is it?

Overview

What Is It?
Androgens are a group of hormones that play a role in male traits and reproductive activity. Present in both males and females, the principle androgens are testosterone and androstenedione.

Androgens may be called "male hormones," but don't let the name fool you. Both men's and women's bodies produce androgens, just in differing amounts. In fact, androgens have more than 200 actions in women.

The principal androgens are testosterone and androstenedione. They are, of course, present in much higher levels in men and play an important role in male traits and reproductive activity. Other androgens include dihydrotestosterone (DHT), dehydroepiandrosterone (DHEA) and DHEA sulfate (DHEA-S).

In a woman's body, one of the main purposes of androgens is to be converted into the female hormones called estrogens.

Androgens in Women

In women, androgens are produced in the ovaries, adrenal glands and fat cells. In fact, women may produce too much or too little of these hormones––disorders of androgen excess and deficiency are among the more common hormonal disorders in women.

In women, androgens play a key role in the hormonal cascade that kick-starts puberty, stimulating hair growth in the pubic and underarm areas. Additionally, these hormones are believed to regulate the function of many organs, including the reproductive tract, bone, kidneys, liver and muscle. In adult women, androgens are necessary for estrogen synthesis and have been shown to play a key role in the prevention of bone loss, as well as sexual desire and satisfaction. They also regulate body function before, during and after menopause.

Androgen-Related Disorders

High Androgen Levels

Excess amounts of androgens can pose a problem, resulting in such "virilizing effects" as acne, hirsutism (excess hair growth in "inappropriate" places, like the chin or upper lip) and thinning hair.

Many women with high levels of a form of testosterone called "free" testosterone have polycystic ovary syndrome (PCOS), characterized by irregular or absent menstrual periods, infertility, blood sugar disorders, and, in some cases, symptoms like acne and excess hair growth. Left untreated, high levels of androgens, regardless of whether a woman has PCOS or not, are associated with serious health consequences, such as insulin resistance and diabetes, high cholesterol, high blood pressure and heart disease.

In addition to PCOS, other causes of high androgen levels (called hyperandrogenism) include congenital adrenal hyperplasia (a genetic disorder affecting the adrenal glands that afflicts about one in 14,000 women) and other adrenal abnormalities, and ovarian or adrenal tumors. Medications such as anabolic steroids can also cause hyperandrogenic symptoms.

Low Androgen Levels

Low androgen levels can be a problem as well, producing effects such as low libido (interest or desire in sex), fatigue, decreased sense of well-being and increased susceptibility to bone disease. Because symptoms like flagging desire and general malaise have a variety of causes, androgen deficiency, like hyperandrogenism, often goes undiagnosed.

Low androgen levels may affect women at any age but most commonly occur during the transition to menopause, or "perimenopause," a term used to describe the time before menopause (usually two to eight years). Androgen levels begin dropping in a woman's 20s, and by the time she reaches menopause, they have declined 50 percent or more from their peak as androgen production declines in the adrenal glands and the midcycle ovarian boost evaporates.

Further declines in the decade following menopause indicate ever-decreasing ovarian function. For many women, the effects of this further decline include hot flashes and accelerated bone loss. These effects may not become apparent until the women are in their late 50s or early 60s.

Treatment for Low Androgen Levels

Combination estrogen/testosterone medications are available for women in both oral and injected formulations. Small studies find they are effective in boosting libido, energy and well-being in women with androgen deficiencies, as well as providing added protection against bone loss. However, the risks from the combination of estrogen and testosterone include increased risk of breast and endometrial cancer, adverse effects on blood cholesterol and liver toxicity.

Testosterone is also an effective treatment for AIDS-related wasting and is undergoing studies for treating premenstrual syndrome (PMS) and autoimmune diseases. Women with PMS may have below-normal levels of testosterone throughout the menstrual cycle, suggesting a supplement may help.

