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?
Menstrual disorders are a disruptive physical and/or emotional symptoms just before and during menstruation, including heavy bleeding, missed periods and unmanageable mood swings.

Some women get through their monthly periods easily with few or no concerns. Their periods come like clockwork, starting and stopping at nearly the same time every month, causing little more than a minor inconvenience.

However, other women experience a host of physical and/or emotional symptoms just before and during menstruation. From heavy bleeding and missed periods to unmanageable mood swings, these symptoms may disrupt a woman's life in major ways.

Most menstrual cycle problems have straightforward explanations, and a range of treatment options exist to relieve your symptoms. If your periods feel overwhelming, discuss your symptoms with your health care professional. Once your symptoms are accurately diagnosed, he or she can help you choose the best treatment to make your menstrual cycle tolerable.

How the Menstrual Cycle Works
Your menstrual period is part of your menstrual cycle—a series of changes that occur to parts of your body (your ovaries, uterus, vagina and breasts) every 28 days, on average. Some normal menstrual cycles are a bit longer; some are shorter. The first day of your menstrual period is day one of your menstrual cycle. The average menstrual period lasts about five to seven days. A "normal" menstrual period for you may be different from what's "normal" for someone else.

Types of Menstrual Disorders
If one or more of the symptoms you experience before or during your period causes a problem, you may have a menstrual cycle "disorder." These include:

  • abnormal uterine bleeding (AUB), which may include heavy menstrual bleeding, no menstrual bleeding (amenorrhea) or bleeding between periods (irregular menstrual bleeding)
  • dysmenorrhea (painful menstrual periods)
  • premenstrual syndrome (PMS)
  • premenstrual dysphonic disorder (PMDD)

A brief discussion of menstrual disorders follows below.

Heavy menstrual bleeding
One in five women bleed so heavily during their periods that they have to put their normal lives on hold just to deal with the heavy blood flow.

Bleeding is considered heavy if it interferes with normal activities. Blood loss during a normal menstrual period is about 5 tablespoons, but if you have heavy menstrual bleeding, you may bleed as much as 10 to 25 times that amount each month. You may have to change a tampon or pad every hour, for example, instead of three or four times a day.

Heavy menstrual bleeding can be common at various stages of your life—during your teen years when you first begin to menstruate and in your late 40s or early 50s, as you get closer to menopause.

If you are past menopause and experience any vaginal bleeding, discuss your symptoms with your health care professional right away. Any vaginal bleeding after menopause isn't normal and should be evaluated immediately by a health care professional.

Heavy menstrual bleeding can be caused by:

  • hormonal imbalances
  • structural abnormalities in the uterus, such as polyps or fibroids
  • medical conditions

Many women with heavy menstrual bleeding can blame their condition on hormones. Your body may produce too much or not enough estrogen or progesterone—known as reproductive hormones—necessary to keep your menstrual cycle regular.

For example, many women with heavy menstrual bleeding don't ovulate regularly. Ovulation, when one of the ovaries releases an egg, occurs around day 14 in a normal menstrual cycle. Changes in hormone levels help trigger ovulation.

Certain medical conditions can cause heavy menstrual bleeding. These include:

  • thyroid problems
  • blood clotting disorders such as Von Willebrand's disease, a mild-to-moderate bleeding disorder
  • idiopathic thrombocytopenic purpura (ITP), a bleeding disorder characterized by too few platelets in the blood
  • liver or kidney disease
  • leukemia
  • medications, such as anticoagulant drugs such as Plavix (clopidogrel) or heparin and some synthetic hormones.

Other gynecologic conditions that may be responsible for heavy bleeding include:

  • complications from an IUD
  • fibroids
  • miscarriage
  • ectopic pregnancy, which occurs when a fertilized egg begins to grow outside your uterus, typically in your fallopian tubes

Other causes of excessive bleeding include:

  • infections
  • precancerous conditions of the uterine lining cells

Amenorrhea
You may also have experienced the opposite problem of heavy menstrual bleeding—no menstrual periods at all. This condition, called amenorrhea, or the absence of menstruation, is normal before puberty, after menopause and during pregnancy. If you don't have a monthly period and don't fit into one of these categories, then you need to discuss your condition with your health care professional.

There are two kinds of amenorrhea: primary and secondary.

  • Primary amenorrhea is diagnosed if you turn 16 and haven't menstruated. It's usually caused by some problem in your endocrine system, which regulates your hormones. Sometimes this results from low body weight associated with eating disorders, excessive exercise or medications. This medical condition can be caused by a number of other things, such as a problem with your ovaries or an area of your brain called the hypothalamus or genetic abnormalities. Delayed maturing of your pituitary gland is the most common reason, but you should be checked for any other possible reasons.
  • Secondary amenorrheais diagnosed if you had regular periods, but they suddenly stop for three months or longer. It can be caused by problems that affect estrogen levels, including stress, weight loss, exercise or illness.

Additionally, problems affecting the pituitary gland (such as elevated levels of the hormone prolactin) or thyroid (including hyperthyroidism or hypothyroidism) may cause secondary amenorrhea. This condition can also occur if you've had an ovarian cyst or had your ovaries surgically removed.

Severe menstrual cramps (dysmenorrhea)
Most women have experienced menstrual cramps before or during their period at some point in their lives. For some, it's part of the regular monthly routine. But if your cramps are especially painful and persistent, this is called dysmenorrhea, and you should consult your health care professional.

Pain from menstrual cramps is caused by uterine contractions, triggered by prostaglandins, hormone-like substances that are produced by the uterine lining cells and circulate in your bloodstream. If you have severe menstrual pain, you might also find you have some diarrhea or an occasional feeling of faintness where you suddenly become pale and sweaty. That's because prostaglandins speed up contractions in your intestines, resulting in diarrhea, and lower your blood pressure by relaxing blood vessels, leading to lightheadedness.

Premenstrual syndrome (PMS)
PMS is a term commonly used to describe a wide variety of physical and psychological symptoms associated with the menstrual cycle. About 30 to 40 percent of women experience symptoms severe enough to disrupt their lifestyles. PMS symptoms are more severe and disruptive than the typical mild premenstrual symptoms that as many as 75 percent of all women experience.

There are more than 150 documented symptoms of PMS, the most common of which is depression. Symptoms typically develop about five to seven days before your period and disappear once your period begins or soon after.

Physical symptoms associated with PMS include:

  • bloating
  • swollen, painful breasts
  • fatigue
  • constipation
  • headaches
  • clumsiness

Emotional symptoms associated with PMS include:

  • anger
  • anxiety or confusion
  • mood swings and tension
  • crying and depression
  • inability to concentrate

PMS appears to be caused by rising and falling levels of the hormones estrogen and progesterone, which may influence brain chemicals, including serotonin, a substance that has a strong affect on mood. It's not clear why some women develop PMS or PMDD and others do not, but researchers suspect that some women are more sensitive than others to changes in hormone levels.

PMS differs from other menstrual cycle symptoms because symptoms:

  • tend to increase in severity as the cycle progresses
  • are relieved when menstrual flow begins or shortly after
  • are present for at least three consecutive menstrual cycles

Symptoms of PMS may increase in severity following each pregnancy and may worsen with age until they stop at menopause. If you experience PMS, you may have an increased sensitivity to alcohol at specific times during your cycle. Women with this condition often have a sister or mother who also suffers from PMS, suggesting a genetic component exists for the disorder.

Premenstrual Dysphoric Disorder (PMDD)
Premenstrual dysphoric disorder is far more severe than the typical PMS. Women who experience PMDD (about 3 to 8 percent of all women) say it significantly interferes with their lives. Experts equate the difference between PMS and PMDD to the difference between a mild tension headache and a migraine.

The most common symptoms of PMDD are heightened irritability, anxiety and mood swings. Women who have a history of major depression, postpartum depression or mood disorders are at higher risk for PMDD than other women. Although some symptoms of PMDD and major depression overlap, they are different:

  • PMDD-related symptoms (both emotional and physical) are cyclical. When a woman starts her period, the symptoms subside within a few days.
  • Depression-related symptoms, however, are not associated with the menstrual cycle. Without treatment, depressive mood disorders can persist for weeks, months or years. If depression persists, you should consider seeking help from a trained therapist.

Diagnosis

Diagnosis

To help diagnose menstrual disorders, you should schedule an appointment with your health care professional. To prepare, keep a record of the frequency and duration of your periods. Also jot down any additional symptoms, such as cramping, and be prepared to discuss health history. Here is how your health care professional will help you specifically diagnose abnormal uterine bleeding, dysmenorrhea, PMS and PMDD:

Heavy menstrual bleeding

To diagnose heavy menstrual bleeding—also called menorrhagia—your health care professional will conduct a full medical examination to see if your condition is related to an underlying medical problem. This could be structural, such as fibroids, or hormonal. The examination involves a series of tests. These may include:

  • Ultrasound. High-frequency sound waves are reflected off pelvic structures to provide an image. Your uterus may be filled with a saline solution to perform this procedure, called a sonohysterography. No anesthesia is necessary.

  • Endometrial biopsy. A scraping method is used to remove some tissue from the lining of your uterus. The tissue is analyzed under a microscope to identify any possible problem, including cancer.

  • Hysteroscopy. In this diagnostic procedure, your health care professional looks into your uterine cavity through a miniature telescope-like instrument called a hysteroscope. Local, or sometimes general, anesthesia is used, and the procedure can be performed in the hospital or in a doctor's office.

  • Dilation and curettage (D&C). During a D&C, your cervix is dilated and instruments are used to scrape away your uterine lining. A D&C may also be used as a treatment for excessive bleeding and for bleeding that doesn't respond to other treatments. It is performed on an outpatient basis under local anesthesia.

You can also expect blood tests to check your blood count for anemia and a urine test to see if you're pregnant, as well as other laboratory tests.

The more information you can give your health care professional, the better. Take notes on the dates and length of your periods. You can do this by marking your calendar or appointment book. You might also be asked to keep a daily track record of your temperature to determine when you are ovulating. Ovulation kits, that use a morning urine sample, are available without a prescription and are easy to use.

During your initial evaluation with your health care professional, you should also discuss the following:

  • current medications
  • details about menstrual flow and cycle length
  • any gynecologic surgery or gynecologic disorders
  • sexual activity and history of sexually transmitted diseases
  • contraceptive use and history
  • family history of fibroids or other conditions associated with AUB
  • history of a breast discharge
  • blood clotting disorders—either your own or in family members.

PMS and PMDD

There are no specific diagnostic tests for PMS and PMDD. You'll probably be asked to keep track of your symptoms and write them down. A premenstrual symptom checklist is one of the most common methods currently used to evaluate symptoms. With this tool, you can track the type and severity of symptoms to help identify a pattern.

Generally PMS and PMDD symptoms:

  • tend to increase in severity as the menstrual cycle progresses.
  • tend to be relieved when menstrual flow begins or soon afterward.
  • are present for at least three consecutive menstrual cycles.

Treatment

Treatment

Treatments for menstrual disorders range from over-the-counter medications to surgery, with a variety of options in between. Your treatment options will depend on your diagnosis, its severity, which treatment you prefer, your health history and your health care professional's recommendation.

Abnormal uterine bleeding

Medication and surgery are used to treat AUB. Typically, less invasive therapies should be considered first. Treatment choices depend on your age, your desire to preserve fertility and the cause of the abnormal bleeding (dysfunctional or structural). Some treatments may reduce your menstrual bleeding to a light to normal flow.

Medication

Medication therapy is often successful and a good first option. The benefits last only as long as the medication is taken, so if you choose this route, you should know that medical treatment is a long-term commitment.

Low-dose birth control pills, progestins and nonsteroidal anti-inflammatory drugs (NSAIDs) may help control heavy or irregular bleeding caused by hormonal imbalances. If your periods have stopped, oral contraceptives and contraceptive patches are highly effective in restoring regular bleeding, although they will not correct the reason you stopped bleeding. Both can also help reduce menstrual flow, improve and control menstrual patterns and relieve pelvic pain during menstruation.

They are considered for PMS treatment if your symptoms are mostly physical, but may not be effective if your primary symptom is mood changes. However, a newer brand of oral contraceptive containing a form of progesterone called drospirenone and marketed under the names YAZ, Yasmin, Ocella, Gianvi and Zarah, may reduce some mood-related symptoms such as anxiety, irritability, tearfulness and tension. And Yaz is FDA-approved for the treatment of PMDD.

Natazia, which contains the synthetic estrogen estradiol valerate, is the first birth control pill FDA-approved for treatment of heavy menstrual bleeding that is not caused by a condition of the uterus. The combination estrogen-progesterone pill may help women who choose oral contraceptives for contraception and do not have risk factors that may make using hormonal birth control inadvisable.

Birth control pills may not be an appropriate treatment choice if you smoke, have a history of pulmonary embolism (blood clots in your lungs) or have bothersome side effects from this medication. The risk of these side effects is even higher if you use the birth control patch, because it contains higher levels of estrogen.

Progestins, either oral or injectable, are also used to manage heavy bleeding, particularly that resulting from a lack of ovulation. Although they don't work as well as estrogen, they are effective for long-term management. Side effects include irregular menstrual bleeding, weight gain and, sometimes, mood changes.

The levonorgestrel intrauterine system (Mirena) is FDA-approved to treat heavy menstrual bleeding in women who use intrauterine contraception as their method of birth control prevention. The Mirena system may be kept in place for up to five years. Over this time, it slowly releases a low dose of the progestin hormone levonorgestrel into the uterus. Mirena is also referred to as an intrauterine device, or IUD.

Nonsteroidal anti-inflammatory drugs (NSAIDs) are available over the counter and with a prescription and can help reduce menstrual bleeding and cramping. These medications include ibuprofen (Advil, Motrin) and naproxen (Aleve). Mefenamic acid (Ponstel) is a prescription-only NSAID. Common side effects include stomach upset, headaches, dizziness and drowsiness.

Tranexamic acid (Lysteda), although new to the United States, has been used successfully to decrease heavy menstrual bleeding in other countries for many years. These tablets are only taken on the days you expect to have heavy bleeding.

Surgery

Except for hysterectomy, surgical options for heavy bleeding preserve the uterus, destroying just the uterine lining. However, most of these procedures result in the loss of fertility, ending your ability to have children.

There are other important considerations for each of these treatment options. Risks common to all surgical options include infection, hemorrhage and other complications.

  • Endometrial ablation. Endometrial ablation involves using heat, electricity, laser, freezing or other methods to destroy the lining of the uterus. These procedures are recommended only for women who have completed their families because they affect fertility. However, following treatment, you must use contraception. Although endometrial ablation destroys the uterine lining, there is a small chance that pregnancy could occur, which could be dangerous to both mother and fetus. Overall, endometrial ablation procedures have a good success rate at reducing heavy bleeding, and some women stop having menstrual periods altogether.

  • Endometrial resection. During this surgical procedure, the surgeon uses an electrosurgical wire loop to remove the lining of the uterus.
  • Dilation and curettage (D&C). During a D&C, your cervix is dilated and instruments are used to scrape away your uterine lining. A D&C may also be used to diagnose abnormal uterine bleeding. It is performed on an outpatient basis under local anesthesia. This treatment is often only a temporary solution to the heavy bleeding.
  • Myomectomy. Fibroids are a common cause of heavy bleeding, and removal of fibroids with a procedure called myomectomy usually resolves the problem. Depending on the size, number and position of the fibroids, myomectomy may be performed with a hysteroscope, laparoscope or through a bikini abdominal incision.
  • Hysterectomy. This is one of the most common surgical procedures performed to end heavy bleeding. It is the only treatment that completely guarantees bleeding will stop. But it is also a radical surgery that removes your uterus. Several factors make elective hysterectomy a serious consideration: It is major surgery and includes all the risks associated with any surgical procedure. A lengthy recovery period, often four to six weeks, may be necessary for some women. Fatigue associated with the procedure can last much longer.

    Several types of hysterectomy are available. More information is available at www.HealthyWomen.org.

Menstrual cramps

If you are experiencing severe menstrual cramps (called dysmenorrhea) regularly, your health care professional might suggest you try over-the-counter and prescription medications and exercise, among other strategies.

Medications such as nonsteroidal anti-inflammatories (NSAIDs), like ibuprofen and naproxen, can be purchased without a prescription. Treatment works best if started hours before the onset of cramping. If you wait until you have pain, it doesn't work as well. This will also help reduce heavy bleeding.

Oral contraceptive pills are also effective for menstrual cramps. If active pills are taken continuously for 90 to 120 days in a row, periods will only occur three to four times a year.

Other ways to relieve symptoms include putting heat on your abdominal area and mild exercise.

PMS and PMDD

To help manage PMS symptoms, try exercise and dietary changes suggested here and ask your health care professional for other options. If you suffer from PMDD, however, don't try to treat on your own; make sure you talk to your health care professional.

Dietary options for PMS include:

  • Cutting back on alcohol, caffeine, nicotine, salt and refined sugar, which can make PMS and PMDD symptoms worse.
  • Increasing the calcium in your diet from sources such as low-fat dairy products, soy products, dark greens such as turnip greens and calcium-fortified orange juice. Increased calcium may help relieve some menstrual cycle symptoms.
  • Increasing the amount of complex carbohydrates in your diet; these include fruits, vegetables, grains and beans.

Exercise is another good way to relieve menstrual cycle symptoms. You will get the greatest benefits from exercise if you do it for at least 30 minutes, five days a week. But even taking a 20- to 30-minute walk three times a week can:

  • Increase brain chemicals that give you more energy and improve mood.
  • Decrease stress and anxiety.
  • Improve deep sleep at night.

Other medical therapies your health care professional might suggest include:

  • Low doses of antidepressants such as paroxetine (Paxil), sertraline (Zoloft), citalopram (Celexa) and fluoxetine (Prozac). These are prescribed because they are effective in regulating the brain compound serotonin, which is related to PMS. Often these can be taken just during the times of expected symptoms.
  • GnRH agonists (Lupron), sometimes in combination with estrogen or estrogen-progestin hormone therapy, for short-term treatment (less than six months). This treatment is used for very severe symptoms since it has numerous side effects, including hot flashes, headaches and vaginal dryness.
  • Oral contraceptives that contain a progesterone called drospirenone may help reduce some mood-related PMS symptoms, such as irritability, anxiety, tearfulness and tension.
  • Diuretic medications, such as spironolactone (Aldactone) to help with water weight gain and bloating.

There's evidence that some nutritional supplements such as calcium, magnesium and vitamin B-6 may help ease symptoms of PMS. Discuss these and other strategies with your health care professional before taking any dietary supplement.

Prevention

Prevention

You cannot prevent abnormal uterine bleeding, but you can manage it once it develops.

Women who experience chronic ovulation problems—failure to ovulate—can regulate their bleeding by continuing to take oral contraceptives.

For other menstrual cycle-related problems, such as cramping or premenstrual syndrome, you can take steps to prevent or minimize your discomfort and pain as described in the Treatment section of this entry.

Additionally, changing your diet, exercising and adopting a regular sleep pattern can all help with PMS and PMDD symptoms. Specifically, try:

  • Changing your diet by reducing refined sugars, salt, nicotine, caffeine and alcohol, which can aggravate PMS symptoms

  • Exercising at least 20 to 30 minutes three times a week, ideally for at least 30 minutes, five days a week

  • Sleeping consistent hours and establishing a bedtime routine to help cue your body and mind for sleeping

  • Keeping a premenstrual symptom checklist to be prepared for highs and lows

For PMDD, antidepressants or anti-anxiety medications, particularly a type called selective serotonin reuptake inhibitors (SSRIs), can help prevent disruptive symptoms. It may not be necessary to take an SSRI every day; taking the medication only during your luteal phase (starting 14 days before your next period) may be sufficient.

Facts to Know

Facts to Know

  1. Abnormal uterine bleeding (AUB) includes menorrhagia (heavy menstrual bleeding), metrorrhagia (bleeding in between menses) and hypermenorrhea (menses too long). Abnormal uterine bleeding also includes amenorrhea or absence of menstrual periods.

  2. Abnormal uterine bleeding can occur at any age, but it is more likely to occur at certain times in a woman's life. For instance, before menopause, your periods may suddenly become lighter or heavier because you are ovulating less often. If you have just begun to menstruate, you may also experience AUB.

  3. Sometimes abnormal bleeding is caused by hormonal problems. A significant number of women with excessive menstrual bleeding fall into this category. Hormonal imbalances occur when your body produces too much or not enough of certain hormones.

  4. Aside from hormonal problems, there are many other causes of abnormal uterine bleeding. They include:

      • certain birth control methods, such as the copper-T intrauterine device (IUD) and birth control pills
      • infection of the uterus or cervix
      • uterine fibroids
      • blood clotting problems
      • some types of cancer, including uterine, cervical and vaginal
      • chronic medical problems, such as hypo- and hyperthyroidism, liver disease, kidney disease and diabetes

  5. Hysterectomy is the only treatment that completely guarantees heavy menstrual bleeding will end permanently. However, this is a radical surgery where your uterus is removed and you will no longer be able to have children.

  6. Some premenopausal women don't have periods at all. Called amenorrhea, or the absence of menstruation, this condition is normal before puberty, after menopause and during pregnancy. There are two kinds of amenorrhea: primary and secondary. Primary amenorrhea is diagnosed if you reach the age of 16 and haven't yet begun to menstruate. Secondary amenorrhea is diagnosed if you've had regular periods, but they suddenly stop for more than three to six months.

  7. Pain from menstrual cramps is caused by contractions of your uterus triggered by prostaglandins, hormone-like substances found in many types of tissue.

  8. Both medication and surgery can be used to treat AUB. Typically, less invasive therapies should be considered first. Treatment depends on your age, desire to preserve fertility and the cause of the bleeding.

  9. Premenstrual syndrome (PMS) is a term commonly used to describe a range of severe physical and psychological symptoms that some women experience about five to seven days prior to the start of their periods and end just after. To qualify as PMS symptoms, they must be associated with the menstrual cycle, become more severe as the menstrual cycle progresses and be present for at least three consecutive menstrual cycles.

  10. Premenstrual dysphoric disorder (PMDD) is different from the more common PMS; it's far more severe. Women who experience PMDD (about 3 to 8 percent of all women) say that it significantly interferes with their lives. The most common symptoms of PMDD are heightened irritability, anxiety and mood swings. Women who have a history of major depression, postpartum depression or mood disorders are at higher risk for PMDD than other women.

Questions to Ask

Questions to Ask

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

  1. Once you've diagnosed my condition, can we try treatment with medications before trying any surgical procedures? If you are recommending a surgical treatment, why haven't we considered a less invasive route first?

  2. What are the advantages, disadvantages and risks connected with the treatment option you are suggesting to control or end my abnormal uterine bleeding (AUB)?

  3. Do any of the recommended diagnostic procedures hurt?

  4. If I have a problem that's causing my AUB, such as uterine fibroids, polyps or scar tissue, can it be successfully treated without a hysterectomy?

  5. If you are recommending any surgical procedure, how many of these procedures have you performed? How many in situations like mine? Have you had any complications with this procedure? If you haven't done many, can you refer me to someone who has, if you think this is the best course of treatment?

  6. What can I do to relieve my menstrual cramps and PMS symptoms?

Key Q&A

Key Q&A

  1. How is abnormal uterine bleeding (AUB) defined? Is my condition serious enough to be considered AUB?

    Abnormal uterine bleeding refers to menstrual periods that are abnormally heavy, prolonged or both. The term may also refer to bleeding between periods or absent periods.

  2. I used to have regular periods, and they've suddenly disappeared over the past few months. Is this something to be concerned about?

    This condition, called secondary amenorrhea, can be caused by problems that affect estrogen levels, including stress, weight loss, exercise or illness. Also you may experience secondary amenorrhea because of problems affecting the pituitary, thyroid or adrenal gland. This condition can also occur if you've had ovarian cysts or have had your ovaries surgically removed. You should consult with a health care professional to determine what is causing you to skip periods.

  3. Is there a certain age group of women who are more likely to have problems with AUB?

    Abnormal uterine bleeding can occur at any age, but it is more likely to occur at certain times in a woman's life. For instance, for a few years before menopause, your periods may suddenly become lighter or heavier because you are ovulating less often. If you have just begun to menstruate, you may also experience AUB.

  4. Can AUB be a problem for me if I've already gone through menopause?

    If you are post-menopausal, any uterine bleeding is considered abnormal and should be evaluated by a health care professional as soon as possible.

  5. Aside from excessive or lengthy bleeding, what other problems can be described as AUB?

    Other types of AUB could include:

    • absence of periods (no bleeding)

    • bleeding between regular periods

    • spotting

  6. What are my treatment options for AUB?

    Generally, both medications and surgery are options. Typically, less invasive therapies should be considered first. Treatment choices depend on your age, your desire to preserve fertility and the cause of the bleeding (dysfunctional or structural).

  7. Is PMS (premenstrual syndrome) a problem I have to learn to live with every month or is there anything I can do to relieve my symptoms?

    PMS is not a disease but a collection of symptoms. Still, there are many things you can try to alleviate your pain, discomfort and emotional distress. They include dietary changes, exercise and medication options . Ask your health care professional for more information.

Lifestyle Tips

Lifestyle Tips

  1. No periods? Find out why.

    If your period is irregular most of the time, or if you've never had a period, see a health care professional for an evaluation. Amenorrhea—the absence of menstruation—during the childbearing years can be caused by a variety of medical conditions, medications or lifestyle issues. For example, anorexia nervosa, hyperthyroidism and excessive exercise affect the menstrual cycle. A complete medical history and blood tests will be the first steps your health care professional takes to identify the cause of your amenorrhea and develop a treatment plan.

  2. Don't put up with painful periods.

    If your menstrual periods cause mild to moderate discomfort, relief may be as close as your medicine cabinet. Acetaminophen (Tylenol) often relieves mild menstrual pain. Ibuprofen, naproxen and mefenamic acid (brands such as Motrin IB, Advil, Bayer Select Pain Relief Formula, Midol IB) can relieve moderate to more severe pain. These medications work best when symptoms first begin. If menstrual pain lasts several days, your doctor may prescribe another type of pain reliever. Discuss your symptoms and treatment options with your health care professional.

  3. Relax yourself to ease painful menstruation.

    Next time you get painful menstrual cramps, lie down with a heating pad on your abdomen. Then use your fingertips to lightly massage your belly in a circular motion. Drinking warm, noncaffeinated beverages can help, as can taking a warm shower or performing waist-bending exercises or walking.

  4. Oral contraceptives or contraceptive patches often alleviate menstrual pain.

    If you have menstrual pain, your doctor may offer to put you on an oral contraceptive as a means of treating your discomfort. Unless you wish to stay on the pill for contraception, you can discontinue taking it after six to 12 months. Many women report continued relief from menstrual pain even after they stop taking oral contraceptives.

  5. Call your health care professional about excessive menstrual bleeding.

    If you have one or two periods with heavy or prolonged bleeding, there's probably no reason to worry. If, however, heavy bleeding (menorrhagia) recurs during three or more consecutive menstrual periods, or if you have bleeding after menopause, or the abnormal bleeding is accompanied by fever or other symptoms, consult your health care professional. Also call your health care professional if the heavy bleeding is accompanied by pain that is not relieved by ibuprofen or acetaminophen. Avoid taking aspirin because it could worsen the bleeding problem.

Organizations and Support

Organizations and Support

For information and support on coping with Menstrual Disorders, 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 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

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

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

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 Institutes of Health (NIH) Office of Research on Women's Health (ORWH)
Website: http://orwh.od.nih.gov
Address: 6707 Democracy Blvd., Suite 400
Bethesda, MD 20892
Phone: 301-402-1770
Email: odorwh-research@mail.nih.gov

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

Society for Menstrual Cycle Research
Website: http://www.menstruationresearch.org
Address: The Gordon and Leslie Diamond Health Care Centre
2775 Laurel Street, Room 4111 - 4th Floor
Vancouver, BC V5Z 1M9
Email: cemcor@interchange.ubc.ca

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

Break in Your Cycle: The Medical & Emotional Causes & Effects of Amenorrhea
by Theresa Francis-Cheung

Curse: Confronting the Last Unmentionable Taboo: Menstruation
by Karen Houppert

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

Honoring Menstruation: A Time of Self-Renewal
by Lara Owen

Is Menstruation Obsolete?
by Elsimar M. Coutinho and Sheldon J. Segal

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

US Dept of Health and Human Services
Website: http://www.womenshealth.gov/espanol/preguntas/menstru.cfm
Address: National Women's Health Information Center (NWHIC)
Hotline: 1-800-994-9662

Medline Plus: Menstrual periods - heavy, prolonged, or irregular
Website: http://www.nlm.nih.gov/medlineplus/spanish/ency/article/003263.htm
Address: Customer Service
8600 Rockville Pike
Bethesda, MD 20894
Email: custserv@nlm.nih.gov

Last date updated: 
Mon, 2016-02-22

What is it?

Overview

What Is It?
Menopause is a natural part of the female reproductive cycle when monthly menstrual periods end permanently, signifying the end of childbearing years. Menopause is said to have occurred when a woman has not had a menstrual period for 12 months.

The change of life. The end of fertility. The beginning of freedom. Whatever people call it, menopause is a unique and personal experience for every woman. It's a natural event that marks the end of fertility and childbearing years. Technically, menopause results when the ovaries no longer release eggs and decrease production of the sex hormones estrogen, progesterone and, to a lesser extent, androgen. Menopause is said to have occurred when a woman has not had a period for 12 months.

Menopause & the Reproductive Cycle

Reproduction
During the reproductive years, a gland in the brain generates hormones that cause an egg from the ovaries to be released from its follicle each month. As the follicle develops, it produces the sex hormones estrogen and, after ovulation, progesterone, which results in a thickened uterine lining. This enriched lining is prepared to receive and nourish a fertilized egg, which could develop into a fetus. If fertilization does not occur, estrogen and progesterone levels drop, the lining of the uterus breaks down and menstruation occurs.

Perimenopause
For reasons unknown, your ovaries gradually begin to function less efficiently during your mid-to-late 30s. In your late 40s, the process accelerates along with greater hormone fluctuations. This affects ovulation and levels of the hormones estrogen and progesterone. During this transition period, called perimenopause, you may experience irregular menstrual cycles and unpredictable episodes of menstrual bleeding. By your early to mid-50s, your periods will likely end.

Most women can tell if they are approaching menopause because their menstrual periods start changing. The "menopause transition" is a term used to describe this time, as is perimenopause.

Menopause
But menopause itself—as defined by health care professionals—is a woman's final menstrual period, which can be confirmed after she goes 12 consecutive months with no period, and no other biological or physiological cause can be identified; it also may occur when both ovaries are surgically removed or damaged. Until that time, a woman in her late 40s or 50s may still be able to get pregnant, despite irregular periods.

Medical Intervention
Although the majority of women experience "natural" or spontaneous menopause, some women may experience menopause due to a medical intervention. Surgically removing both ovaries, a procedure known as bilateral oophorectomy, triggers menopause at any age. Induced menopause can also occur if the ovaries are damaged by radiation, chemotherapy or certain drugs. Some medical conditions also may cause menopause to occur earlier.

Naturally Occurring
Just as every woman's body is unique, each woman's menopause experience will be highly personal. In fact, some women experience no physical symptoms at all, except the end of their menstrual periods.

Menopause can occur as early as your 30s and, rarely, as late as your 60s. However, there is no correlation between the time of a woman's first period and her age at menopause. In addition, age at menopause is not influenced by race, height, the number of children a woman has had or whether she took oral contraceptives for birth control.

Early Menopause
Although the average age for menopause in the United States is 51, some women experience it later or earlier. Early menopause is defined as occurring at any age younger than age 45. Menopause that occurs in women younger than 40 is called premature menopause or premature ovarian failure. and can occur naturally.; But symptoms of premature menopause, such as irregular periods, may signal an underlying condition, so it is important to discuss any symptoms with your health care professional.

What influences the time of menopause? Genetics are a key factor. The age at which your mother stopped her periods may be similar to when you stop your menstrual periods. And women who smoke cigarettes experience menopause two years earlier, on average, than nonsmoking women.

Symptoms of Menopause

  • Irregular Periods: About four to eight years prior to natural menopause, typically in a woman's late 40s, menopause-related changes may begin. One of the most common and annoying symptoms you may notice during your 40s is that your periods become irregular. They may be heavy one month and very light the next. They may get shorter or last longer. You may even begin to skip your period every few months or lose track of when your periods should start and end. These symptoms are caused by irregular estrogen and progesterone levels.
  • Changes in Hormone Levels: Levels of hormones vary erratically and may be higher or lower than normal during any cycle. For example, if you don't ovulate one month—which is common for women in their late 40s—progesterone isn't produced to stimulate menstruation, and estrogen levels continue to rise. This can cause spotting throughout your cycle or heavy bleeding when menstruation does start.

    One note of caution: although irregular menstrual periods are common as you get closer to menopause, they can also be a symptom of uterine abnormalities or uterine cancer. See your health care professional as soon as possible if your periods stop for several months and then start again with spotting or heavy bleeding; if you have irregular spotting; if you have bleeding after intercourse; or if you start bleeding after menopause. Be sure to mention any menstrual irregularities during regular checkups. Uterine biopsy and vaginal ultrasound are the only ways to evaluate these symptoms and determine whether they are caused by abnormalities in the uterus. Irregular spotting can also be a symptom of cervical cancer, which may be picked up by a Pap test (see screening in Treatment section).

Other changes and signs of menopause include:

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

Menopause-Related Health Conditions
Although there is a wide range of possible menopause-related conditions, most women experiencing natural menopause only have mild disturbances during the perimenopausal years. However, you should be aware that there are at least two major health conditions that can develop in the post-menopausal years: coronary artery disease and osteoporosis.

  • Coronary Artery Disease: Your body's estrogen helps protect against plaque buildup in your arteries. It does this by helping to raise HDL cholesterol (good cholesterol), which helps remove LDL cholesterol (the type that contributes to the accumulation of fat deposits called plaque along artery walls). As you age, your risk for developing coronary artery disease (CAD)—a condition in which the veins and arteries that take blood to the heart become narrowed or blocked by plaque—increases steadily. Heart attack and stroke are caused by atherosclerotic disease, in most cases.
  • Osteoporosis: Your body's own estrogen helps prevent bone loss and works together with calcium and other hormones and minerals to build bones. Your body constantly builds and remodels bone through a process called resorption and deposition. Up until around age 30, the body makes more new bone than it breaks down. But once estrogen levels start to decline, this process slows down.

By menopause, your body breaks down more bone than it rebuilds. In the years immediately after menopause, some women may lose as much as 20 percent of their bone mass in the first five to seven years following menopause. Although loss of bone density eventually levels out, in the years ahead, keeping bone structures strong and healthy to prevent osteoporosis becomes more of a challenge. Osteoporosis occurs when bones become too weak and brittle to support normal activities.

Preventing Menopause-Related Health Condition with Exercise
Not all women develop heart disease or osteoporosis. Many more things affect your heart and your bones than estrogen alone. For example, exercise improves your cardiovascular system—your heart, lungs and blood vessels—at any age. It can help decrease high blood pressure, a concern for half of women over age 60, and can help maintain bone mass. It can also help reduce weight gain, a major risk factor for heart disease, diabetes and many other health conditions common to older women.

You are never too old to begin or continue exercising. A simple walking routine for 30 minutes four to five days a week can provide health benefits. There are other exercise options. Talk to your health care professional about which ones fit your lifestyle and medical needs.

If your bones are strong and healthy as you enter menopause, you'll have better bone structure to sustain you as you age. Bone loss varies from woman to woman. You can improve bone strength as you age by exercising regularly and making sure you get enough calcium in your diet or from supplements. Exercise also helps improve balance, muscle tone and flexibility, which can diminish with aging. Weakness in these areas can lead to more frequent falls, broken bones and longer healing periods.

Women today can expect to live as much as one-third of their lives beyond menopause. The years following menopause can be healthy years, depending on how you take care of yourself.

Diagnosis

Diagnosis

Menopause is diagnosed when a woman who has a uterus has not had a menstrual period for one year.

Some of the more common signs of the menopause transition (a term that refers to the five or more years around the time of menopause) that may prompt a woman to seek consultation with a qualified health care professional include:

  • Hot flashes
  • Vaginal dryness
  • Urinary tract infections or painful urination
  • Stress incontinence (leaking of urine)
  • Night sweats
  • Insomnia
  • Headaches
  • Heart palpitations
  • Forgetfulness
  • Mood changes
  • Anxiety and irritability
  • Diminished concentration
  • Decreased sexual desire

Ask your health care professional about any changes you notice. And remember, menopause is not a disease; it is another life stage. (The changes listed above have not all been scientifically proven to be related to menopause.)

As part of the evaluation of symptoms that may be caused by menopause, your health care professional will carefully assess your symptoms and administer a thorough physical examination. You will also be asked to provide a complete medical history; be sure to include information about your family medical history, as well.

Laboratory tests may include baseline serum chemistry studies, lipid evaluation and hormonal evaluation. Other tests may include:

  • Pap test
  • Mammography
  • Bone density screening
  • Assessment of the uterine lining, when indicated
  • Pelvic ultrasound screening, when indicated

Menopause is associated with consistently increased follicle stimulating hormone (FSH) levels. In perimenopausal women, elevated FSH levels are sometimes detected; however, this FSH elevation is often intermittent (and therefore unreliable), so the ultimate determining factor in knowing whether you have experienced menopause is if you have not had a period for 12 consecutive months.

Treatment

Treatment

Menopause Management

Many women pay close attention to their gynecological health during their younger years and start to ignore it after menopause. Your wellness plan after menopause should include, at minimum, annual visits to a health care professional. These visits should include:

  • An annual breast examination by a health care professional

  • A mammogram every one to two years

  • An annual gynecologic exam

  • A Pap test every three years or a Pap test combined with an HPV (human papillomavirus) test every five years.

    The American Congress of Obstetricians and Gynecologists (ACOG) recommends that beginning at age 30, women who have had three normal test results in a row get screened every three years with either the standard Pap test or liquid-based test.

    Women who have certain risk factors such as diethylstilbestrol (DES) exposure before birth, HIV infection, a history of cervical cancer or moderate to severe cervical dysplasia or a weakened immune system due to organ transplant, chemotherapy or chronic steroid use may need more frequent Pap tests.

    Women who are age 65 or older and who have had adequate prior screening with normal results and who are not at high risk for cervical cancer may stop getting Pap tests.

  • One of the following tests—fecal occult blood test (FOTB), fecal immunochemical test (FIT) or stool DNA test (sDNA), all of which check for colon cancer—is recommended annually beginning at age 50. Talk to your doctor about which of the three tests is best for you.