Diagnosis

Diagnosis

Your androgen levels may be normal, too high (hyperandrogenism) or too low (hypoandrogenism). A health care professional can assess whether your symptoms suggest abnormal levels and can order a blood test to measure hormone levels. But results from blood tests are often misleading and may not be conclusive because there is no agreement on just what constitutes "normal" androgen levels in women. Plus, levels fluctuate depending on a woman's age, the timing of her menstrual cycle and her menopausal status. Nonetheless, it is easier to diagnose androgen levels that are too high than levels that are too low.

If you suspect you have a hyperandrogenic condition, it is important to seek a diagnosis and develop and begin a treatment plan. Hyperandrogenism can produce bothersome cosmetic symptoms like unwanted hair on your upper lip and chin. Psychologically, the clinical manifestations of hyperandrogenemia (persistent acne, excess facial or body hair, thinning of hair on the scalp and obesity) can be devastating to young girls and women of reproductive age and may contribute to feelings of low self-esteem, anxiety, depression and antisocial behavior. Women with excessive, uncomfortable sexual tension may also have high levels of androgens.

Hyperandrogenic conditions are also associated with serious health problems like insulin resistance (a precursor to diabetes), diabetes and heart disease.

Hyperandrogenic syndromes often go undiagnosed, even though symptoms may be treated. For example, you may be treated for acne, without being evaluated for glucose tolerance or asked about menstrual regularity. It may be up to you to tie together some of your hyperandrogenic symptoms and ask for a more integrated evaluation and treatment approach.

The signs and symptoms of hyperandrogenism are:

  • Hirsutism (excess facial or body hair)

  • Persistent acne and/or oily skin

  • Alopecia (thinning hair on the head)

  • Insulin resistance

  • Acanthosis nigricans (raisin-like skin tags)

  • High blood pressure

  • Low HDL cholesterol ("good cholesterol") and high LDL cholesterol ("bad cholesterol")

  • Obesity around the mid-abdomen

  • Irregular or absent periods or frequent skipped cycles

  • Enlargement of the clitoris

  • Deep or hoarse voice

  • Feelings of excessive sexual tension

If your symptoms include irregular or absent periods, you may have polycystic ovary syndrome (PCOS)—the most common condition associated with hyperandrogenism. The menstrual irregularity indicates infrequent or absent ovulation, making PCOS a leading cause of female infertility, which is often treatable.

Some women with hyperandrogenism may experience spontaneous ovulation, and pregnancies may occur. However, women with high androgen levels also have an increased risk of miscarriage.

Hyperandrogenic symptoms may also be caused by a genetic disease called congenital adrenal hyperplasia (CAH), which affects about one in 14,000 women. Severe cases can result in such extreme effects as genital malformation and virilization (facial hair, acne) at a young age.

Milder cases may look a lot like PCOS, with symptoms possibly including facial hair, irregular periods and high blood pressure. Women with mild CAH may also be shorter than their parents, vulnerable to infections and have a somewhat "masculine build," with square shoulders and narrow hips.

A thorough medical history and physical examination provide the most important initial diagnostic information. Laboratory tests usually serve to confirm the presence of hyperandrogenemia. A blood test for total and free testosterone may be ordered, as well as a lipid profile (to measure cholesterol levels), luteinizing hormone (LH), follicle-stimulating hormone (FSH), prolactin and a fasting glucose test. Several endocrine function tests may also be ordered to determine the site(s) of abnormal androgen secretion, such as DHEAs. Thyroid tests are usually included in the evaluation.

Hormone therapy, which consists of either estrogen and progestin (referred to as hormone therapy, or HT) or estrogen-only therapy (ET), and birth control pills containing estrogen, are other treatment options. Oral estrogens boost sex hormone binding globulin (SHBG) levels, thus reducing levels of free testosterone, which may be triggering symptoms. Glucocorticosteroids (often prescribed for asthma or inflammation) can also suppress production of androgens.

Androgen Deficiency

Androgen levels in women peak during their 20s. Then a decline in daily production begins that continues throughout a woman's life. The only time a sudden drop-off in androgen levels occur is in women who have had their ovaries removed (about half of all androgens are produced in a woman's adrenal glands and half in her ovaries). By the time a woman reaches menopause, blood androgen levels are about half of what they were at their peak.