  • Colon cancer screening with colonoscopy every 10 years beginning at age 50 unless you or someone in your family has had benign colon polyps or colorectal cancer or an inflammatory bowel disease, such as ulcerative colitis, irritable bowel syndrome or Crohn's disease, in which case you should start screening earlier. African Americans are at higher risk than other groups for getting colon cancer and dying from the disease. The American College of Gastroenterology recommends that African Americans begin screening for colon cancer at age 45.

  • Blood pressure check at least every two years (more often if it's chronically high), and blood cholesterol screening every five years (more often if it's chronically high or you have other risk factors for heart disease or stroke); ask your health care professional for guidance.

  • Bone density screenings, such as a dual-energy X-ray absorptiometry (DEXA or DXA) if you are over age 65, or at a younger age if you are at risk for developing osteoporosis; ask your health care professional about how often you should have this test; in some parts of the country, peripheral screening for bone density is available using peripheral dual-energy X-ray absorptiometry (pDXA) or ultrasound of the calcaneus (heel bone), however the results of these tests are not equivalent to the results of a DXA scan and should not be used to diagnose or manage osteoporosis.

  • Annual screenings for diabetes (again, your health care professional may tell you this test is needed less frequently, depending on your risk factors).

  • Thyroid function testing every five years, if recommended by your health care professional.

  • Age-appropriate flu shots and other immunizations.

Discuss any unusual or uncomfortable symptoms with your health care professional. Keep track of medications that you take and ask your health care professional or pharmacist about potential drug interactions, if you are told to take a new medication. Be sure to discuss with your health care professional any alternative medical treatments or herbal products you use or may wish to use.

The Menopause Transition

As your body transitions into menopause (a process that typically lasts about four to eight years) you may notice some physical and emotional changes. The most common include:

  • Irregular menstrual periods
  • Hot flashes
  • Vaginal dryness
  • Urinary tract infections
  • Stress incontinence
  • Night sweats
  • Insomnia
  • Headaches
  • Heart palpitations
  • Forgetfulness
  • Mood changes
  • Anxiety and irritability
  • Diminished concentration

There are a variety of options available to relieve these symptoms, if you find they interfere with your lifestyle. Discuss your symptoms and your concerns with your health care professional to determine which options make the most sense for you.

The following tips may be recommended to relieve the most common menopausal symptoms:

Hot flashes. Although no one knows for sure what causes hot flashes, they're believed to be the result of a narrowing of the temperature range that normally tells the brain to adjust your internal temperature. The pituitary gland in your brain increases the amount of follicle stimulating hormone (FSH) and luteinizing hormone (LH) aimed at the ovaries. Falling estrogen levels and the increase in FSH and LH levels disturb your body's internal temperature. This creates instability in your vasomotor balance and results in a hot flash.

About 75 of every 100 women approaching or going through menopause have hot flashes, which usually last for about three to five years. Hot flashes may get more intense and more frequent around your last menstrual period and then taper off, usually stopping altogether after one to five years. Some women continue to have hot flashes past age 70, however.

During a hot flash, you may experience a sudden sensation of heat in your face, neck and chest. You may sweat profusely and your pulse may become more rapid. Some women get dizzy or nauseous. A hot flash typically lasts about two to four minutes—which can seem like an eternity. For some women hot flashes are intolerable, occurring at inconvenient moments or at night, disrupting sleep.

There are a variety of strategies for coping with hot flashes, ranging from short-term hormone therapy (estrogen alone or estrogen plus progesterone for approximately two to three years and no more than five years) and other medical options to herbal remedies, but lifestyle strategies may be the easiest and quickest changes to try first:

  • Dress in layers that may be removed if you find you're getting too warm.

  • Sleep in a cool room.

  • Drink plenty of water.

  • Avoid hot foods such as soups, spicy foods, caffeinated foods and beverages and alcohol, which can trigger hot flashes.

  • Try to decrease stress.

  • Exercise regularly.

  • Breathe deeply and slowly, if you feel a hot flash starting; rhythmic breathing may help to "turn down" the heat of a hot flash or prevent it from starting altogether.

  • Use a hand-held fan.

Insomnia. Sleep is often a casualty of menopause, whether it is interrupted by hot flashes (called night sweats when they occur at night) or difficulty falling or staying asleep. Hormonal ups and downs are partly responsible. Plus, as you age, your sleep patterns may change. Older people may sleep less, awaken earlier and go to sleep sooner or later than they did at younger ages.

Lifestyle changes for coping with insomnia include:

  • Sleep in a cool room to help relieve hot flashes that may be disturbing your sleep. In hot weather, you may want to lower your bedroom thermostat at night and use a small fan to keep air circulating.
  • Exercise regularly.
  • Set and keep a regular routine and hour for going to sleep.
  • Drink a glass of warm milk right before bedtime but avoid other foods.
  • Avoid alcoholic beverages or smoking before sleep.
  • Avoid watching TV in bed (some programs are anything but relaxing!).
  • Practice relaxation techniques like deep breathing.
  • Review any medications you are taking to see if they may cause sleeplessness.

Mood swings. For reasons still not well understood, declining and fluctuating estrogen levels during the menopausal transition can cause emotional highs and lows and irritability. Lack of sleep due to night sweats may also contribute to feeling irritable and depressed. Though your periods are coming to an end, you may continue to experience the symptoms of premenstrual syndrome (PMS). In fact, emotional symptoms may become worse for some women as they approach menopause. You may also notice that you've lost interest in sex. Declining estrogen and changes in estrogen/testosterone ratios in women at this time may lower your sex drive.

Lifestyle strategies for coping with mood swings and sexuality concerns include:

  • Make physical activity part of your schedule; exercise can improve mood and make you feel better about yourself.
  • Try relaxation techniques such as meditation or massage, which can be calming and reduce irritability.
  • Discuss your symptoms and what may be causing them with your partner; try different approaches to intimacy.

Vaginal dryness and frequent urinary tract infections. Estrogen, a natural hormone produced by the body, helps keep the vagina lubricated and supple. Following menopause, as estrogen levels decline, the vagina becomes drier and the vaginal wall thins. Sex may become painful. The wall of the urethra becomes thinner, too, as estrogen levels fall, and increases the risk of more frequent urinary tract infections. Urine leakage may become a problem as muscle support for the bladder and urethra weakens. (This may also occur from strain on tissues as a result of childbirth).

Strategies for coping with vaginal dryness and frequent urinary infections include:

  • Use nonhormonal vaginal creams or gels (prescription or nonprescription).

  • If moisturizers and lubricants are not enough, vaginal estrogen (a prescription medication) is available as creams, rings or tablets.

  • Drink plenty of water to help your body stay hydrated.

  • Use long-lasting vaginal moisturizers.

  • Exercising to maintain muscle tone.

    Practice Kegel techniques to strengthen the pelvic floor muscles that support the bladder and urethra. Kegel exercises help firm the vaginal canal, control urine flow and enhance orgasm. To make sure you know how to contract your pelvic floor muscles correctly, try to stop the flow of urine while you're going to the bathroom. If you can do this, you've found the right muscles.

    To do Kegel exercises, empty your bladder and sit or lie down. Contract your pelvic floor muscles for three seconds, then relax for three seconds. Repeat 10 times. Once you've perfected the three-second contractions, try doing the exercise for four seconds at a time and then resting for four seconds, repeating 10 times. Gradually work up to keeping your pelvic floor muscles contracted for 10 seconds at a time, relaxing for 10 seconds in between. Aim to complete a set of 10 exercises, three times a day.

  • Tell your health care professional about any medications you're taking. Some may worsen vaginal dryness. Also, if you have a urinary tract infection, you may need antibiotics.

Heart palpitations. Some women in their late 40s are frightened by their hearts beating fast in their chests for no apparent reason. This symptom, called a heart palpitation, is caused by the heart beating irregularly or missing one or two beats. Though this symptom can be associated with several types of serious heart-related conditions, it is also common during the transition to menopause and typically is not related to heart disease. For example, a woman's heart rate can increase seven to 15 beats during a hot flash.

If you think you are experiencing heart palpitations:

  • See your health care professional immediately if you have shortness of breath; pounding or irregular heartbeat; dizziness; nausea; pain in the neck, jaw, arm or chest that comes and goes; or tightness in the chest. Any could be a sign of a serious heart condition.

  • Ask your health care professional to rule out conditions that may cause heart palpitations, such as thyroid disorders.

  • Ask your health care professional about appropriate options for relieving heart palpitations, such as decreasing caffeine, and whether any medications are needed.

Forgetfulness or difficulty concentrating. During and after the menopause transition, many women are troubled to find they have difficulty remembering things, experience mental blocks or have trouble concentrating. Not getting enough sleep or having sleep disrupted can contribute to memory and concentration problems. Stress associated with major life changes—such as caring for aging parents or having your children leave home—can also interfere with sleep. And recently, the Study of Women's Health Across the Nation (SWAN), funded by the National Institute on Aging and published in the May 2009 issue of the journal Neurology, confirmed that there are real cognitive changes that take place in perimenopausal women, especially in the area of learning. Researchers at the University of California Los Angeles looked at 2,362 women aged 42 to 52 and gave them tests of verbal memory, working memory and processing speeds at four different points in their menopause transitions: premenopause, early perimenopause, late perimenopause and postmenopause. They found that women do not learn as well in early or late perimenopause but regain their capacities to learn once menopause has been reached.

The study also uncovered a possible explanation. Researchers concluded that women taking hormones before their last period improved their cognitive skills, but for women who started hormones long after menopause, hormone therapy had a detrimental effect. However, you should still discuss the risks and benefits of hormone therapy with your health care professional. And keep in mind that although they can be upsetting, these memory-related issues are rarely associated with serious medical conditions such as Alzheimer's disease.

Other strategies for coping with memory problems and lack of concentration include:

  • Recognize that these symptoms may be caused by menopausal changes and aging and don't put pressure on yourself.
  • Rely on strategies for remembering things, such as developing daily reminder lists or messages to help get you through periods of forgetfulness.
  • Practicestress-reduction techniques, such as deep breathing exercises, yoga and meditation, and try to be physically active on a regular basis.

If you find the strategies you've tried don't relieve your discomfort, ask your health care professional about medical options. Medical strategies to relieve various menopausal symptoms include:

Oral contraceptives. Oral contraceptives can help ease symptoms associated with menopause, including irregular periods and mood swings, among others. Typically, oral contraceptives are recommended to women who are still having periods. For many women in their 40s, oral contraceptives provide the added benefit of preventing pregnancy. Still, taking oral contraceptivess close to menopause can make it difficult to determine when you have stopped menstruating. Women who smoke, have high blood pressure, experience migraines associated with aura or have diabetes, a history of gall bladder disease or blood clotting disorders should not use oral contraceptives. Discuss your health history with your health care professional and ask for guidance on this treatment option.

If you're considering taking hormones other than oral contraceptives to manage menopausal symptoms, be aware that the doses of estrogen and progesterone typically taken to manage menopausal symptoms are not adequate to provide protection against an unwanted pregnancy. A woman who is still fertile must use contraceptives containing higher levels of hormones or use additional birth control methods in addition to hormone replacement.

Antidepressant medication. The antidepressants venlafaxine (Effexor), fluoxetine (Prozac) and paroxetine (Paxil) may offer some relief for hot flashes. Antidepressants are not FDA-approved for the treatment of hot flashes, however.

Cardiovascular medication. Low doses of the blood pressure drugs clonidine (Catapres) or methyldopa (Aldomet) may also help ease hot flashes in some women. These drugs are not FDA-approved for hot flashes, however, and unpleasant side effects are common.

Menopausal Hormone Therapy

Menopausal hormone or estrogen therapy. Once prescribed as the first choice for the long-term prevention of osteoporosis and heart disease as well as for the short-term relief of menopausal symptoms such as hot flashes, hormone therapy is now only prescribed on a short-term basis (up to five years) for the management of menopausal symptoms in women without certain risk factors, such as a history of breast cancer, coronary artery disease and a previous blood clot or stroke.

Hormone therapy comes in several forms: synthetic or bioidentical estrogen, either alone or combined with progesterone or with a synthetic progestin. When combined with progestin, it is called hormone therapy (HT). It is given only to women who still have their uterus because progesterone reduces the risk of uterine cancer that comes with supplemental estrogen.

When given as estrogen alone, hormone therapy is called estrogen therapy (ET). It is typically given to women who no longer have a uterus.

Postmenopausal hormone therapy comes in a variety of forms: pills, creams, skin patches, vaginal rings and injections.

Some hormones are called "bioidentical," meaning they are chemically, i.e., molecularly, identical to the substance as it occurs in your body. These hormones, however, don't come from your body (or another woman's body). Most bioidentical estrogens and progesterone come from soy (estrogen) or yams (progesterone).

They are also not "natural," or in their natural state, when you take them. To create a hormone women can use, the plant or animal-based hormones are synthesized, or processed, through a several-step process in a laboratory.

While all hormonal supplements, including bioidenticals, are made in a laboratory, the difference between a bioidentical hormone and a synthetic hormone is that the synthetic hormone is a patented molecular compound created in the laboratory to mimic the action of naturally occurring hormones and mass produced. Prempro, for instance, is a combination of two synthetic hormones.

Synthetic and bioidentical hormones work in the same way: by binding in a kind of lock-and-key process to special proteins on cell surfaces called receptors. Once a hormone—whether synthetic or bioidentical—locks onto these receptors, the messages from that hormone can be transferred to the cell.

There are two main types of bioidentical hormones: those that are FDA-approved and commercially available with a prescription, such as Estrace, Climara, Vivelle, EstroGel, Divigel and Estrasorb, and those that are produced on an individual basis for women, in compounding pharmacies.

Estrogen products produced via compounding are typically called "bi-estrogen" or "tri-estrogen," since they contain varying amounts of the two or three types of estrogen. The individual prescription is typically created based on a saliva test that identifies the forms of estrogen in which a woman may be deficient. Keep in mind that saliva tests do not accurately reflect the amount of circulating estrogen, as women's estrogen levels vary day by day and at different times of the day and are not clinically useful for determining estrogen dosing.

A woman should not take any form of HT until she has weighed the pros and cons and discussed these risks and benefits with her doctor. Because of the potential risks that go along with HT, the U.S. Food and Drug Administration (FDA) now advises health care professionals to prescribe postmenopausal hormone therapies at the lowest possible dose and for the shortest possible length of time to achieve treatment goals.

This recommendation was made after findings from major studies of postmenopausal women with and without heart disease, conducted as part of the landmark federal Women's Health Initiative (WHI), indicated that while estrogen and progestin are effective for short-term relief from hot flashes and night sweats, they have no significant impact on general health or quality of life factors, such as energy, mental health, symptoms of depression or sexual satisfaction.

Among other findings:
The National Cancer Institute found a 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.

Results from the Women's Health Initiative (WHI) published in 2002 showed that daily use of combined HT increases a woman's chance of developing breast cancer by about 5 to 6 percent with each year of use. In other words, if 10,000 women took combined HT for a year, there would be about eight more cases of breast cancer per year than if they had not taken HT. The longer HT is used, the more the risk increases. In the same study, women who took HT also had a higher risk of breast cancer detected at a more advanced stage, and they were more likely to have breast changes seen on mammograms.

An update of the WHI study, published in October 2010, with 11 years of follow-up on the participants, showed that breast cancer had spread to the lymph nodes at a significantly higher rate in women taking combined estrogen-progestin than in nonusers. There was no difference in the rate of estrogen-receptor positive tumors between hormone users and nonusers.

However, researchers still have questions about the link between combined HT and breast cancer risk. Some experts theorize that part of the risk from combined HT may be due to the progestin. Researchers are currently looking into whether the progestin dose can be lowered to decrease the risk of breast cancer but still protect the endometrium.

Women who no longer have a uterus should take ET instead of HT because they don't need a progestin to protect against uterine cancer, so there is no reason for them to increase their breast cancer risk by taking a progestin.

One piece of good news is that the risks associated with HT apply only to women who are currently taking or who have recently taken combined HT. Once a woman stops taking HT, her breast cancer risk drops to that of the general population (if she has no other risk factors).

The WHI also looked at women who had had a hysterectomy and whose ovaries had either stopped working or had been removed. Those who were taking ET only did not have an increased risk of breast cancer.

However, the "Million Women Study," conducted in Britain, and numerous other similar studies have shown a slightly increased risk of breast cancer—about 1 to 3 percent with each year of use—in women who took ET. This is lower than the risk seen in women who took HT in the WHI study.

In addition:

  • HT does not appear to help women with heart disease and may even make existing heart conditions worse. However, some research shows that ET may decrease the risk of heart disease when taken early in the postmenopausal years. A randomized, controlled clinical trial—called the Kronos Early Estrogen Prevention Study (KEEPS)—is currently exploring estrogen use in younger postmenopausal women.

  • Research shows that HT can prevent bone loss after menopause, decreasing the risk of hip fractures related to osteoporosis.

  • Older women taking HT have a higher risk of developing dementia, including Alzheimer's disease, and, therefore, HT is not recommended after age 65.

Discuss the individual risks and benefits of hormone therapy with your health care professional. If you are considering hormone therapy, you may want to consider one of many low-dose HT preparations now available.

Alternatives to Hormone Therapy

For heart protection. Lifestyle strategies for cardiovascular health include exercise, not smoking, maintaining a healthy weight and limiting salt and alcohol. A balanced diet rich in vegetables, fruits and fish, and low in saturated fat can also provide some heart-health benefits.

Your health care professional may prescribe medication to reduce cholesterol and blood pressure levels and reduce your risk of heart disease.

For reduced sex drive. Testosterone is a hormone that plays an important role in women's bodies. Often thought of incorrectly as exclusively a male sex hormone, testosterone is secreted by the ovaries and adrenal gland and is natural to the female body. Surgical menopause (removal of the ovaries) may have a negative effect on sex drive, and testosterone therapy is sometimes prescribed to help.

Testosterone is not FDA approved for the treatment of low libido, however, and we don't know what doses are appropriate for women. Too much testosterone may not help with sexual desire but may, instead, make you feel agitated, overly aggressive and/or depressed. Higher doses can cause masculinizing side effects that may not go away after stopping therapy, such as facial and body hair growth, acne, an enlarged clitoris, a lowered voice and muscle weight gain.

Testosterone may also be associated with adverse heart-related conditions, such as increased risk for atherosclerosis. There are currently no FDA-approved testosterone-alone preparations for women, although it is often prescribed "off-label" for women. There's a specific prescription combination estrogen (esterified estrogens) and testosterone (oral methyltestosterone) pill called Syntest DS that may help combat testosterone deficiency. Do not use Syntest if you have liver disease; a recent history of heart attack, stroke or circulation problems; a hormone-related cancer such as breast or uterine cancer; abnormal vaginal bleeding; or if you are pregnant or breast-feeding. It also increases your risk of endometrial hyperplasia, which may lead to cancer of the uterus.

Since the safety of taking testosterone for extended periods has not been established, women should be very cautious when considering this type of hormone treatment. Discuss the risks and benefits with your health care professional.

Osteoporosis. Lifestyle changes shown to improve bone density in young women and prevent fractures in older women include dietary calcium and avoiding smoking and excessive alcohol consumption.

Additionally, several prescription drugs are available to treat and/or prevent osteoporosis.

Herbal Remedies

Some women report that vitamin and herbal supplements are helpful in managing menopausal symptoms. For instance, phytoestrogens—naturally occurring compounds in certain plants, herbs and seeds—are similar in chemical structure to estrogen and produce estrogen-like effects.

Soy products (tofu, tempeh, soy milk, soy burgers and roasted soy nuts), certain herbs (red clover) and legumes (chickpeas, lentils and various kinds of beans) contain specific types of phytoestrogens called isoflavones. These are healthy foods that are excellent sources of protein and calcium and can be added to your diet.

Some studies show that the isoflavones (weak, plant-derived estrogens) in soy foods and dietary supplements can reduce mild hot flashes. But most studies show they are no more effective than a placebo. Talk to your doctor before taking any form of isoflavones.

Black cohosh has been widely used in Europe for the treatment of hot flashes, and it has become more popular among U.S. women who want something to curb their hot flashes. The supplement's safety record is good, but there is no real good research supporting its effectiveness in treating menopausal symptoms. Talk to your doctor about black cohosh before taking any form of the supplement.

There is also no scientific evidence to support the effectiveness of evening primrose oil, ginseng, kava, licorice, sage and dong quai root. Discuss any herbal or vitamin supplements you are considering taking with your health care professional. Bear in mind that studies related to their effectiveness are sparse, and the FDA doesn't oversee the production of supplements and does not require manufacturers to prove their products are safe. Also be aware that high doses of certain vitamins and herbal supplements can be dangerous. For example ephedra used in some weight-loss products has potentially serious side effects. Mixing herbal supplements with some prescription drugs can also be dangerous. So again, be sure to tell your health care professional everything you take.

Prevention

Prevention

You can't stop menopause, but you can prepare for its arrival. These strategies can help make your transition to menopause and your postmenopausal years healthy:

  • Be prepared for how and why your body will change.

  • Be informed about health issues after age 50.

  • Develop a wellness plan that includes regular health screenings, regular exercise and a healthy diet throughout the years ahead.

  • To improve your cardiovascular health and decrease your risk for osteoporosis, avoid smoking, weight gain, and excessive alcohol consumption. (Moderate drinking for women is defined as one drink per day equaling one 12-ounce bottle of beer or wine cooler; one 5-ounce glass of wine; or 1.5 ounces of 80 proof distilled spirits, according to the National Institute on Alcohol Abuse and Alcoholism. Anything beyond that is considered excessive.)

  • Eat a balanced diet.

  • Consider strength-training exercises and other weight-bearing exercises to increase your bone strength to prevent fractures as you age. Also consider taking dietary calcium and vitamin D, particularly if you're over 65.

Women today don't have to surrender to old age. Life after menopause can be as healthy, independent and fulfilling as any of the younger stages of a woman's life; many postmenopausal women find their lives more satisfying.

Facts to Know

Facts to Know

  1. After age 55, more than half of all deaths in women are caused by heart disease. And despite being thought of as a man's disease, more women die from heart disease than men. Women can protect themselves against heart disease by not smoking, eating a healthy diet and getting regular exercise.

  2. There is a direct relationship between osteoporosis—a disease in which bones lose calcium and become brittle and more likely to fracture—and the lack of estrogen after menopause. Early menopause (before age 45) and any other extended period during which hormone levels are low and menstrual periods are absent can cause a decrease in bone mass.

  3. About 6,000 women in the United States reach menopause every day for a total of more than 2 million per year.

  4. In one study, 80 percent of women in menopause reported no decrease in quality of life, and 75 percent felt they had no loss in their attractiveness.

  5. According to the North American Menopause Society, most women—about 62 percent—report positive attitudes toward menopause.

  6. Some women continue to experience premenstrual syndrome (PMS) symptoms as they approach menopause. These symptoms can include swollen or tender breasts, bloating, nausea and moodiness.

  7. Fertility decreases gradually as menopause approaches. However, you can still get pregnant, even if your periods are irregular. A significant number of unintended pregnancies occur in women aged 40 to 44. Thus the need for reliable contraception remains important.

  8. As estrogen levels decline, vaginal tissue and tissue in the lower urinary tract become thinner, drier and less supple, causing painful intercourse and more frequent urinary tract infections in some women. Osteoporosis and heart disease are other consequences of declining estrogen levels in the decades following menopause.

  9. As you approach menopause, you may notice that you feel more irritable and moodier than usual. Some researchers believe this moodiness is due to the changes in your estrogen levels, but others think it may be more the result of the other symptoms that accompany menopause, such as hot flashes and fatigue, coupled with other stressors that often plague women in middle age. Severe depression, however, is not a symptom of menopause.

Questions to Ask

Questions to Ask

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

  1. How many women in my age group do you treat? What percentage does this number represent of your total practice?

  2. Are you comfortable treating perimenopausal and postmenopausal women? If not, can you refer me to a colleague who is?

  3. Do you consider yourself up-to-date on treatment options for perimenopausal and postmenopausal health concerns, including hormone therapy and other medical therapies?

  4. Can you arrange for evaluations for osteoporosis and heart disease? At what age should I have these evaluations?

  5. If I am interested in alternative therapies, will you work with me to help identify those that might be helpful or refer me to someone who is a safe and knowledgeable practitioner?

  6. I don't feel well in several different ways. Are my symptoms due to menopause or another condition?

  7. How do I know if my on-again, off-again bleeding is perimenopause or another problem?

  8. My sex drive is low. Can this be due to menopause or other factors in my life?

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

  10. Can you discuss the most recent research about hormone therapy and its safety with me? How do the benefits and risks of hormone therapy apply to my personal health needs?

Key Q&A

Key Q&A

  1. Will these menopause symptoms last for the rest of my life?

    For most women, menopause symptoms last for a relatively short time. However, a woman's level of estrogen naturally remains low after menopause. This can affect many parts of the body, including the sexual and urinary organs, the heart and bones. So in that sense, the changes of menopause will be lifelong. But eating right, exercising and making other positive lifestyle changes can help you feel great and live a long, healthy life after menopause.

  2. What can be done to relieve pain during sex?

    Sexual penetration may be painful when there is not enough moisture in the vagina or when the tissue lining the vagina becomes fragile because of lower estrogen levels. The vaginal canal may actually shorten, and the opening may become more closed. Several methods are available to help. One of the most effective is frequent sexual activity. Other remedies include short-acting, water-based lubricants, such as Astroglide or K-Y lubricants, that supply moisture immediately before intercourse. Long-acting vaginal moisturizers are also available, while prescription estrogen-based vaginal creams, rings or tablets may also help. Lubricants described as "warming" or "stimulating" may cause vaginal or vulvar irritation.

  3. Since I began menopause, I've had an embarrassing problem—urine leaks when I laugh or cough. What can be done to prevent this?

    Some women have problems with bladder control after menopause begins. This happens because the muscles that surround the bladder and hold the urine inside become weaker as a woman ages. It may also be a result of strain during childbirth. Fortunately, simple exercises—known as Kegel exercises—can strengthen these muscles. To do Kegel exercises, empty your bladder and sit or lie down. Contract your pelvic floor muscles for three seconds, then relax for three seconds. Repeat 10 times. Once you've perfected the three-second contractions, try doing the exercise for four seconds at a time and then resting for four seconds, repeating 10 times. Gradually work up to keeping your pelvic floor muscles contracted for 10 seconds at a time, relaxing for 10 seconds in between. Aim to complete a set of 10 exercises, three times a day.

    Doing regular Kegels can markedly improve bladder control—and may even enhance sexual pleasure. Declining estrogen has been associated with worsening prolapse and incontinence.

  4. My health care professional has recommended hormone therapy, but I've heard that I'll have menstrual periods again if I take it. Is that true? Is hormone therapy safe?

    Hormone therapy is only recommended for short-term use for women whose menopausal symptoms have become disruptive to their lives and cannot be controlled using nonhormonal approaches. Newer hormone therapy dosing schedules, which include both estrogen and progestogen daily, may cause some uterine bleeding or spotting for the first six months, but this bleeding eventually tapers off. If you experience bleeding while taking hormone therapy, talk to your health care professional; he or she may want to rule out other causes or change your dose to eliminate bleeding.

    Hormone therapy has been associated with some serious risks, especially in women with certain risk factors like a history of breast cancer or blood clots. Therefore, hormone therapy should always be used at the lowest effective dose and for the shortest amount of time to achieve treatment goals.

  5. Even though my eating habits have not changed, I've gained weight recently. Is that linked to menopause?

    It may be. Everyone's metabolism begins to slow during the early to mid-30s. This change occurs gradually, so it may take a while for the impact of eating habits to affect weight. Also, many women notice a thickening around the waist after menopause. It is important to make a sensible, nutritious diet and healthy behaviors, such as getting enough exercise, goals for life. There is some evidence that eating a diet that includes lean protein, is low in fat and low in carbohydrates may help. The only reliable way to lose weight is to reduce caloric intake and increase caloric expenditure by exercising daily.

  6. I seem to be very forgetful lately and I'm worried. What's happening?

    Many postmenopausal women have problems with short-term memory like forgetting the location of keys or eyeglasses, skipping appointments they didn't remember or losing the end of a thought when speaking or writing. These may be due to a busy lifestyle and/or stress at home or work, aging and possibly, hormonal changes. Several medical studies have shown distinct differences in memory in women who have active ovaries producing estrogen or are taking estrogen therapy compared to women with low levels of estrogen due to menopause. These cognitive differences seem to be most pronounced in the years leading up to menopause, according results of a study published in the May 2009 issue of Neurology. The Study of Women's Health Across the Nation (SWAN), funded by the National Institute on Aging, found a noticeable decline in cognitive skills in perimenopausal women, particularly in the area of learning. The women improved once they hit post-menopause, however, indicating that there is a time limit to the decline. The study also revealed that women who were taking hormones before their last period showed improvements in their ability to learn, suggesting that when taken in the years leading up to menopause, hormones may help prevent problems in learning and memory. After perimenopause, the hormones had a detrimental effect, however. If you notice a serious memory deficit, or are unable to remember what a common item is used for, consult your doctor, and if you are perimenopausal, discuss with him or her the possibility of hormone therapy.

  7. How will menopause affect my daily activities and lifestyle?

    That all depends on you. Menopause is a natural part of life, not a disease or a health crisis. However, menopause may occur when many other changes are happening in your life. For instance, your children may be marrying or leaving home, your parents may be ill or dying or you may be wondering what you'll do when you retire. That's why it is probably more helpful to think of how your daily activities and lifestyle could affect your postmenopausal years.

    For instance, making sure that you exercise and eat right can make a real difference in how you feel and can even help prevent some of the long-term effects that are linked to estrogen deficiency (like osteoporosis).

    Physical changes do occur with menopause and with aging. But the changes that happen during this period can be minimized by healthy living and a sense of purpose in life. If your symptoms are severe enough to interfere with your life, consult your doctor to go over your options for treatment.

Lifestyle Tips

Lifestyle Tips

  1. Cooling off those hot flashes without hormone therapy

    Try dressing in light layers that can be taken off when a hot flash starts; using a hand-held fan (battery operated or manual); and taking a tepid or cool shower before bedtime. For some women, alcohol or caffeine can trigger hot flashes, so it may help to avoid these substances. If stress brings on hot flashes, try relaxation techniques, such as deep breathing and meditation.

  2. Weight gain at menopause common but not inevitable

    Most women gain weight, especially in their midsection, around menopause. This midlife weight gain is partly because of hormonal changes associated with menopause. However, weight gain is also associated with inadequate physical activity, and women tend to be less physically active as they grow older. To avoid weight gain, reduce calorie intake and make exercise a priority. In fact, you may need to eat less and exercise more than you did when you were younger to lose weight or to maintain a healthy weight because your metabolism naturally slows as you age.

  3. Calcium, vitamin D key to bone health, overall health

    Adequate calcium intake-in the presence of adequate levels of vitamin D-plays a major role in reducing the incidence of osteoporosis, a bone-thinning disease that can lead to fractures. In addition, calcium also appears to have beneficial effects in several non-skeletal disorders, such as high blood pressure, colorectal cancer, obesity and kidney stones. According to the National Osteoporosis Foundation, women aged 19 through 49 should get 1,000 mg of elemental calcium, and, to ensure adequate calcium absorption, 400 to 800 IU per day of vitamin D. Women 50 years of age and older should get 1,200 mg of calcium and 800 to 1,000 IU of vitamin D per day. Calcium is best absorbed from whole foods, or in supplement doses of 500 mg or less at a time, so split your 1,000 to 1,200 mg into two or three doses.

  4. Vaginal dryness easily conquered

    As estrogen levels drop at menopause, the vagina's natural lubricants decline, resulting in dryness and itching that can make intercourse painful. The paradox is that regular sexual activity that leads to orgasm can help keep the vagina moist. Before intercourse, try inserting a nonprescription water-soluble lubricant around the opening and a small amount into the vagina. You may also try long-lasting vaginal moisturizers. If nonprescription remedies don't help, talk to your health care professional about estrogen vaginal cream or another form of estrogen therapy.

Organizations and Support

Organizations and Support

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

American Menopause Foundation (AMF)
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 20815-5817
Hotline: 1-800-HORMONE (1-800-467-6663)
Email: hormone@endo-society.org

MGH Center for Women's Mental Health
Website: http://www.womensmentalhealth.org
Address: Perinatal and Reproductive Psychiatry Program Simches Research Builiding
185 Cambridge St Suite 2200
Boston, MA 02114
Phone: 617-724-7792

National Program on Women and Aging
Website: http://iasp.brandeis.edu/womenandaging
Address: The Heller School for Social Policy and Management
Institute on Assets and Social Policy, MS 035 Brandeis University
Waltham, MA 02454
Phone: 781-736-3826 or 781-736-3863

National Women's Health Network (NWHN)
Website: http://www.nwhn.org
Address: 1413 K Street, NW, 4th floor
Washington, DC 20005
Hotline: 202-682-2646
Phone: 202-682-2640
Email: nwhn@nwhn.org

North American Menopause Society (NAMS)
Website: http://www.menopause.org
Address: Post Office Box 94527
Cleveland, OH 44101
Phone: 440-442-7550
Email: info@menopause.org

Older Women's League (OWL)
Website: http://www.owl-national.org
Address: 1828 L Street NW Suite 801
Washington, DC 20036
Hotline: 1-800-825-3695
Phone: 202-332-2949
Email: owlinfo@owl-national.org

Prime Plus/Red Hot Mamas
Website: http://www.redhotmamas.org
Address: 7712 Georgetown Chase
Roswell, GA 30075
Phone: 770-640-1018
Email: info@redhotmamas.org

Women's Place at the University of Virginia
Website: http://healthsystem.virginia.edu/internet/women
Address: P.O. Box 800566
Charlottesville, VA 22908
Hotline: 1-800-723-3678
Phone: 434-982-3678

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

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

The American Medical Association Essential Guide to Menopause
by The American Medical Association

Could It Be...Perimenopause?
by Steven R. Goldstein and Laurie Ashner

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

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

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

New Menopausal Years, The Wise Woman Ways: Alternative Approaches for Women 30-90
by Susun S. Weed

Menopause: Questions You Have... Answers You Need
by Annette Thevenin Doran and Lisa Bonnell Samalonis

The Menopause Sourcebook
by Gretchen Henkel

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

The Premature Menopause Book: When the "Change of Life" Comes Too Early
by Kathryn Petras

Menopause: The Silent Passage, Revised and Updated
by Gail Sheehy

This Is Not Your Mother's Menopause: One Woman's Natural Journey Through Change
by Trisha Posner

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

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

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

Last date updated: 
Thu, 2012-03-15

What is it?

Overview

What Is It?
Ovulation and sperm deficiencies are the most common infertility problems, accounting for two-thirds of all cases.

Infertility is far more common than most people think. According to Resolve, The National Infertility Association, approximately one in eight couples in the United States—about 12 percent of the reproductive-age population—experience fertility problems and have difficulty achieving pregnancy.

The truth is that hundreds of variables must coincide precisely for conception to occur and for a woman's body to successfully maintain a pregnancy for nine months. A healthy, fertile 30-year-old woman who has regular unprotected intercourse has about a 20 percent chance of conception during each menstrual cycle. Once she reaches age 40, the odds drop to about 5 percent each cycle.

There is no "typical" infertile patient. Lack of ovulation and sperm deficiencies are the most common infertility problems.

Ovulation is a complicated communication process between the hormones in a woman's brain and the eggs and hormones in her ovaries. To understand ovulation problems related to infertility, you must first understand ovulation. As your menstrual cycle begins (day one of your period), your estrogen levels are low. Your hypothalamus (the area of your brain responsible for maintaining hormone levels) tells your pituitary gland to start producing a hormone called follicle stimulating hormone (FSH). The FSH triggers eggs that are ready to start developing to grow. One of these egg follicles will develop into the dominant mature egg destined to ovulate, and the others degenerate.

Follicles produce estrogen, and when the estrogen levels reach a certain threshold, the egg is mature and ready to be released. The pituitary gland then releases a hormone called luteinizing hormone (LH) that causes the egg to mature and be released from the ovary wall and begin its 48- to 72-hour or so journey through the fallopian tube.

Ovulation problems can occur due to a number of factors:

  • The ovaries may no longer contain eggs
  • Eggs are present in the ovary but ovulation is disrupted because of a breakdown in the hormonal communication cycle

Age is also a major factor in a woman's fertility. After age 35, a woman's fertility rapidly declines. By age 43, there are fewer normal eggs remaining in her ovary, and she is less likely to conceive.

The quality of a woman's eggs is critical to her chances of becoming pregnant. If a woman is having trouble conceiving, she may have an ovarian reserve test. If it indicates few high-quality eggs or a very low probability of conception, her physician may recommend using donor eggs.

While an older woman is more likely to have poor egg quality than a younger one, the condition can also affect younger women. Each year, about 20,000 in vitro fertilization (IVF) cycles include the use of donor eggs. Less common identifiable fertility problems for women include structural problems or scarring of the fallopian tubes and/or uterus caused by pelvic inflammatory disease (PID) or endometriosis (a condition causing adhesions and cysts), uterine fibroids or, very rarely, birth defects.

Sperm deficiencies can include low sperm production (oligospermia) or lack of sperm (azoospermia). Sperm may also have poor motility—they don't move properly once inside the female reproductive tract to achieve fertilization. Additionally, sperm cells may be malformed or may not survive long enough to reach the egg.

About one-third of identifiable causes of infertility are due to male factors and about one-third are caused by female factors. Roughly one-third of infertility is couple-related, with a combination of problems in both partners preventing conception

An estimated 20 percent of infertility cases are unexplained; the source of the problem cannot be identified.

The majority of infertility cases are treated with medication or surgery. In vitro fertilization (IVF) and other types of assisted reproductive technologies (ART)—in which barriers to successful conception are overcome in the laboratory—account for a much smaller percentage of infertility treatments.

Diagnosis

Diagnosis

Most specialists recommend that couples with no known reproductive health problems try to get pregnant through intercourse for 12 months before seeking medical advice.

However, if a woman is 35 or older, has menstrual or ovulatory irregularities, known tubal problems, a history of miscarriages or thyroid conditions, she should consult a specialist much earlier in the process, usually at six months or sooner.

Men with known sperm deficiencies or a history of infections, cancer treatment or scrotal surgery should also consult a specialist early in the process.

If you are worried about fertility, you and your partner should:

  • Consult a specialist early on.
  • Educate yourself as much as possible about all aspects of infertility.
  • Ask questions.
  • Know your treatment options and what is financially and emotionally possible.