Low androgen levels in women during their reproductive years, as well as following menopause, result in three noticeable symptoms: low libido, fatigue and a reduced sense of well-being. Low androgen levels also have been linked to bone loss and osteoporosis (a disease that causes thin, fragile bones), possibly explaining the phenomenon of bone loss in some women who go through ovarian failure or surgical removal of the ovaries.

Low sex drive and vaginal dryness are two common symptoms experienced by some women during the transition to menopause, making sex uncomfortable or painful. These changes have been related to low estrogen as well as low androgen levels. If you recognize any of the following changes, you should see your health care professional to discuss your concerns.

  1. Have you noticed that it takes longer for your vagina to become lubricated before or during sex?

  2. Have you noticed that the amount of vaginal lubrication is less?

  3. Do you have discomfort or pain during vaginal penetration?

  4. Do you have sex less frequently?

  5. Do you and/or your partner wish you had sex more often?

  6. Are you less responsive to sexual stimulation?

  7. Do you have difficulty reaching orgasm?

  8. Has your desire for sex decreased?

To diagnosis androgen deficiency, your health care professional will consider symptoms such as low libido and fatigue. Other conditions that can cause similar symptoms will also need to be ruled out. Blood tests for testosterone and sex hormone binding globulin (SHBG) will likely be part of your evaluation. SHBG binds to testosterone, making it less available for influencing cellular actions.

Blood testing for testosterone in hypoandrogenic women is problematic. Health care professionals have not reached a consensus about what constitutes low levels in women, and levels at the lower end of the female range are difficult to measure. For this reason, Endocrine Society Clinical Practice Guidelines recommend against making a formal diagnosis of androgen deficiency.

The causes of androgen deficiency are varied. The most common cause of low androgen is aging. If your symptoms bother you, you may want to talk to your health care professional about androgen replacement.

Androgen deficiency may be a problem if:

  • Your ovaries have been removed

  • You have undergone early menopause (generally defined as menopause occurring prior to age 40)

  • You have Turner's syndrome, a genetic growth disorder that occurs in about one in 2,000 girls that arises when one, or part of one, of the two X chromosomes is missing (two X's code for a female, an XY for a male). This is a condition in which the ovaries fail to develop.

  • You are postmenopausal

  • You have undergone chemotherapy or radiation treatment for cancer

Other conditions associated with low testosterone include hypothalamic amenorrhea (absence of menstrual periods resulting from excessive dieting and exercising) and hyperprolactinemia (characterized by high levels of prolactin, the hormone that drives milk production when a woman breastfeeds). Additionally, a variety of pituitary gland tumors are also associated with low production of testosterone (as well as other hormones).

Sometimes there is no obvious cause of androgen deficiency. Otherwise healthy women of reproductive age can suffer from low androgens, which can be diagnosed with blood tests and after other potential causes of low libido and fatigue are eliminated.

To exclude other potential causes of symptoms, your health care professional may ask you about past psychological or relationship problems and check for other potential causes of fatigue, such as hypothyroidism and iron deficiency.

If you are postmenopausal and are taking hormone replacement therapy (estrogen alone or an estrogen/progestin combination), your estrogen levels may be checked to ensure your estrogen dosage is high enough.

Treatment

Treatment

Androgen disorders cannot be cured but they can be treated, usually with medication. If you are overweight, losing as little as 5 to 10 percent in body weight can restore fertility and decrease hirsutism in some women with androgen excess.

For example, if you are of reproductive age, the right oral contraceptive choice can reduce hyperandrogenic symptoms, while the wrong one can make them worse. When you hear the term oral contraceptives or birth control pills, it most often refers to "combination pills"—pills that contain both estrogen and progestin. The estrogen used is almost always ethinyl estradiol in varying doses, but numerous progestins are used, also in varying doses. The key is the type of progestin included. Some progestins can mimic androgens and make symptoms worse, but some avoid this problem, allowing the estrogen in birth control pills to raise levels of sex hormone binding globulin (SHBG), reducing blood levels of free testosterone and improving symptoms. Talk to your health care professional about a pill formulation with progestins that do not have an androgen effect and which are known to elevate SHBG, such as norgestimate, drospirenone or desogestrel.