Some obstetricians/gynecologists may have gained significant on-the-job experience in treating infertility, combined with specialized coursework to enhance their knowledge. There are many fertility tests and treatments a competent ob/gyn can perform.

Fertility specialists are subspecialists in the field of obstetrics and gynecology known as reproductive endocrinology. Because the field is so specialized, there are far fewer reproductive endocrinologists in the United States than there are ob/gyns.

Urologists with a subspecialty in andrology are specialists who diagnose and treat male infertility.

Finding board-certified physicians in reproductive endocrinology—which means they completed extensive training and passed both oral and written examinations in the subspecialty—is one way to ensure that your health care professional is truly a specialist.

When looking for a specialist, be sure to ask about his or her training and how long the specialist has been practicing in the field of infertility. As with most medical evaluations, identifying potential fertility problems should begin with the easiest, least expensive and least invasive approach. An initial evaluation should include:

  • Medical histories of both partners, including questions about pelvic infections, sexually transmitted diseases (STDs), cycle length, prior obstetric history, surgeries, etc.
  • Blood tests to screen for certain hormonal abnormalities in men or women
  • An assessment of how often you ovulate
  • Semen analysis (the quantity and quality of the man's sperm).
  • Hysterosalpingogram (HSG). A special dye is injected into the uterus through the vagina during an X-ray. This helps your health care professional to see both the uterine cavity and the fallopian tubes to see if they are open.
  • Transvaginal ultrasound. This examination allows your health care professional to look at the thickness of your endometrium and for any abnormalities such as polyps, fibroids or ovarian cysts to see how well an egg could implant in the uterine lining. Newer tests that infuse a mixture of saline and air (Femvue) can also determine whether the fallopian tubes are functioning properly. Additionally, an antral follicle count can be performed during the ultrasound to determine the quantity of eggs remaining in the ovary. This is one of the ""ovarian reserve tests" commonly performed.
  • Laparoscopy. During a laparoscopy, the surgeon inserts a thin telescope through a small incision below the belly button to view the outside of the uterus, ovaries and fallopian tubes. If the surgeon finds endometriosis or adhesions, he or she can remove them during the procedure. Laparoscopy is usually performed under general anesthesia.
  • Hysteroscopy. During a hysteroscopy, a small telescope is inserted into the uterus. Small fibroids, polyps or scar tissue that may be preventing implantation can then be removed.

Insurance coverage varies for these diagnostic procedures. While some plans may cover some tests and specialized treatments, most are far from comprehensive. Check your insurance coverage carefully so you understand what tests are covered during the diagnosis and treatment stages.

Treatment

) are medications frequently used for women who do not ovulate regularly. Women who ovulate early, before the egg is ready, can also use Gn-RH analogs. These medications work by acting on the pituitary gland to change when the body ovulates. They are usually injected or given with a nasal spray.

Because of their means of action, gonadotropins can be very successful in some patients.

These agents are much more apt to lead to multiple births because they stimulate the release of several eggs. Up to 30 percent of pregnancies that result from gonadotropins are multiples. Additionally, in rare situations, gonadotropins may cause severe and potentially life threatening medical complications, such as ovarian hyperstimulation syndrome (OHSS). Thus, they should only be prescribed by clinicians specifically trained in their use.

  • Other medications. These drugs include:
    • Leuprolide (Lupron) is a synthetic hormone that mimics gonadotropin releasing hormone (GnRH). Drugs like leuprolide are called GnRH agonists. Though these drugs mimic GnRH in action, their net effect is to suppress the release from the pituitary gland of both FSH and LH and therefore, ovulation. If given early in the cycle these drugs will cause a "flare" of pituitary gonadotropins. Long-term use of an agonist also cuts off estrogen production in the ovaries and prevents a woman from ovulating. These drugs can be used to treat endometriosis and uterine fibroids. In IVF, these drugs are used to prevent a woman from ovulating while she takes gonadotropins to stimulate egg maturation.
    • Ganirelix (Antagon) and cetrorelix (Cetrotide) are GnRH antagonists similar in structure to GNRH. These drugs differ from agonists like leuprolide in that they directly cut off the production of FSH and LH (in contrast to leuprolide, which overstimulates the pituitary gland so it eventually stops producing FSH and LH). Like leuprolide, the GnRH antagonists help prevent premature ovulation during IVF.
    • Metformin (Glucophage) is an insulin-sensitizing drug used to boost ovulation when insulin resistance is a known or suspected cause of infertility. Insulin resistance may contribute to the development of polycystic ovarian syndrome (PCOS). Metformin is sometimes used with clomiphene or FSH.
    • Bromocriptine (Parlodel) is a medicine used for women with ovulation problems resulting from high levels of prolactin, a hormone that causes milk production.

For women receiving donor eggs, a combination of two or three hormonal medications is used to manipulate the menstrual cycle. The goal is to keep the egg recipient on the same cycle as her egg donor so her uterine lining is prepared to support the embryo once it is ready for implantation. Leuprolide is used to suppress the menstrual cycle, and estrogen supplements are used to get the cycle in synch with the donor's cycle. Progesterone is usually used to prepare the uterus for implantation when the donor is ready for retrieval.

Fertility drugs may cause a variety of physical and emotional side effects. There was also some concern that they may increase the risk of ovarian cancer, but the most recent research shows this isn't the case. However, infertility itself is a risk factor for ovarian cancer, while having children and using oral contraceptives protects against ovarian cancer.

Intrauterine Insemination (IUI)

Intrauterine insemination (also called artificial insemination) is a procedure in which the woman is injected with specially prepared sperm. In some cases, the woman takes medications to stimulate ovulation before the IUI procedure. IUI is a treatment option for couples in which the male has mild male factor infertility or the woman has problems with her cervical mucus, or in cases of unexplained infertility.

Assisted Reproductive Technologies (ART)

Assisted reproductive technologies offer another step in infertility treatment. These include:

  • In vitro fertilization (IVF). During this procedure, the ovaries are stimulated with one or more fertility drugs so they produce multiple eggs. The developing eggs are then removed in a minor surgical procedure lasting only a few minutes; mild anesthesia is usually given.
  • Intracytoplasmic sperm injection (ICSI). ICSI is used when there are problems with sperm function or number or to improve chances of fertilization. With ICSI, an embryologist injects a single sperm directly into each egg. ICSI is a highly specialized procedure performed in conjunction with IVF.

    In IVF and ICSI, the eggs and sperm are then combined in a petri dish, which is placed in an incubator in specialized media to promote fertilization. After about 24 hours, the eggs are examined to see if they have been fertilized. If fertilization occurs, one or more embryos are transferred to the uterus during another procedure several days later or frozen for later use. According to the 2012 Assisted Reproductive Technology National Report from the U.S. Centers for Disease Control and Prevention (CDC), the success rate for IVF using fresh non-donor eggs or embryos is 40 percent of cycles for women under ages 35; 31 percent for women ages 35 to 37; 22 percent for women ages 38 to 40; 12 percent for women 41 to 42; 4 percent for women 43 to 44; and 2 percent for women over 44.
  • Donor egg. Donor eggs are an option for women who cannot produce eggs or for whom egg quality is an issue. Another woman donates her eggs to be used for an IVF procedure. A woman using a donor egg becomes the biological mother to the offspring, but she doesn't share the child's genetic makeup. However, if the male partner's sperm was used in the fertilization process, the child shares his genetic background. Each year, about 20,000 IVF cycles include the use of donor eggs. This procedure is most often recommended for women over 40 and for younger women with poor quality eggs.
  • Donor sperm. Tested, screened and quarantined donated sperm is available with many sperm banks. The sperm can be used for IVF or related procedures.
  • Gestational carrier. This is an option for women who cannot carry a pregnancy. A couple's egg and sperm, or embryo, are placed in another woman's uterus; she is known as the gestational carrier, who will carry the pregnancy and deliver the baby. However, she has no genetic relationship to the baby.
  • Assisted hatching. This procedure is sometimes done in addition to IVF. After the embryo forms but prior to its transfer to the uterus, a special solution or laser is used to thin or make a hole in the outer covering of the embryo (called the zona pellucida). This might improve implantation by helping the cells of the embryo emerge from the outer shell, or hatch. This method is usually suggested for women over the age of 40 who have failed one or more IVF attempts or to remove fragments of cells from the embryo, but its use is still considered controversial and benefits have not been proven.
  • Preimplantation genetic testing (PGT): With PGT, it's now possible to screen embryos created by IVF for genetic diseases or defects before implantation. The goal is to decrease the chances of miscarriages or births with genetic abnormalities or genetic diseases such as cystic fibrosis or Tay Sachs disease. There are two types of PGT: preimplantation genetic diagnosis (PGD) and preimplantation genetic screening (PGS). PGD is done when parents carry a genetic condition to determine whether that condition has been transmitted to the egg or embryo. PGS is done when parents have no known genetic abnormalities but want to screen for chromosomal abnormalities (aneuploidy) such as Down Syndrome.
  • Egg freezing. Another option is to freeze some of your eggs to help preserve your fertility. You may want to consider egg freezing if you will be undergoing radiation or chemotherapy for cancer treatment or if you want to store younger eggs for the future. Many fertility treatment centers now offer egg freezing. Ask your health care provider if egg freezing may be a good option for you.

If you decide to undergo fertility treatments and are choosing a treatment center, here are some questions you may want to ask:

  • What is your center's clinical pregnancy rate? You can look this up online at www.sart.org. Keep in mind that the success rates of an IVF center depend on many factors, and a comparison of clinic success rates may not be meaningful because patient characteristics and treatment approaches vary from clinic to clinic.
  • What exclusion criteria does your center use to select patients for in vitro fertilization?
  • What is the cancellation rate of patients my age? (Most fertility centers have a criteria that determines when they will cancel the IVF process before egg retrieval. For example, a center may cancel a cycle in which a woman produces too few follicles or follicles that are too small). Centers that have a very low cancellation rate may be highly selective in who they accept as patients.
  • How many embryos does your center routinely implant for IVF? (Centers that implant more than two or three may have good pregnancy rates, but they will also have more multiple pregnancy rates, which can be risky to mother and babies).
  • What are the center's success rates for different types of procedures, particularly those I might face? (Figures should represent live birth rates, not just pregnancies.)
  • Is the center still working with the same laboratory and specialists as when the statistics were generated?

To see a summary of ART success rates and reports from fertility clinics around the country, check the statistics reported by the Society for Assisted Reproductive Technologies SART at www.sart.org.

Prevention

Prevention

There is no way to prevent infertility because there are many factors that contribute to your ability to ovulate, conceive and carry a pregnancy to term. Likewise, your male partner also has numerous factors—natural and environmental—that can contribute to infertility. The condition is not exclusively a woman's problem. About one-third of infertility cases involve male factor problems alone, and approximately one-third involve problems with both partners.

For women, factors that could lead to infertility include:

  • Being very overweight or very thin, either of which can affect ovulation and fertility.
  • Chronic, debilitating diseases, such as unregulated diabetes, lupus or thyroid problems that can interfere with normal ovarian function. Also, some medications such as high-dose steroids can interrupt ovulation. If you have a chronic health condition, be sure to discuss it with your health care professional. Most women with chronic conditions can become pregnant, have a healthy pregnancy and deliver a healthy baby.
  • Polycystic ovarian syndrome (PCOS). Symptoms include irregular or infrequent periods, excessive facial hair and acne.
  • Surgeries on the cervix, abnormal Pap smears including cryosurgery or cone biopsy that can affect the function of the cervix.
  • Hormonal imbalances that cause abnormalities in your menstrual cycles.
  • Multiple miscarriages (two or more early pregnancy losses).
  • Environmental factors, such as cigarette smoking, alcohol consumption, illegal drugs and exposure to workplace hazards or toxins.
  • Medication including herbal or natural medication.
  • Age. Even if your fertility does not seem at risk now, remember that fertility declines with age. A healthy, fertile 30-year-old woman who has regular unprotected intercourse has about a 20 percent chance of conception during each menstrual cycle. Once she reaches age 40, the odds drop to 5 percent each cycle.
  • Sexually transmitted diseases (STDs), which occur at a rate of nearly 20 million cases each year in the United States. Some STDs don't cause symptoms at first but, if left untreated, can lead to pelvic inflammatory disease (PID)—an infection of the upper genital tract that may compromise fertility by scarring and blocking the fallopian tubes; it can also lead to an ectopic pregnancy. To reduce your risk of STDs, use latex condoms during sex, avoid having sex with multiple partners and see a health care professional if you have any unusual symptoms such as pain, fever or vaginal discharge. Also make sure your partner is treated if you do have an STD. The best way to avoid STDs is abstinence or monogamy.
  • Fallopian tube disease accounts for about 25 percent of infertility cases. If you are having trouble conceiving or are worried about your future fertility, consult with your health care professional. Make sure you disclose if you have ever had pelvic pain, unusual vaginal discharge, bleeding or fever; pelvic surgery for ruptured appendix, ectopic pregnancy or an ovarian cyst.
  • Endometriosis, a disease in which endometrial tissue is found outside of the uterus, typically on the ovaries, fallopian tubes bladder and bowel, occurs in reproductive age women. While the connection between endometriosis and infertility is not clearly understood, advanced-stage endometriosis makes it very difficult for the egg and sperm to reach each other. Treatment of early stage endometriosis doesn't seem to make a difference in pregnancy rates, but knowing you have it may influence your choice of reproductive technology. Be sure to report these symptoms to your health care professional: painful menstrual cramps that get worse over time, extremely heavy menstrual flow, diarrhea or painful bowel movements (especially around the time of your period) and painful sexual intercourse.

For men, a variety of factors can lead to infertility. Many researchers believe the causes of declining sperm count during this century are environmental, including pesticide and chemical exposure, drug use, radiation and pollution. Specific risks include:

  • Exposure to toxic substances or hazards on the job, such as lead, cadmium, mercury, ethylene oxide, vinyl chloride, radioactivity and X-rays
  • Cigarette or marijuana use
  • Heavy alcohol consumption
  • Prescription drugs for high blood pressure (calcium channel blockers), ulcers and psoriasis
  • Chronic exposure of the genitals to elevated temperatures as may occur in some occupations can diminish sperm counts. Occasional visits to the sauna or hot tub will have no effect, however. Though some men may prefer boxers over briefs, boxers aren't any better for sperm production.
  • Medical conditions, including hernia repair, undescended testicles, history of prostatitis or genital infection, and mumps after puberty
  • Some STDs can lead to epididymitis (inflammation of the duct that carries sperm). Ultimately, infertility can be a consequence of STDs. To decrease this risk, practice safe sex by using latex condoms. Also have any unusual symptoms checked out and treated early—and make sure both partners are treated simultaneously.

Infertility Research

Infertility research is robust. Recent efforts include:

  • Oocyte cryopreservation. This is now offered at many fertility centers to preserve a woman's fertility, either for medical or social reasons. Freezing eggs can be performed without having to first fertilize them. This means that patients at risk of becoming infertile from cancer treatments or aging can preserve some eggs to retain the possibility of reproduction even after their eggs would have been either destroyed by chemotherapy or depleted due to aging.
  • Ovarian tissue cryopreservation. This can be performed before chemotherapy or radiation treatments for cancer patients who do not have time to undergo an IVF cycle and freeze eggs. While some babies have been born as a result of this tissue being replaced back into the body, it is still considered experimental.
  • Genetics and male factor infertility. The more we learn about the origins of male fertility problems, the more we find they have a genetic origin. Understanding the genetic errors that lead to poor semen quality and sperm production can lead to better management of these conditions.
  • Embryo selection methods. These have been improving with the goal of being able to one day select the single embryo to transfer that will have the greatest probability of developing, thereby reducing the risk of multiple pregnancy. The latest advancement is development of the Embryoscope, an incubator that maintains the necessary conditions required to support a living embryo in the IVF lab. A special camera captures time-lapse images of an embryo's development and records them in a video.

Facts to Know

Facts to Know

  1. Infertility affects 6.7 million American women and their partners—about 12 percent of couples of reproductive age.

  2. Disorders of both the male and female reproductive systems cause infertility with almost equal frequency.

  3. Some infertile couples have more than one factor contributing to their infertility.

  4. Recent improvements in medication, microsurgery and in vitro fertilization (IVF) techniques make pregnancy possible for about half of couples pursuing treatment.

  5. Fallopian tube blockage or disease accounts for approximately 25 percent of all female infertility problems.

  6. Irregular or abnormal ovulation accounts for approximately 25 percent of all female infertility cases.

  7. Up to 30 percent of couples who have a complete fertility assessment are diagnosed with unexplained infertility because no specific cause is identified.

  8. The number of babies born each year as the result of assisted reproductive technology is growing. The CDC's most recent assisted reproductive technologies (ART) annual report stated that 67,996 babies were born as a result of assisted reproductive technologies in 2013, up 2,836 from 2012.

Questions to Ask

Questions to Ask

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

  1. Are you board certified? Are you an ob/gyn? Are you trained in reproductive endocrinology and infertility?

  2. How long should my partner and I try to get pregnant before seeing a specialist?

  3. At what time of month am I most fertile?

  4. How can I tell when I'm ovulating?

  5. Should my partner be evaluated?

  6. What kinds of tests will you perform?

  7. How much will these tests and treatments cost?

  8. What is the likelihood that the treatment you're recommending will result in pregnancy? What is the likelihood that an alternative option will result in pregnancy?

  9. What is the next step if the treatment fails?

  10. What other treatments should we consider?

  11. What are the risks (short and long-term) of the treatment you are prescribing? What is the risk of multiples and how do we limit this risk?

  12. I need to talk to someone about my feelings and my partner's feelings about infertility. Is there a support group or a counselor you can refer us to?

Key Q&A

Key Q&A

  1. I've been taking birth control pills for 10 years. Will that affect my ability to become pregnant when I'm ready?

    The birth control pill itself doesn't affect long-term fertility. In the short term, a small number of women will have a delay after stopping the pill until they start ovulating again. This is more likely if the woman is either under- or overweight or engages in heavy aerobic exercise. For most women, ovulation resumes about two weeks after the last pill is taken. There is no need to wait to try to get pregnant after pill use. The common recommendation to wait three months has no scientific basis.

    Depo-Provera is an injectable form of hormonal contraception. One injection provides protection against pregnancy for up to four months. But its effects on fertility can last up to two years. This is not a rapidly reversible contraceptive and shouldn't be used by women who wish to get pregnant within one year.

  2. I've had chlamydia and was wondering if this sexually transmitted disease affects my fertility?

    Chlamydia is one of the most common STDs in the United States. This STD frequently has no symptoms, especially in women. According to the CDC, only 5 to 30 percent of infected women experience symptoms. If left untreated, chlamydia can lead to pelvic inflammatory disease (PID), which can cause scarring of the fallopian tubes and eventually infertility. Infection without any symptoms can persist for years without detection. It is important for women to be screened for chlamydia through blood testing or cervical DNA testing.

    Chlamydia can be treated with oral antibiotics, though chronic infections may require a longer than typical treatment period. Acute infections with chlamydia can be treated with intravenous (IV) antibiotics. Despite proper treatment, ectopic pregnancy is more common in patients with a history of an STD.

    Other sexually transmitted diseases (STDs) can also affect fertility and, if you get pregnant, affect the health of a baby. Women who have had a history of STDs or known exposure to infection should discuss this issue with their health care professional to determine how fertility may be affected. Screening for STDs is a good idea at any time, but especially if you're considering getting pregnant. Remember, a Pap test is not a test for STDs. Ask your health care professional specifically for an STD screen.

  3. My husband and I are ready to have a family. What can we do to ensure a healthy pregnancy?

    When planning a pregnancy, couples should begin by pursuing a healthful lifestyle. Eliminating cigarettes, alcohol and other recreational drugs, and increasing your focus on good nutrition, stress reduction and moderate exercise are the first steps to achieving a healthy pregnancy. Talk with your health care professional about your plans.

  4. Are hot tubs really bad for men?

    Not if the exposure is limited to a few minutes daily or less. Still, high temperatures can decrease sperm production. That's why the scrotum is located outside the body—sperm production occurs at 95 degrees, cooler than normal body temperature. Thus, it's a good idea for a man to avoid prolonged exposure to hot tubs, saunas and steam rooms when a couple is trying to become pregnant.

  5. What's the most common cause of female infertility?

    Anovulation, when a woman fails to ovulate. Other causes include blocked fallopian tubes, which can occur when a woman has had pelvic inflammatory disease or endometriosis (a condition causing adhesions and cysts). Congenital anomalies (birth defects involving the structure of the uterus) and uterine fibroids are associated with repeated miscarriages.

  6. What is IVF and how much does it cost?

    In vitro fertilization (IVF) is used when a woman has blocked or absent fallopian tubes or when a man has a low sperm count or for other causes of infertility not responding to conventional treatment. In IVF, drugs are given to stimulate multiple eggs to develop, and then eggs are removed from the ovary and mixed with sperm outside the body in a petri dish. After about 24 hours, the eggs are examined to see if they've been fertilized and are growing. After an additional one to four days, some of these fertilized eggs (embryos) are then placed in the woman's uterus. According to the American Society for Reproductive Medicine, the average cost of an IVF treatment in the United States is about $12,400.

  7. When is a donor egg used?

    Donor eggs are an option for women who cannot produce eggs or who have problems with the quality of their eggs. A woman using a donor egg becomes the biological mother to the baby, but she doesn't share the child's genetic makeup. However, if the male partner's sperm was used in the fertilization process, the child shares his genetic background. Approximately 20,000 IVF procedures per year involve use of donor eggs.

  8. I have lupus and was wondering if that means I won't ever be able to conceive?

    Chronic, debilitating diseases, such as unregulated diabetes, lupus or thyroid problems, can interfere with normal ovarian function. Also, some medications such as high-dose steroids can interrupt ovulation. On the other hand, if you don't get pregnant, your chronic condition may not be the cause; many other things can affect fertility. Optimizing your health by treating your condition is critical before you conceive a pregnancy. Discuss your condition with your health care professional so that he or she can work with you to determine the real cause of your infertility—and don't assume anything!

Organizations and Support

Organizations and Support

For information and support on coping with Infertility, 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 Fertility Association (The AFA)
Website: http://www.theafa.org
Address: 305 Madison Avenue, Suite 449
New York, NY 10165
Hotline: 1-888-917-3777
Email: info@theafa.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

American Society of Andrology
Website: http://www.andrologysociety.com
Address: 1100 E. Woodfield Road, Suite 520
Schaumburg, IL 60173
Phone: 847-619-4909
Email: info@andrologysociety.com

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 Research on Reproduction and Women's Health
Website: http://www.med.upenn.edu/crrwh
Address: 1355 Biomedical Research Building II/III
University of Pennsylvania Medical Center, 421 Curie Blvd.
Philadelphia, PA 19104
Phone: 215-898-0147

Center for the Evaluation of Risks to Human Reproduction
Website: http://cerhr.niehs.nih.gov
Address: NIEHS EC-32
P.O. Box 12233
Research Triangle Park, NC 27709
Phone: 919-541-3455
Email: cerhr@niehs.nih.gov

International Council on Infertility Information Dissemination
Website: http://www.inciid.org
Address: P.O. Box 6836
Arlington, VA 22206
Phone: 703-379-9178
Email: INCIIDinfo@inciid.org

International Premature Ovarian Failure Association
Website: http://www.pofsupport.org
Address: P.O. Box 23643
Alexandria, VA 22304
Phone: 703-913-4787
Email: info@pofsupport.org

Medivizor
Website: https://medivizor.com

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

Organization of Parents through Surrogacy
Website: http://www.opts.com
Address: P.O. Box 611
Gurnee, IL 60031
Phone: 847-782-0224
Email: bzager@msn.com

Resolve: The National Infertility Association
Website: http://www.resolve.org
Address: 1760 Old Meadow Rd., Suite 500
McLean, VA 22102
Phone: 703-556-7172

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

Complete Fertility Organizer
by Manya DeLeon Miller

Complete Guide to Fertility
by Sandra Ann Carson, Peter R. Casson, Deborah J. Shuman, and American Society for Reproductive Medicine

Expecting Miracles: On the Path of Hope From Infertility to Parenthood
by Christo Zouves

Getting Pregnant and Staying Pregnant: Overcoming Infertility and Managing Your High-Risk Pregnancy
by Diana Raab and M.D. Hal C. Danzer

Getting Pregnant Naturally: Healthy Choices to Boost Your Chances of Conceiving Without Fertility Drugs
by Winifred Conkling

Inconceivable: Winning the Fertility Game
by Julia Indichova

Rewinding Your Biological Clock: Motherhood Late in Life
by Richard J. Paulson and Judith Sachs

The Fertility Guide: A Couples Handbook for When You Want to Have a Baby (More Than Anything Else)
by John C. Jarrett and Deidra T. Rausch

Unofficial Guide to Overcoming Infertility
by Joan Liebmann

Whole Person Fertility Program: A Revolutionary Mind-Body Process to Help You Conceive
by Niravi B. Payne

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

University of Maryland Medical Center: Infertility Overview
Website: http://www.umm.edu/pregnancy_spanish/000094.htm
Address: University of Maryland Medical Center
22 S. Greene St.
Baltimore, MD 21201
Hotline: 1-800-492-5538
Phone: 410-328-8667

Last date updated: 
Mon, 2016-01-18

What is it?

Overview

What Is It?
A hysterectomy is a common surgical procedure that removes a woman's uterus. Hysterectomies are performed to treat various medical conditions including uterine fibroids, abnormal uterine bleeding, pelvic prolapse and several kinds of cancer.

A hysterectomy, or surgery to remove the uterus, is the second most common major surgery among women in the United States, second only to cesarean section. About one-third of American women will have a hysterectomy by the time they are 60.

Why Is a Hysterectomy Performed?

Several medical conditions can be treated or cured with a hysterectomy. Of the approximately 600,000 hysterectomies each year in the United States, about one-third are performed to treat uterine fibroids. Hysterectomies are also performed to treat endometriosis and to stop abnormal uterine bleeding, although alternative, less invasive treatments for these conditions now are available. Other reasons to have a hysterectomy include:

  • endometrial hyperplasia with atypia, an overgrowth of the uterine lining in which uterine cells contain precancerous changes
  • cancer of the uterus, ovaries, fallopian tubes or cervix
  • pelvic prolapse, in which the ligaments that support pelvic structures like the uterus weaken and the organs drop
  • uterine fibroids, when other, less invasive treatments have not provided relief. (Myomectomy, removal of just the fibroids, is a less invasive surgical option for fibroid removal.)
  • colon or bladder cancer that has spread to the uterus
  • uncontrollable bleeding after childbirth (rarely)

Pros and Cons of a Hysterectomy

For some women, a hysterectomy is the answer to years of suffering from uterine problems. For others, hysterectomy is a last resort to treat cancer or another life-threatening condition.

Unless you have a severe pelvic infection, cancer or uncontrollable bleeding, there is usually no reason to rush into the decision. Because most hysterectomies are elective procedures (as opposed to emergencies), there is usually plenty of time to explore all options.

Diagnosis

Diagnosis

A hysterectomy may be recommended as treatment for a variety of gynecologic conditions. However, in most cases, a hysterectomy is the most invasive option and only one of various treatments that may be available to you. Like any major surgery or treatment, it should be considered carefully, and you should understand why it's being recommended and the risks and benefits associated with it.

There has been much concern in recent years that too many unnecessary hysterectomies are performed. To decide if a hysterectomy is the right procedure for you, consider getting a second opinion. Most insurance companies will cover the cost. You may want to ask your primary care doctor for a referral to another doctor. Seeking the advice of another health care professional could reveal options you may not have considered.

Below is a list of conditions that often are treated with a hysterectomy; benefits and risks of other treatment options are also included.

Abnormal Uterine Bleeding (AUB)

Many women with abnormal uterine bleeding (AUB) have a hysterectomy, but this approach may be more aggressive than necessary. Abnormal uterine bleeding, or menorrhagia, refers to menstrual periods that are abnormally heavy, prolonged or both or may refer to bleeding between periods. In general, AUB is diagnosed when abnormal bleeding interferes with daily activities and there is no evidence of a physical cause (like cancer or endometriosis).

Abnormal uterine bleeding is a common problem for women between ages 40 and 50 when hormone levels begin to change in the five to seven years before menopause—when menstrual periods end forever.

Here are several alternatives to hysterectomy as a treatment option for AUB:

  • Endometrial ablation. This minimally invasive surgery uses electrical energy, heat, a balloon or freezing to destroy the endometrium, or uterine lining. It can minimize or stop heavy bleeding, but should only be considered in women who are certain they no longer wish to ever become pregnant.

    Success rates of endometrial ablation vary depending on the specific procedure used and the patient, but success rates for the following three to five years are generally quite high.

    Risks of endometrial ablation are rare. They include:

    • perforation of the uterus

    • injury to other pelvic organs

    • bleeding

    • infection

    • overloading of fluid into the bloodstream

    • accumulation of blood within the uterus because of scarring.

  • Hormonal treatments. Abnormal uterine bleeding can also be treated with hormonal treatments, like oral contraceptives (estrogen and progestin) that help to balance your body's hormones. Natazia, which contains the synthetic estrogen estradiol valerate, is the first birth control pill FDA-approved for treatment of heavy menstrual bleeding that is not caused by a condition of the uterus. The combination estrogen-progesterone pill may help women who choose oral contraceptives for contraception and do not have risk factors that may make using hormonal birth control inadvisable.

  • Progesterone IUD. Mirena, an intrauterine device that contains the progesterone levonorgestrel, helps decrease heavy bleeding for some women by slowly releasing progestin into the uterus for up to five years.

Uterine or Endometrial Cancer

Uterine (endometrial) cancer is the most common reproductive cancer in women. Hysterectomy, together with some form of cancer therapy, may be the only treatment choice you have. Your chances of curing this cancer are usually good if it's diagnosed in its early stages—when the cancer is confined to the uterus and hasn't spread to other organs.

The type of treatment recommended depends on when the cancer is diagnosed. Hysterectomy is the most common treatment. It generally involves removing the uterus and cervix. This type of hysterectomy is called a total hysterectomy. (Details about other types of hysterectomy can be found in the Treatment section of this topic.) The surgeon may also remove pelvic lymph nodes to determine if the cancer has spread beyond the uterus.

Surgery may be preceded or followed by radiation therapy and, in some cases, chemotherapy.

Ovarian Cancer

Ovarian cancer is the fifth-leading cause of cancer death among women. It is the leading cause of death from gynecologic cancer because less than 20 percent of cases are diagnosed before the cancer has spread beyond the ovaries. If diagnosed and treated at an early stage, however, the five-year survival rate is up to 94 percent.

The initial treatment for ovarian cancer is surgery to remove the ovaries. A hysterectomy is often performed, too, depending on how far the disease has spread and a woman's age.

Fibroids

About one-third of hysterectomies are performed every year in the United States to treat fibroid tumors. Noncancerous balls of muscular tissue, fibroids can grow inside the uterus, on the surface of the uterus or in the muscular wall of the uterus. They can range in size from less than an inch in diameter to the size of a grapefruit. They don't always produce symptoms.

However, even small fibroids that bulge into the uterine cavity can cause heavy menstrual bleeding. Plus, these fibroids may affect fertility by interfering with an embryo's ability to attach to the uterus. Large fibroids might cause frequent urges to urinate; they can also cause heaviness and discomfort in the pelvic region.

If fibroids aren't causing any problems, however, you don't need treatment. Plus, because fibroids tend to shrink after menopause, women in their late 40s or early 50s with fibroid-related symptoms may opt to wait to see if symptoms go away with menopause.

Although hysterectomy permanently removes fibroids (because a hysterectomy removes your uterus), there are other options for treating fibroids. These include:

  • Hormone-suppressing drugs. Drugs called gonadotropin-releasing hormones (GnRH) agonists, such as leuprolide (Lupron), nafarelin nasal (Synarel) and goserelin (Zoladex) that are typically used to treat endometriosis, can also help shrink fibroids. Their effects, however, are usually temporary, and the fibroids may eventually grow back larger than before. GnRH agonists also produce side effects in some women, such as hot flashes, headaches, vaginal dryness, constipation and decreased sex drive.

  • Myomectomy. This procedure is one of the best options for treating fibroids if you want to preserve your fertility. During an abdominal myomectomy, fibroids are cut out of the uterus and removed through an incision in the abdomen, and the uterine muscle wall is reconstructed with sutures.

    If fibroids are located in the uterine cavity, they may be removed through the vagina without an abdominal incision in a procedure called hysteroscopic myomectomy. The technique involves the use of an instrument called a hysteroscopic resectoscope and is primarily useful for women with bleeding or fertility-related problems.

    They may also be removed laparoscopically, using a small telescope called a laparoscope. During this procedure, a few small cuts are made in your abdomen or pelvis, which allow the laparoscope and other small instruments to be slipped inside, thus enabling the surgeon to remove the fibroids without having to make a large incision.

    The benefit of a myomectomy is that it preserves the uterus and cervix so pregnancy is still possible. Myomectomy is also an option for women who wish to preserve their uterus for any reason.

    Also, it may take longer to recover from an abdominal myomectomy than from a vaginal or laparoscopic hysterectomy. Although the goal of myomectomy is to preserve your uterus and your ability to have children, the procedure may cause scarring in the uterus that could require you to have a cesarean with your next pregnancy.

  • Uterine artery embolization (UAE). In this minimally invasive procedure, a narrow, flexible tube called a catheter is passed through the femoral artery in the groin into the uterine artery. Once there, tiny plastic particles the size of grains of sand are slowly released into the blood vessels feeding the fibroid. The particles wedge in the vessels (but can't travel to other parts of the body), blocking blood flow to the tumor. Without a blood supply, the fibroids shrink.

    Fibroid embolization usually requires an overnight hospital stay. Most women return to normal activities within a week. Risks include moderate to severe pain and cramping in the first few hours after the procedure, and nausea, fever and infection. Rarely, a woman might enter menopause after embolization. A small percentage of women are readmitted to the hospital after the procedure for complications, some of whom require additional surgery.

Endometriosis

Endometriosis occurs when cells from the endometrium—or your uterine lining—grow outside the uterus and adhere to other parts inside your pelvis, such as the ovaries, bowel, fallopian tubes or bladder.

Hysterectomy is generally recommended for endometriosis only when the disease is severe.

Hormone-suppressing drugs used to treat fibroids are also considered effective for endometriosis since both conditions are affected by your body's production of estrogen. As with fibroids, benefits from these treatments may be temporary.

Aside from hysterectomy, surgical treatments for endometriosis include:

  • Electrocautery techniques, in which stray endometrial tissue is burned away

  • Excision, in which endometrial tissue is cut out

  • Laser vaporization, which uses the laser to destroy the affected tissue

These procedures can usually be done laparoscopically and are often used when preserving fertility is important. Endometriosis frequently recurs, but the addition of postsurgical medical therapy, such as birth control pills or GnRH agonists, such as leuprolide (Lupron) or danazol (Danocrine), for six months may increase the pain-free interval.

The only definitive treatment for endometriosis is removing the ovaries to reduce your body's production of estrogen, which triggers the growth of endometrial tissue.

Pelvic Prolapse

Pelvic prolapse (a term that describes when the uterus drops into the vaginal canal) occurs when the ligaments that support the pelvic organs fail.

This weakening can occur with age, estrogen deficiency, obesity or after multiple births. Once this pelvic support weakens, pelvic organs, including the uterus, bladder and rectum, may sag, resulting in pressure, rectal discomfort and problems with bladder and bowel control.

Losing weight, stopping smoking and avoiding constipation by getting plenty of liquids and fiber in your diet can sometimes help. Additionally, you can strengthen your pelvic muscles with Kegel exercises. To do these exercises, tighten and relax the muscles used to stop the flow of urine. This strengthens the vaginal canal and pelvic floor muscles, helping control urine flow and enhancing orgasm.

You may also be fitted with a pessary, a device placed in the vagina that holds the organs in place.

Another treatment is short-term hormone therapy to make the vaginal tissue suppler. Estrogen prevents drying and thinning of the vaginal tissues. Supplemental estrogen can help strengthen vaginal tissues. However, because of the potential risks of estrogen therapy, such as increased risk of blood clots, breast cancer and gallbladder disease, the decision to use estrogen must be made only after you and your doctor have weighed all the pros and cons.

Surgery can be an option when organs have prolapsed. Surgery may involve creating a sling for the bladder or using specialized surgical tape to keep the bladder or uterus in place, or removing the uterus, via hysterectomy.

Dysplasia

Removing the uterus and cervix was once standard practice for a common precancerous condition called dysplasia, or cervical intraepithelial neoplasia (CIN). Today, cutting, burning or freezing the diseased portion of the cervix is generally recommended for CIN, and hysterectomy is rarely performed for this condition.

Treatment depends on the severity and location of dysplasia, your age, health status and whether you want to preserve your ability to have children.

Treatment

Treatment

A hysterectomy is used to treat several conditions. If you decide to have a hysterectomy, you and your health care professional should discuss which type is most appropriate. There are three types:

  • Total hysterectomy. During this procedure, your uterus and cervix are removed. Your ovaries and fallopian tubes may or may not be removed at the same time. If your ovaries are not removed, you will continue to have menstrual cycle-related hormonal changes, but you won't have any bleeding.

    If your ovaries and fallopian tubes are also removed, called a bilateral salpingo-oophorectomy, you won't have monthly hormonal changes. Removing only the uterus can reduce the blood supply to the ovaries, ultimately decreasing their function, however, this only occurs about 10 percent of the time.

    The decision about removing the ovaries depends on a few factors, including how close you are to menopause, your current estrogen levels and your risk for some other diseases and conditions. Premenopausal women may opt to keep their ovaries to provide a natural source of the hormones estrogen, progesterone and testosterone, which are important for maintaining sexual interest and function and preventing menopausal symptoms like hot flashes and decreased bone density. On the other hand, some premenopausal women with severe PMS, menstrual migraines or other hormone-related conditions may experience an improvement in their symptoms by removing their ovaries.

    As far as disease risk is concerned, a study published in the January 2013 issue of Menopause reported that removing both ovaries during a hysterectomy is associated with a decreased risk of ovarian cancer but an increased risk of osteoporosis, problems with cognition and sexual function, and coronary artery disease. As such, women should review their individual risk factors and the pros and cons before making the decision of whether or not to remove their ovaries during a hysterectomy.

    Ask your health care professional to explain this information to you so you can better understand your surgical options and the best plan for you.

  • Subtotal, partial or supracervical hysterectomy. In this procedure, only the part of your uterus above the cervix is removed. There is a small risk that cancer could develop in the remaining part of the cervix, but routine Pap smears will detect pre-cancer in an easily treatable form. Nonetheless, there may be some benefits to leaving the cervix intact, including a reduced risk of vaginal prolapse (the vagina falling out), shorter recovery time and less postoperative pain. Some women note that leaving the cervix allows intercourse to remain pleasurable.