For some women, the most bothersome symptoms of high levels of androgen are acne and hirsutism. For women with such symptoms, spironolactone (Aldactone or Spironol) may be prescribed. The drug, a diuretic, has few side effects, and at high doses can clear oily skin and make unwanted hair finer. The combination of spironolactone and oral contraceptives is frequently used. If you are trying to conceive, however, do not take this drug because it can harm an unborn baby.

Bear in mind that it can take up to nine months to see effects on hair growth and a year to achieve peak effect. The hair will still be there, but will generally grow more slowly and will be lighter and finer. Electrolysis or repeated laser treatments are the only ways to get rid of the hair for extended periods or permanently.

A class of drugs called 5-alpha reductase inhibitors may help some women, though they should be taken only with extreme caution. These drugs inhibit an enzyme crucial to converting testosterone to dihydrotestosterone (DHT). Finasteride (Propecia and Proscar) and flutamide (Eulexin) are in this class. They were designed to treat prostate growth and cancer in men (which is exacerbated by excessive androgen levels), while Propecia is also prescribed as a treatment for male pattern baldness.

These drugs are not specifically approved by the U.S. Food and Drug Administration for use in women, and manufacturers advise against women taking them. If one is prescribed for you, you will have to be especially vigilant about birth control, because both cause birth defects. Flutamide has the potential, although infrequent, adverse effect of fatal liver toxicity.

Treating congenital adrenal hyperplasia (CAH) is a bit more complex, because CAH is characterized not just by high levels of androgens, but by low levels of two other hormones, cortisol and aldosterone. Treatment in an adult woman may incorporate a glucocorticoid, such as prednisone, to make up for the missing cortisol.

Androgen Deficiency

If you are androgen deficient, the benefits of a hormonal supplement can make it worth your while to investigate whether such a drug is right for you. Although not typically prescribed solely to prevent osteoporosis, testosterone supplements have been shown in several studies to not only slow bone loss, but also to stimulate bone formation in postmenopausal women and women with surgically induced menopause.

Some compounding pharmacies may be able to provide testosterone creams that are applied to the vulva for more targeted delivery of the hormone, but such formulations are not widely available. And there is a lack of published data demonstrating safety, whether or not they are effective and if the specially made batch will be exactly the same each time.

There's also a prescription combination estrogen (esterified estrogens) and testosterone (oral methyltestosterone) pill called Estratest that may help combat androgen deficiency. However, there is conflicting evidence and opinion in the medical community concerning whether or not the benefits of the combination of estrogen and testosterone outweigh the risks, which may include increased risk of breast and endometrial cancer, adverse effects on blood cholesterol and liver toxicity.

Recent information from the Nurses' Health Study indicated that the combination of estrogen and androgen used to treat hypoandrogenism could increase breast cancer risk. However, other recent studies indicate androgens may decrease breast cancer risk. A recent report from the follow-up studies on the Women's Health Initiative said that women who received estrogen and no progestogen showed a significant decrease in cardiovascular disease (CVD) and breast cancer. This is causing a reconsideration of androgens added to estrogens. Still, the FDA is requiring demonstration of CVD and breast cancer safety for any product containing androgens or estrogen plus an androgen.

Women with androgen deficiency may benefit from treatment with dehydroepiandrosterone (DHEA), a hormone produced by the adrenal glands. DHEA is available over-the-counter without a prescription in the United States and is not FDA-regulated. It may improve such androgen-deficiency side effects as sexual dysfunction. However, while the hormone is available over the counter, it should not be taken without medical guidance.

The quantity and quality of DHEA contained in available preparations are not routinely monitored or tested for contaminants or consistency. Therefore, it's important that your health care professional monitor blood levels of DHEA and any side effects if you're taking the hormone.