  • Radical hysterectomy. This type of hysterectomy is performed in some cases of cancer. During this procedure, your uterus, cervix, supporting ligaments and tissues, the upper portion of the vagina and the pelvic lymph nodes are removed. Cancer specialists usually perform this type of hysterectomy.

In addition to discussing which organs should be removed during a hysterectomy, you and your health care professional should discuss how the surgery will be performed. The surgical technique you choose should depend on your individual diagnosis, personal preference and your surgeon's training. They include:

  • Abdominal, or open, hysterectomy. This is the classic form of hysterectomy, involving an abdominal incision. This allows the surgeon to easily view the pelvic organs and provides more operating space than a vaginal hysterectomy. It is generally used for large fibroids or cancer.

    If you have this form of hysterectomy, expect a two- to three-day hospital stay and a six-week recuperation time. In most cases, your surgeon can make a "bikini line" incision that your bathing suit hides. Exceptions include cancer surgery or surgery to remove extremely large fibroids. Complete recovery from abdominal hysterectomy can take six to eight weeks, during which time you'll gradually feel your strength return and gradually be able to resume your normal activities.

  • Vaginal hysterectomy. In this procedure, the surgeon removes the uterus and the cervix through an incision in the vagina, so there's no large external scar. This form of hysterectomy is ideal when there is uterine prolapse and minimal uterine enlargement.

    Vaginal hysterectomy can be performed in two ways: entirely through the vagina or using a laparoscope, a small, telescope-like device inserted into the abdomen through a small incision, enabling the surgeon to visualize the pelvic region, also called a laparoscopic-assisted vaginal hysterectomy. Laparoscopically assisted vaginal hysterectomy (LAVH) may be used if standard vaginal hysterectomy would be difficult or if the surgeon wishes to better visualize the ovaries or other pelvic organs during surgery. During this procedure, the uterus is removed through the vagina.

    Vaginal hysterectomy and abdominal hysterectomy each take between one and two hours and are performed under regional (epidural or spinal) or general anesthesia. One study found that women who had vaginal hysterectomies had significantly fewer complications than those having abdominal hysterectomies. Additionally, the women had shorter hospital stays and returned to their normal activities quicker than the women who had abdominal hysterectomies.

    Women with large ovarian cysts, a serious case of endometriosis or large fibroids may not be candidates for vaginal hysterectomy.

  • Laparoscopic supracervical hysterectomy (LSH). This newer type of hysterectomy also uses laparoscopic techniques to remove the uterus but leaves the cervix intact; in the past, some studies suggested leaving the cervix might help reduce the complications associated with total hysterectomies, such as pelvic prolapse and urinary incontinence. However, the most recent research shows there is no compelling reason to leave the cervix if it can be easily removed along with the uterus. Hospital stay is usually no more than one night, and recovery takes about two weeks.

  • Computer-assisted (robotic) surgery. Robotic-assisted laparoscopic hysterectomy is similar to a laparoscopic hysterectomy, but the surgeon conducts the operation from outside the body, using a robotic system of surgical tools. This equipment allows the surgeon to view the hysterectomy on a three-dimensional screen and use wrist movements to control the procedure. Hospital stay is usually one night or less, and full recovery can take up to two to four weeks. Robotic surgery is more expensive, takes longer and has more visible incisions than laparoscopic surgery.

Possible Complications

While discussing hysterectomy techniques with your health care provider, you should also talk about possible complications. Rarely, women who undergo a hysterectomy experience complications from surgery, most of which are minor or reversible. Possible complications include:

  • fever and infection following surgery

  • urinary tract infection or injury

  • if your ovaries are removed, menopausal symptoms, such as hot flashes, night sweats and vaginal dryness,

  • constipation

  • depression or other emotional problems

  • pain or discomfort during intercourse

  • loss of sexual pleasure or interest in sex

More serious, but rarer, complications may include:

  • hemorrhage requiring transfusion

  • injury to the bowel, bladder or other internal organs during surgery, requiring repair

  • bowel blockage

  • life-threatening cardiopulmonary events such as a heart attack

If your ovaries are removed, you may experience a sudden drop in hormone levels, which may produce menopausal symptoms such as hot flashes, night sweats and dizziness. Postmenopausal estrogen therapy (ET), taken soon after surgery, may offset menopausal symptoms. Although the FDA now requires a warning on all estrogen products for use by postmenopausal women advising health care professionals to prescribe estrogen products at the lowest dose and for the shortest possible length of time, estrogen therapy may still be recommended after surgery to remove the ovaries.

Prevention

Prevention

There likely isn't anything you can do or could have done to prevent the conditions for which you are considering a hysterectomy, but there is a lot you can do to prepare for this surgery. Fortunately, few hysterectomies are emergencies, so there usually is plenty of time to prepare.

First, be sure this treatment option is right for you.

A hysterectomy may be the only course of treatment for some conditions, such as cancer of the uterus, for example. But other treatment options may be available. Be sure you are comfortable with your health care professional's recommendation. If you want a second opinion, ask what you should do to get one.

These suggestions may help you prepare and recover from your surgery more easily:

  • Plan the surgery two or three months ahead of time.

  • Review the surgery and recovery needs with your physician. Be sure you understand why and how the surgery is being done. Ask questions if you're not sure.

  • Be sure sure you know what to expect after surgery. How long will recovery take? What type of activities will you be able to do and not do?

  • Review family and/or work schedules to determine what timing may work best.

  • Ask for (and accept) help from friends and family with your routine; then, schedule it. This might include help with children's schedules, cooking, pets or household chores, for example.

Facts to Know

Facts to Know

  1. Many alternatives to hysterectomy now exist including hormonal therapy, the progesterone IUD, endometrial ablation, laparoscopic excision of endometriosis, myomectomy by hysteroscopy, laparoscopy or abdominal incision and uterine artery embolization.

  2. About one-third of American women will have a hysterectomy by age 60. The United States has one of the highest hysterectomy rates in the world. Many of these procedures may be unnecessary. Hysterectomy rates are higher for African-American women.

  3. A hysterectomy is often performed to stop abnormal uterine bleeding. It may also be recommended to treat fibroids that cause symptoms that aren't successfully managed by other treatment options.

  4. A considerable number of hysterectomies are performed to correct symptoms of endometriosis. Endometriosis occurs when endometrial tissue, which forms the lining of the uterus, grows in other parts of the body, causing scar tissue and subsequent pain.

  5. Some hysterectomies are performed to treat abnormal uterine bleeding (AUB), or menstrual bleeding excessive enough to disrupt a woman's life. Abnormal uterine bleeding may be caused by structural problems in the uterus (fibroids, for example), certain medical conditions or hormonal imbalances.

  6. Some women elect to undergo hysterectomy to correct pelvic prolapse, which occurs when the ligaments that support a woman's pelvic organs weaken and lose their supportive ability.

  7. Hysterectomies can be done several ways: A total or complete hysterectomy removes the uterus, including the cervix. A subtotal, partial or supracervical hysterectomy removes the uterus above the cervix. A radical hysterectomy, performed for certain cancers of the reproductive organs, removes the uterus, cervix, supporting ligaments and tissues, the upper portion of the vagina and the pelvic lymph nodes.

  8. Developments in laparoscopic procedures have added two more surgical options. In laparoscopically assisted vaginal hysterectomy, a surgeon inserts a laparoscope (small telescope) through a woman's belly button to view the entire pelvis. Parts of the hysterectomy are performed through other small incisions in the abdomen, but most will be completed through the vagina. In a laparoscopic hysterectomy, the entire procedure is performed through laparoscopic incisions in the abdomen.

  9. Depending on the type of hysterectomy you have, you may need to stay in the hospital for a few days. Although normal activities may be resumed gradually, a woman may not be fully recovered until four to six weeks or longer following surgery, depending on the surgical approach used.

  10. Some women's health centers and hospitals offer support groups or social workers to emotionally support hysterectomy patients. Ask your health care professional for a referral.

Questions to Ask

Questions to Ask

The following Questions to Ask may help you talk with your surgeon or health care professional:

  1. What kinds of problems are treated with a hysterectomy?

  2. What are all the methods available to treat this problem?

  3. Why are you recommending one medical or surgical approach over others to treat my condition?

  4. What is the worst that can happen if I decide not to follow this recommendation?

  5. If I need a hysterectomy, what surgical approach is most appropriate for me?

  6. What changes should I anticipate following surgery?

  7. What resources can you recommend to help me learn more about hysterectomy, as well as other treatment options?

  8. How many times have you performed my procedure? How many complications have you had in cases like mine and what were they?

  9. What's the success rate for this procedure, and how is success measured?

  10. Can I talk to other patients who had this same procedure? (Although patient information is confidential, your health care professional may know women who have indicated an interest in helping others.)

  11. If my ovaries are removed, would I be a candidate for postmenopausal hormone therapy? What are the risks and benefits of hormone therapy in my case?

Key Q&A

Key Q&A

  1. What are the medical reasons for a hysterectomy?

    Hysterectomy often is recommended for abnormal uterine bleeding and for treating cancer of the ovaries, uterus or fallopian tube. Hysterectomy can relieve chronic abdominal pain and fibroids, endometriosis and certain other disorders, including pelvic prolapse. In rare instances, hysterectomy may be recommended for colon, rectum or bladder cancers that have spread to the reproductive organs, as well as invasive cervical cancer.

  2. How is a hysterectomy performed?

    The uterus may be removed through either an incision in the abdomen or through an incision in the vagina. Abdominal hysterectomies are usually performed for cancer or large fibroids. Vaginal hysterectomies are usually performed when the uterus is small or when close inspection of other reproductive organs is not necessary. Laparoscopic hysterectomy (LH) occurs through a tiny incision in the abdomen using an instrument with a small camera on the end. Laparoscopically assisted vaginal hysterectomy (LAVH) is performed through the vagina, with the assistance of the laparoscope. A laparoscopic supracervical hysterectomy (LSH) leaves the cervix intact.

  3. Are the ovaries always removed during a hysterectomy?

    No. When one or both ovaries are removed (in a procedure called oophorectomy), it's usually because one or both organs are diseased or because the woman is past menopause and wishes to eliminate the risk of ovarian or breast cancer. In premenopausal women, bilateral oophorectomy produces "surgical menopause." Menopausal symptoms, such as hot flashes, vaginal dryness, insomnia and night sweats can occur suddenly and be more severe compared with natural menopause symptoms. Beginning hormone therapy (HT) soon after oophorectomy can reduce or alleviate these symptoms. Removal of the ovaries may increase long-term health risks. Discuss the risks and benefits associated with hormone therapy with your health care professional.

  4. How long does it take to recover from surgery?

    Although normal activities may be resumed gradually, full recovery generally takes two to four weeks following laparoscopic or vaginal hysterectomy and four to six weeks following abdominal hysterectomy. Fatigue following any of these procedures may last weeks longer.

  5. What are the possible complications from these surgeries?

    Hysterectomy is not without its risks; some women who undergo the procedure experience complications. Most of these problems are minor or reversible. They can include:

    • fever and infection following surgery

    • urinary tract infection or discomfort

    • menopausal symptoms, such as hot flashes, night sweats and vaginal dryness

    • constipation

    • depression or other emotional problems

    • pain or discomfort during intercourse

    • loss of sexual pleasure or interest in sex

    More serious, but rarer, complications may include:

    • hemorrhage requiring transfusion

    • injury to the bowel, bladder or other internal organs during surgery, requiring repair

    • bowel obstruction

    • life-threatening cardiopulmonary events such as a heart attack

  6. What are the emotional aspects of hysterectomy?

    Emotional responses vary, based on the woman's life experiences, medical and mental health history and her level of support from family and friends.

    These feelings can include:

    • a sense of loss of the uterus or ovaries and of reproductive function (menstruation and fertility)

    • sadness, anger, depression or anxiety in response to loss

    • a diminished sense of femininity, attractiveness or self-worth

    • anxiety about sexual functioning

  7. Will I be able to resume normal sexual activity after a hysterectomy?

    Ask your health care professional when you may begin sexual activity after surgery. Because your vagina may be shorter after a total hysterectomy, you and your partner may want to experiment with different positions to find one that is comfortable. Foreplay may enable the vagina to lengthen before intercourse.

Lifestyle Tips

Lifestyle Tips

  1. Determine your need for Pap tests

    If your cervix was removed along with your uterus for a noncancerous condition, and you do not have a history of cervical cancer or serious pre-cancer, you won't need a Pap test anymore, according to the American Cancer Society. If you've had a hysterectomy and your cervix was left intact, then routine Pap tests should be continued. Ask your health care professional for guidance.

  2. Resume your sex life

    Your sex life may improve after your hysterectomy, especially if the surgery was performed because of pelvic pain or discomfort. A landmark two-year study conducted at the University of Maryland Medical Center in 1999 involving interviews with about 1,300 women who had hysterectomies found that the percentage of women who engaged in sexual relations increased significantly and rates of painful sex dropped. Researchers also found women had higher rates of sexual activity and more frequent orgasms following hysterectomy.

  3. Pace your recovery

    Traditional hysterectomy through a large abdominal incision requires about four to six weeks for recovery, and recovery from vaginal hysterectomy takes about two to four weeks. Overall, recovery could be between two and eight weeks. With less invasive approaches, such as vaginal hysterectomy, laparoscopically assisted vaginal hysterectomy (LAVH) and laparoscopic supracervical hysterectomy (LSH), recovery time is shorter. Potential, yet relatively uncommon, side effects of hysterectomy include incontinence, pelvic pain, pelvic prolapse, constipation and sexual dysfunction. Some hysterectomy patients feel fatigued for several weeks or months following surgery.

  4. Seek help with depression

    Another potential side effect is depressive-like symptoms or other mental health problems, but there is no known physiological link between hysterectomy and psychological side effects. Depression may occur because the procedure ends a woman's ability to become pregnant, marking a life-stage transition that may be traumatic. Discuss your feelings and any fears about hysterectomy with your family and friends, and consider talking to a mental health professional if you experience emotional difficulties before or after surgery.

Organizations and Support

Organizations and Support

For information and support on Hysterectomy, 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

Hysterectomy Educational Resources and Services (HERS) Foundation
Website: http://www.hersfoundation.org
Address: 422 Bryn Mawr Avenue
Bala Cynwyd, PA 19004
Hotline: 1-888-750-HERS (1-888-750-4377)
Phone: 610-667-7757
Email: hersfdn@earthlink.net

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

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

Coping With Endometriosis
by Robert H. Phillips, Glenda Motta

Dr. Susan Love's Menopause and Hormone Book
by Susan M. Love, Karen Lindsey

Health, Happiness & Hormones: One Woman's Journey Towards Health after a Hysterectomy
by Arlene Swaney

Hysterectomy: Before and After: A Comprehensive Guide to Preventing, Preparing for, and Maximizing Health
by Winnifred Berg Cutler

Just as Much a Woman: Your Personal Guide to Hysterectomy and Beyond
by Nancy Rosenfeld, Dianna W. Bolen

Official Patient's Sourcebook on Endometrial Cancer
by Icon Health Publications

The Woman's Guide to Hysterectomy: Expectations & Options
by Adelaide Haas, Susan L. Puretz

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

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

Beth Israel Deaconess Medical Center: A Teaching Hospital of Harvard Medical School
Website: http://www.bidmc.org/YourHealth/MedicalProcedures.aspx?ChunkID=103903
Address: Beth Israel Deaconess Medical Center
330 Brookline Ave
Boston, MA 02215
Phone: 617-667-7000

Last date updated: 
Wed, 2016-02-10

What is it?

Overview

What Is It?
Human papillomavirus (HPV) is a virus that often causes no symptoms but can cause cervical cancer.

Chances are you have been exposed to the human papillomavirus (HPV) and didn't even know it. In fact, it is estimated that at least 50 percent of the reproductive-age population has been infected with one or more types of genital HPV, and an estimated 6 million new infections occur each year. As many as 20 million Americans are infected with the genital form of the virus.

The good news: In the vast majority of cases, the virus causes no symptoms or health problems and will go away on its own when a healthy immune system clears the infection. The bad news: A persistent infection with high-risk strains of HPV occurs in about 5 percent of women and causes nearly all cases of cervical cancer, which the American Cancer Society estimates affected an estimated 12,170 women in 2012, killing about 4,220.

HPV can also lead to anal cancer in both men and women, a cancer that affects about 4,430 women and 2,630 men per year and causes 550 deaths in women and 330 in men. Other health problems can result from HPV infection as well, including: genital warts; recurrent respiratory papillomatosis (RRP), a rare condition where warts grow in the throat; and other less common but potentially serious cancers, including cancer of the vulva, vagina and penis, and oropharyngeal cancer, a type of head and neck cancer that affects the back of the throat, base of the tongue and the tonsils.

In many ways, the issues raised by infection with high-risk strains of HPV are similar to those raised by genital herpes. Both often have no symptoms; both can cause medical problems in some women; and both have become widespread in this country. Like herpes, persistent HPV is incurable, though some forms of HPV disappear, and it is not yet known whether they completely go away or merely enter a dormant stage, like herpes. Unlike herpes, however, HPV can cause cancer.

There are more than 150 strains of HPV and at least 40 HPV types that can infect the genital and anal areas. The HPV family of viruses is called papillomavirus because they tend to cause warts, or papillomas—benign (noncancerous) tumors. Warts may appear on the hands and feet or on the genital and anal areas. The strains of HPV that cause warts to grow on hands and feet, however, are rarely the same type that causes warts in the genital and anal areas.

The U.S. Food and Drug Administration (FDA) has approved two HPV vaccines, called Gardasil and Ceravix, which can protect women against the HPV types that cause most cervical cancers. Gardasil also protects women against vaginal and vulvar cancers and protects both men and women against most genital warts and anal cancers. (See Prevention section for more information.)

In addition to the HPV vaccine, the Pap test and the HPV test are important screening tests to prevent cervical cancer in women. When combined with a Pap test in women age 30 and older, the HPV test is better at identifying women at risk for developing cervical cancer than the Pap test alone. (See Diagnosis section for more information.) There is no FDA-approved HPV screening test for men.

Because of early detection and treatment of cell changes, the number of invasive cervical cancer cases and deaths in the United States has steadily decreased over the past several decades. The cervical cancer death rate declined by 74 percent between 1955 and 1992, and the incidence of cervical cancer dropped significantly by 2.3 percent per year between 1999 and 2008.

Conversely, the number of new anal cancer cases has been increasing for a number of years, with most cases occurring in adults, with the average age being in the early 60s. Anal cancer affects women more often than men.

How is HPV spread?

HPV is spread by skin-to-skin contact with an HPV-infected area. Infections can be subclinical, meaning the virus lives in the skin without causing symptoms. This is why many people with HPV do not know they have it or that they could spread it. For a person exposed to a partner who has a low-risk genital wart-causing strain of HPV such as HPV 6 or 11, it usually takes about six weeks to three months for genital warts to appear. However, infections with high-risk strains of HPV cause no symptoms and can only be detected on Pap or HPV tests.

Researchers already know that condoms don't always protect against the virus because the virus can grow on areas of the genitals not covered by a latex barrier.

Researchers don't know whether people infected with genital HPV but who don't have symptoms are as contagious as people with symptoms. They also don't know how much HPV is transmitted through sexual contact versus skin-to-skin contact.