Since DHEA is converted to estrogen and testosterone in women, the levels of these hormones should also be measured when taking DHEA. The results of studies on the benefits of DHEA supplementation in both men and women with androgen deficiency have been mixed. In one randomized, double-blind study of 15 men and 24 women with primary adrenal insufficiency resulting in androgen deficiency, 50 milligrams a day of DHEA improved self-esteem and overall sense of well-being, with less fatigue and improved mood in the evening. However, in another 12-month study of 106 men and women with adrenal insufficiency, DHEA did not improve fatigue, cognitive function or sexual function and had minimal effect on well-being. A recent review of studies found no convincing evidence for the effectiveness of oral DHEA in treating symptoms of hypoandrogenism in women.

Androgen supplements are generally safe at the dosages prescribed for women, but possible side effects include facial hair growth, deepening of the voice, thinning hair and acne.

Noncosmetic side effects can include fluid retention, liver toxicity and unfavorable changes in your cholesterol levels, which should be monitored periodically. If they occur, side effects can be minimized or eliminated with lower androgen doses and can usually be reversed by discontinuing therapy. Higher doses can cause deepening of the voice or clitoral enlargement, which may be irreversible. However, this is not often seen in doses prescribed for women. Early side effects usually include facial hair, oily skin or acne. If they occur, talk to your health care professional about decreasing your dose before more serious side effects occur.

Research continues on patches, skin gels and vaginal creams that could raise androgen levels in women. Testosterone patches for women, sold under the brand name Intrinsa, have been approved for use in Canada and Europe but not in the United States. A testosterone-containing skin gel and vaginal creams containing DHEA and testosterone are in clinical studies.

Androgen supplements are not the answer for everyone with a slumping libido and fatigue––particularly if you have any signs of androgen excess, such as hirsutism, acne or thinning hair. Such medications are also ruled out if you are pregnant or nursing.

As your body changes, it is very important to communicate with both your partner and your health care professional. Tell both about your symptoms and the changes in your body. Your partner's support can be helpful to ease the stress caused by symptoms that affect intimacy. Because every woman is unique, you and your health care professional will need to work together to determine which treatment option best meets your medical and personal needs.

Prevention

Prevention

Researchers are still working to characterize fully the role of androgens in women and the nature of androgen disorders.

You can, however, prevent some of the worst consequences of androgen-related disorders. If you are hyperandrogenic, you may be at higher risk for glucose intolerance, diabetes and high cholesterol. Medication to reduce your androgen levels can reduce these risks, but you may want to talk to a health care professional about monitoring for these conditions and about lifestyle changes (such as diet and exercise) that might help reduce risk.

If you are hypoandrogenic, supplementing with testosterone may help prevent bone loss and osteoporosis and may provide a lift to your sex life and energy levels. Remember that communicating with your partner and health care professional about your symptoms is vital to maintaining a healthy lifestyle and sex life.

And be sure to tell your partner about the treatments recommended by your health care professional. Being open about problems and treatments is the best way to maintain a healthy relationship.

Facts to Know

Facts to Know

  1. Mistakenly thought of as only a male sex hormone, androgens are also natural to the female body, where they are produced in the ovaries, adrenal glands and other tissues.

  2. Testosterone is the androgen you've probably already heard about. Others include dihydrotestosterone (DHT), androstenedione and dehydroepiandrosterone (DHEA) and DHEA sulfate (DHEA-S).

  3. Androgens are partly responsible for the growth spurt at puberty and are believed to regulate the function of many organs, including the reproductive tract, bone, kidneys, liver and muscle.

  4. Androgens have been reported to play a key role in a woman's sex drive, or libido, cognitive abilities, energy level and sense of well-being.

  5. Androgens, either directly or indirectly through conversion to estrogen, affect bone cells or the environment surrounding bone cells, leading to better bone health.

  6. Androgen production drops as you age. By the time you reach menopause, it has dropped 50 percent or more from its peak in your 20s. Androgen levels also quickly drop after a woman undergoes surgery to have her ovaries removed.

  7. Low androgen levels most commonly occur in women during the transition to menopause. By the time a woman reaches menopause, her androgen levels have declined 50 percent or more from their peak in her 20s.

  8. If you take an androgen supplement, watch out for "virilizing" side effects, such as facial hair growth, thinning hair on your head and changes in your voice. If an androgen dose is too high, it can have adverse effects on your cholesterol levels.

  9. The right oral contraceptive choice can reduce hyperandrogenic symptoms, while the wrong one can exacerbate them. The key component is the type of progestin included. Talk to your health care professional about a pill formulation whose progestin component is norgestrel, drospirenone or desogestrel.

  10. If you have symptoms of hyperandrogenism (hirsutism, acne and/or irregular periods), see a health care professional. If the symptoms stem from polycystic ovary syndrome, you could be at higher risk for heart disease and diabetes.

Questions to Ask

Questions to Ask

Review the following Questions to Ask about androgen so you're prepared to discuss this important health issue with your health care professional.

  1. Do you consider yourself up-to-date on hormonal disorders such as androgen deficiency and hyperandrogenism and their treatment? If not, can you make a referral to a health care professional with that expertise?

  2. Do the symptoms I have suggest a possible androgenic disorder?

  3. What other conditions could cause these symptoms?

  4. Will an androgen abnormality affect my fertility?

  5. How will you determine my androgen levels? What is too low? Too high?

  6. I seem to have less interest in sex now that I'm older. What medical steps can be taken to address this issue?

  7. Does the birth control pill I'm taking have anti-androgenic effects?

  8. If medication is prescribed, what side effects should I watch for?

  9. How long should I take this medication?

  10. What happens if I stop taking the medication?

Key Q&A

Key Q&A

  1. Why do women need androgens?

    Androgens were formerly thought of as the "male sex hormones," but now we know that they have an important role in women as well, even though women's levels are much lower than men's. In women, androgens have more than 200 cellular actions, includinghelping maintain a healthy sex drive, preventing fatigue and contributing to a woman's overall sense of well-being. They also prevent bone loss and bone disease and play a role in the formation of estrogen.

  2. What happens if my body does not produce enough androgens?

    Your sex drive, or libido, may drop, and you may experience fatigue and a decline in your overall sense of well-being. Low androgen levels can also contribute to bone loss and bone disease.

  3. What happens if my body produces too much androgen?

    Androgen levels in women peak during their twenties. Then a decline in daily production begins that continues throughout a woman's life. The only time a sudden drop-off in androgen levels occurs is in women who have had their ovaries removed (about half of all androgens are produced in a woman's adrenal glands and half in her ovaries). By the time a woman reaches menopause, blood androgen levels are about half of what they were at her peak.

    As your androgen levels rise, you may experience such "virilizing" effects as facial hair growth, androgenic alopecia (thinning of the hair on your head), acne and oily skin. In addition to these cosmetic effects, if your androgen excess is related to polycystic ovary syndrome (PCOS), you may experience irregular periods that indicate you are not ovulating. Hyperandrogenism or PCOS can also put you at risk of heart disease, glucose intolerance and diabetes.

  4. Is medication available to treat hypoandrogenism?

    Yes, oral methyltestosterone is available in combination with esterified estrogens by prescription (Estratest). This combination is not without its risks, however, so if you are considering this treatment, discuss these risks with your doctor. In addition, DHEA, a hormone that is converted into an androgen, is available without a prescription in the United States, but is not FDA regulated. Therefore, monitoring of serum DHEA levels and side effects is essential in anyone taking this hormone. Some compounding pharmacies may also be able to provide vulval creams for more targeted delivery. Remember, efficacy and safety studies are lacking in non-FDA regulated products.

  5. What are the side effects of those medications?

    If the dosage is too high, you may experience symptoms of hyperandrogenism, such as facial hair growth, acne or oily skin, or a deepening of your voice. Androgen supplements may also negatively affect cholesterol levels (thus increasing your risk of heart disease). If you notice any side effects, tell your health care professional at once. A lower dose can usually resolve side effects, and stopping taking it may reverse them altogether.

  6. I clearly have the symptoms of hypoandrogenism, so why won't my health care professional prescribe supplements?

    The symptoms of low androgen levels-reduced libido and energy, sense of malaise-mirror those of many other disorders. A health care professional should be cautious and rule out other common problems before considering testosterone replacement, particularly if you are under 40 and have no other condition that would cause hypoandrogenism, such as ovarian failure. A health care professional may want to explore your health history, and test for conditions like hypothyroidism and iron deficiency.

  7. Is medication available to help reduce testosterone?

    Yes, a variety of medications may help reduce testosterone or prevent its conversion into an active form. They include oral birth control pills (with norgestimate or norgestrel); spironolactone (Aldactone or Spironol), a diuretic; and flutamide (Eulexin) and finasteride (Propecia), which are used in men to treat prostate growth and cancer and male pattern baldness.

  8. What precautions should I take with those medications?

    You should adhere to a birth control regimen with added vigilance if a health care professional prescribes an androgen-inhibiting drug. These medications can cause birth defects if taken while pregnant. Talk to a health care professional about other possible side effects. See the oral contraceptives topic on this site for a complete discussion of the side effects of birth control pills.

  9. What's the difference between hyperandrogenism and polycystic ovary syndrome (PCOS)?

    Polycystic ovary syndrome is a hyperandrogenic disorder; it is distinguished by irregular or absent periods, which indicate a woman may not be ovulating.



Organizations and Support

Organizations and Support

For information and support on Androgen, please see the recommended organizations, books and Spanish-language resources listed below.

American College of Obstetricians and Gynecologists (ACOG)
Website: http://www.acog.org
Address: 409 12th Street, SW
P.O. Box 96920
Washington, DC 20090-6920
Phone: 202-638-5577
Email: resources@acog.org

American Menopause Foundation (AMF)
Website: http://www.americanmenopause.org
Address: 350 Fifth Avenue, Suite 2822
New York, NY 10118
Email: menopause@earthlink.net

Association of Reproductive Health Professionals (ARHP)
Website: http://www.arhp.org
Address: 1901 L Street, NW, Suite 300
Washington, DC 20036
Phone: 202-466-3825
Email: arhp@arhp.org

Hormone Foundation
Website: http://www.hormone.org
Address: 8401 Connecticut Avenue, Suite 900
Chevy Chase, MD 20815
Hotline: 1-800-HORMONE (1-800-467-6663)
Email: hormone@endo-society.org

100 Questions & Answers About Menopause
by Ivy M. Alexander and Karla A. Knight

Dr. Susan Love's Menopause and Hormone Book
by Susan M. Love

It Hot In Here? Or Is It Me? The Complete Guide to Menopause
by Barbara Kantrowitz, Pat Wingert Kelly

Making Love the Way We Used to...or Better: Nine Secrets to Satisfying Midlife Sexuality
by Alan M. Altman, Laurie Ashner

Medline Plus
US National Library of Medicine and the National Institutes of Health
Androgen Insensitivity Syndrome
Website: http://www.nlm.nih.gov/medlineplus/spanish/ency/article/001180.htm
Address: US National Library of Medicine
8601 Rockville Pike
Bethesda, MD 20894
Email: custserv@nlm.nih.gov

MD Consult Preview
Website: http://www.mdconsult.com/das/patient/body/141062723-2/0/10041/31455.html?tab=span
Address: MD Consult
11830 Westline Industrial Drive
St. Louis, MO 63146
Hotline: 1-800-401-9962
Phone: 314-997-1176
Email: mdc.customerservice@elsevier.com

Last date updated: 
Mon, 2011-05-23

Modern Birth Control Methods

young woman talking to doctor about birth control pillsWe could have titled this article, "Contraception: Not Your Mother's Birth Control," because women today have never had more options when it comes to birth control. Did you know there are at least 17 forms of contraception today? And that several of these options can do more than just prevent pregnancy.

Continue Reading

Genital Itchiness: What You Need to Know About Lichen Sclerosus

middle aged womanIt's probably not something you want to talk about, but have you been itching "down below" lately? Does it get worse at night? Do you sometimes feel a burning sensation? You could have a condition called "lichen sclerosus," or LS.

Continue Reading

Lifestyle and Dietary Changes for Endometriosis

woman in supermarketThere's no question that endometriosis can play havoc with your quality of life. In this condition, tissue that normally lines the uterus grows outside the uterus.

Continue Reading