Diagnosis

Diagnosis

Because human papillomavirus (HPV) infections often cause no symptoms in men or women and are hard to identify, you must rely on your health care professional for diagnosis.

Genital warts can be flesh-colored and hidden inside the cervix, vagina, penis, scrotum or anus. They can be small or large, alone or in clusters, flat or round. They can spread along the groin or thigh or be found in the mouth.

Genital warts come in two forms—growths that can be seen with the naked eye and are on the surface of the skin and smaller, less visible growths called squamous intraepithelial lesions (SILs) that cover the cervix and require a special instrument, called a colposcope, to see.

Studies find that specific HPV types are responsible for the development of genital warts, previously known as "condyloma acuminata." Each HPV type has been numbered and divided into "high risk" or "low risk" categories depending on whether the virus is associated with the development of cancer.

For example, HPV types 6 and 11, which are usually associated with genital warts, are considered "low risk." HPV types 16, 18, 31, 33 and 45, found on the genitals and in the anus, have been linked to most HPV-related cancers in both men and women and are therefore considered "high risk."

If you notice warts, see your health care professional. You should also seek an examination if:

  • You see any unusual growths, bumps or skin changes on or near the penis, vagina, vulva or anus.

  • You experience unusual itching, pain or bleeding in the genital or anal area.

  • You have a sexual partner who tells you that he or she has genital HPV or genital warts.

During your examination, your health care professional may use a colposcope, a lighted magnifying lens, to find small warts or abnormal areas. Your health care professional may also apply a vinegar solution to the genitals, which causes abnormal tissue to turn white. This doesn't hurt, but it does make it easier to see warts or precancerous lesions.

You may also have a Pap test, which was designed to identify cervical cancer in its earliest stage but can also find abnormal precancerous cells and active HPV infections.

The Pap test is a simple procedure. In the Pap test, a health care professional uses a special brush and/or spatula to collect cells from the cervix and places them on a glass slide or in a liquid preservative, which is sent to a laboratory for evaluation.

There is also an anal Pap test that is much like the Pap test for cervical cancer. It involves swabbing the anal lining and looking at the swabbed cells under a microscope. The anal Pap test is relatively new and hasn't been studied well enough to determine when, how often and on whom it should be performed or if it actually reduces risk of anal cancer. Some experts recommend it be done regularly in men who have sex with men.

There are different classifications for abnormal results for the cervical Pap test, but the most common is called atypical squamous cells of undetermined significance (ASCUS).

In conjunction with the Pap test, which screens for abnormal cells once cell changes have taken place, there are also tests that look specifically for HPV. These tests can detect HPV infection early on, before cell changes have occurred. The most common test looks for DNA from several high-risk types of HPV, but it doesn't indentify which types are present. Another test looks specifically for DNA from HPV types 16 and 18, the HPV types that cause most cancers associated with HPV. A third test can detect DNA from several high-risk HPV types and can distinguish whether HPV-16 or HPV-18 is present, and a fourth test looks for RNA from the most common types of high-risk HPV.

At this point, these HPV tests are FDA-approved for two indications only—for follow-up testing for women whose Pap tests reveal abnormal cells and for cervical cancer screening in combination with a Pap test in women over age 30.

There are currently no recommended screenings or FDA-approved tests that detect HPV infection in men, but research is continuing.

Along with medical history and evaluation of other risk factors, the HPV test helps physicians determine what follow-up might be necessary if there is an abnormal result from a Pap test.

Pap Test Screening Guidelines

The American Cancer Society (ACS), the American College of Obstetricians and Gynecologists (ACOG) and the U.S. Preventive Services Task Force recommend the following guidelines for Pap tests and early detection of cervical cancer:

  • All women should begin screening at age 21.

  • Women ages 21 to 29 should have a Pap test no more than once every three years to five 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 recommend the two tests together every five years; the USPSTF recommends either schedule. The organizations agree that a Pap test alone once every three years is acceptable if HPV testing is not available.)

  • 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.

If your health care professional identifies any unusual cell changes, he or she will recommend a plan of action, depending on the result and your health history. That may include a waiting period, a repeat Pap test, a DNA-based HPV test, a colposcopy or a more thorough examination and biopsy of the abnormal area. If the Pap reveals ASCUS and the HPV test is positive, a colposcopy will be required. 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. Mild dysplasia (CIN 1) should not be treated, but the Pap will be repeated in six to 12 months. For CIN 2 or CIN 3, further treatment is needed to remove the abnormal cells.

Regular Pap tests are equally important for lesbians and bisexual women who, studies find, may be less likely to seek routine health care because of the discomfort they feel discussing or revealing their sexual orientation to health care professionals. They also may not want to be screened because they feel that they are not at risk. Lesbian and bisexual women are also at risk for HPV infection and cervical cancer (for example, through prior male partners, vibrators and other sexual aids or skin-to-skin contact with an infected partner).

Treatment

Treatment

There is no cure for HPV, but there are treatments for genital warts. In addition, young women may be vaccinated against four common strains of HPV, as well as the types that cause most HPV-related cervical cancers. (See Prevention section for details.) For women over 26, the best defense against HPV is to learn as much as possible about the disease to try to minimize your risk. Using condoms, limiting your number of sexual contacts and continuing to have regular Pap tests are important steps to reducing risk.

Most people with HPV infections don't require treatment. Your body's immune system simply gets rid of the virus on its own. Only a small portion of women develop problems, ranging from warts to cervical cancer, that require treatment.

Most genital warts are treated because you may not like the way they look or because of symptoms—not because treatment prevents them from reforming or from you transmitting the infection to someone else. In fact, genital wart recurrence is common, especially within the first three months. Studies also find that small warts of short duration (less than one year) respond better to therapy than large warts of long duration. All wart treatments may cause mild local irritation.

Experts reviewing current genital wart treatment practices find that no single treatment is ideal for all women. They recommend that you be involved in making any treatment decisions with your health care professional. So it's important that you understand your options.

You may not even need treatment. There is no treatment available for subclinical genital HPV infection (i.e., no visible warts diagnosed by colposcopy, biopsy, acetic acid application or HPV laboratory tests). That's because there's no certain way to diagnosis subclinical genital HPV infection and no effective therapy. The infection with these low-risk strains will eventually go away on its own.

In the past, treatments for genital warts were administered by health care professionals and often caused more damage than the disease itself. Traditional treatments ranged from cryotherapy, which froze the warts with liquid nitrogen, to electrocautery, which burned off the warts. Today, there are a wide variety of treatments that can be administered by you or your health care professional.

The goal of treatment should be to remove visible genital warts and relieve annoying symptoms. No available treatment is any better than another, and no single treatment is ideal for all cases. Thus, the CDC has developed the following guidelines:

Self-applied treatments:

  • Podofilox (Condylox). This 0.5 or 0.15 percent solution or gel is a relatively cheap, safe, easy-to-use treatment. It is applied directly to the warts every day for three weeks or twice a day for three days, followed by four days of no therapy, for a total of three to four weeks. Warts may return after treatment.

  • Imiquimod (Aldara). This 5 percent cream is used to treat external genital warts and perianal warts, which appear around the anus. It is safe, effective and easy to use. The cream works by stimulating the immune system to target the warts. Apply three times a week at bedtime for up to 16 weeks. Warts may recur after treatment.

  • Sinecatechin (Veregen). This is a 5 percent ointment made from a green tea extract. The active ingredients in sinecatechin are components in green tea called catechins. Apply the ointment three times a day until the warts disappear.

People tolerate these three therapies differently, so podofilox may work better for you while imiquimod or sinecatechin works better for someone else. Discuss with your doctor which therapy you should try. Side effects of all three drugs may include tenderness, irritation and localized burning. None has been deemed safe to use during pregnancy.

Treatments applied by health care professionals:

  • Cryotherapy (freezing off the wart with liquid nitrogen). This treatment is relatively inexpensive. It is usually performed without an anesthesia, and you may experience some discomfort. You may require several treatments a week for up to six weeks to remove all warts.

  • Podophyllin resin 10 percent to 25 percent. This solution is applied once a week, typically for up to four weeks and must be washed off within one to four hours after application to reduce local irritation. It is more likely to cause side effects than the less-toxic, over-the-counter podofilox. There's no evidence that it's safe for use during pregnancy.

  • Trichloracetic acid (TCA) (10-25 percent) or bichloracetic acid (BCA) (80-90 percent). These are two other chemicals that are applied to the surface of the wart once a week for up to four consecutive weeks. These chemicals are stronger forms of the over-the-counter acids used to remove external warts. Because the procedure can be painful, most health care professionals use a topical anesthetic.

  • Laser therapy (using an intense light to destroy the warts) or surgery (cutting off the warts) gets rid of warts in a single office visit. However, treatment can be expensive and the health care provider must be well trained in these methods. A local or general anesthetic may be used. If not performed correctly, laser therapy can cause burning and scarring.

Because HPV is a virus, your immune system plays a role in whether your warts return or not. The virus travels to a deeper level of tissue where it can remain indefinitely. You should watch for recurrences, which occur most frequently during the first three months after treatment.

Eating a balanced diet, exercising regularly and avoiding illegal drugs, tobacco and alcohol are simple ways to help maintain a strong immune system.

Prevention

Prevention

At least 50 percent of sexually active adults by the time they reach age 50 will have acquired an infection with one of the genital HPV strains at some point.

The U.S. Food and Drug Administration (FDA) has approved two HPV vaccines, called Gardasil and Ceravix, which can protect women against the HPV types that cause most cervical cancers. Gardasil also protects against most strains of genital warts, as well as anal, vaginal and vulvar cancers. Vaccination should be given before an infection occurs, ideally, before a girl becomes sexually active. The vaccines are given in three doses, and it is important for females to get all three doses for the best protection. Either vaccine is recommended for girls ages 11 and 12, as well as for females ages 13 to 26 who did not receive any or all of the shots when they were younger. The vaccines can also be given to girls as young as age nine.

Gardasil also protects males against most genital warts and anal cancers. Therefore, it is recommended for 11- and 12-year-old boys and males ages 13 through 26 who did not get any or all of the shots when they were younger.

It's important to note that vaccination doesn't protect against all HPV strains. Therefore, continued lifelong screening with Pap tests and the HPV test if appropriate is necessary. The vaccines are not effective for a particular strain of the virus if a woman is already infected with this HPV type. For this reason, vaccinating before a woman is sexually active and exposed to the virus is optimal to provide the greatest protection.

Women age 30 and older who test positive for HPV are more likely to have a persistent infection that was not cleared by the immune system. And only women with persistent infections with HPV are at risk for developing cellular changes that can lead to cervical cancer. Therefore, when combined with a Pap test in women 30 and older, the HPV test is better at identifying women at risk for developing cervical cancer than the Pap test alone. In addition, four tests have been approved by the FDA to look for high-risk strains of HPV. (See Diagnosis section for guidelines on Pap tests and HPV tests.)

Health experts advise women to use one or more of the following options to reduce contact with the virus, which is transmitted via skin-to-skin contact:

  • Use condoms whenever you are intimate with a new or casual sexual partner. Latex condoms, when used correctly and consistently from start to finish each time you have sex, can provide some protection if they cover the area of HPV infection. 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.

  • Be aware that spermicidal foams, creams or jellies are not effective against any sexually transmitted disease (STD), including HPV. The FDA has advised consumers that using vaginal contraceptives containing nonoxynol-9 can increase vaginal irritation, which may increase the risk of infection.

  • If you're having oral sex, use a dental dam, plastic wrap or a split and flattened unlubricated condom. These materials provide a moisture barrier between the mouth and the vagina or anus during oral sex. Avoid brushing or flossing your teeth right before having oral sex, which may tear the lining of your mouth, increasing your exposure to viruses.

  • Be careful about sharing sexual toys. It's possible that HPV could be transmitted via sexual toys that are inserted in the vagina but aren't thoroughly cleaned before being used on your partner.

Facts to Know

Facts to Know

  1. If you have HPV, you are not alone. It is estimated that as many as 50 percent of the reproductive-age population has been infected with one or more types of sexually transmitted human papillomavirus (HPV), and an estimated 6 million new infections occur each year.

  2. Most HPV infections have no symptoms and are hard to identify. Warts are caused by low-risk strains of the virus and can be flesh-colored and hidden inside the cervix, vagina or anus. They can be small or large, alone or in clusters, flat or round. They can spread along the groin or thigh or be found in the mouth. High- risk cancer-causing strains of HPV cause no symptoms and are detected by an abnormal Pap test or the HPV test.

  3. HPV infection is a direct cause of cervical cancer. Cervical cancer was once one of the most common causes of cancer death for American women but is now one of the most preventable, with fatality rates dropping because of early detection and treatment.

  4. In addition to cervical cancer, other health problems can result from HPV infection as well, including recurrent respiratory papillomatosis (RRP), a rare condition where warts grow in the throat, and other less common but potentially serious cancers, including cancer of the vulva, vagina, anus and penis, and oropharyngeal cancer, a type of head and neck cancer that affects the back of the throat, base of the tongue and the tonsils.

  5. In the vast majority of cases, the body's immune system clears the infection within two years. Because the virus travels to lower-level tissues where it may remain indefinitely, researchers don't know if the virus is completely eliminated or just suppressed to such a low level that it's hard to detect with routine screening. However, women who test negative for the high-risk strains of HPV using the HPV test have almost no chance of developing serious cell changes in the near future. This can provide tremendous peace of mind.

  6. Women who are 30 and older who have persistent HPV infection are more likely to have the cancer-causing, or high-risk, types of HPV, and if they test positive for HPV two times in a row, will require further testing even if their Pap test is normal.

  7. In conjunction with the Pap test, the HPV test can be used in women age 30 and older to help detect HPV infection. 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.

  8. It is important that you work with your health care professional to determine which HPV treatment (whether for low-risk HPV causing genital warts or for high-risk HPV causing dysplasia) is most appropriate for you.

  9. Because HPV is so common, and it is impossible to determine when someone was infected, notifying a partner of a prior HPV infection is not considered mandatory. A patient with an active infection with genital warts, however, should use protection and notify a partner, who may choose to forego sex because the condom isn't completely protective, and the genital wart virus is highly infectious.

  10. Genital warts are uncommon in children. When they occur, they are most often the result of sexual abuse.

Questions to Ask

Questions to Ask

Review the following Questions to Ask about human papillomavirus (HPV) so you're prepared to discuss this important health issue with your health care professional:

  1. How can I tell whether or not I have HPV? How does it affect my risk for developing cervical cancer and other diseases?

  2. Am I a good candidate for the HPV test?

  3. What procedures can you do if I have an abnormal Pap test? Does that mean I have cancer? Which follow-up tests should I have?

  4. Please explain the treatment you recommend. Given the wide variety of treatment options available, why is one better for me than the others?

  5. How much will each treatment cost, and how many treatments will it take to permanently remove my warts?

  6. What are the side effects of this treatment?

  7. What should I do if my symptoms or treatments become painful?

  8. Can I have sex during the treatment period?

  9. If I'm pregnant, or plan to get pregnant, how will HPV affect me and my baby?

Key Q&A

Key Q&A

  1. How can I tell if I'm infected with human papillomavirus (HPV) if I don't have genital warts?

    If you or your partner do not have warts, it is virtually impossible for you to determine whether you have HPV. An estimated 20 million Americans are infected with the virus, but many people are unaware they have it.

    Occasionally, people may notice itching or skin changes, but more often HPV is a silent infection. For this reason, women are strongly encouraged to see their health care professional for regular pelvic examinations and Pap tests. Men should also see their health care professional to learn as much as possible about this disease.

    Because HPV can be a predictor of the presence or future development of cervical cancer, many medical professionals now also test for the virus as an adjunct to the Pap test. There are now four tests available that look for high-risk HPV types that can lead to cervical cancer. These tests can detect HPV infection early on, before cell changes have occurred.

  2. Can I get HPV from someone performing oral sex on me?

    Yes. HPV is spread by skin-to-skin contact, primarily during sexual relations, even if a wart is not visible. HPV infections are most commonly found in the genital area, anus and mouth. An increasing number of oral and tonsillar cancers are caused by high-risk strains of HPV thought to be related to an increase in oral sex.

  3. If I have a wart removed, will it come back?

    Because HPV is a virus, your immune system plays a role in whether your warts recur. In some cases they do return; however, in the majority of cases, the infection clears within two years. However, because the virus hides in lower-level tissue, it is impossible to know if the virus is completely eliminated or just suppressed to such a low level that it's hard to detect.

  4. If I use a condom, can I still get (or spread) HPV?

    Yes. Unfortunately, condoms do not provide complete protection against HPV because they do not cover all the possible infection sites, which include the genital area, anus and mouth. This does not mean you should not use them. While condoms are not foolproof, they provide the best available protection, especially for those who have several sexual partners. Studies have shown that condoms do reduce the risk of HPV infections but are not completely protective.

  5. If I have HPV, does that mean I am at risk for other sexually transmitted infections or cervical cancer?

    Yes. Having HPV increases the likelihood that a woman may have other sexually transmitted diseases or cervical cancer. Although only certain types of HPV cause cervical cancer, it is important that women of all ages have a regular gynecologic exam and all the recommended screening tests including testing for other STDs including chlamydia, gonorrhea and HIV, if necessary. Talk with your health care professional about how often you should be tested.

  6. How does HPV affect my fertility?

    HPV is not like other sexually transmitted diseases (such as chlamydia) that can affect your fertility. Of greater concern is that a high-risk HPV strain can lead to cervical cancer. In addition, certain HPV treatments may cause scarring or damage the cervix (such as LEEP or cone biopsy), which may impair fertility or impact a pregnancy (such as increased risk of premature delivery), so it is important to discuss the options with your health care professional.

  7. What is the best treatment for HPV?

    This will depend on whether you have strains that cause genital warts or dysplasia. There is no one treatment that all HPV patients should receive. Each case is different, and you should work with your health care professional to choose the one that best fits your needs. A wide variety of treatments have been developed for treating genital warts. In most cases, treatment will require repeat applications.

  8. If my partner is diagnosed with HPV, does that mean he or she has cheated on me?

    HPV is a group of more than 150 viruses, 40 of which can infect the genital area. HPV can take weeks, months or years to produce symptoms (if they appear at all). If your partner is diagnosed with HPV, it does not automatically mean there has been recent infidelity. The most important thing you and your partner can do is to learn as much as possible about this disease. It is estimated that as many as 75 percent of reproductive-age men and women have been infected with one or more types of HPV at some point, and most don't know it because not all viruses produce warts. Furthermore, the immune system naturally fights off the virus and evidence of the virus goes away in one to two years.

Lifestyle Tips

Lifestyle Tips

  1. Understand testing for human papillomavirus (HPV) infection

    HPV infections are very common and your immune system spontaneously clears most infections. Therefore, even if you have HPV, your risk of developing cervical cancer is extremely low. It's important, however, to have regular Pap test screenings according to guidelines established by the American Cancer Society. It recommends all women begin getting Pap tests at age 21 and be screened every three years. Starting at age 30, women may opt to stretch out screenings to every five years if they get both a Pap test and an HPV test. Women may stop screenings at age 65 if they've had regular screenings and are not at high risk for cervical cancer.

    Think of screening for HPV in much the same way you'd screen for cholesterol or other health risk factors: you want to determine what your risks are for having or developing the disease. For women with minor abnormalities on their Pap test, doctors use the HPV test to determine if they have a high-risk HPV infection and need further workup such as a colposcopy. Those who are not infected with high-risk strains of HPV need only regular Pap tests.

    For women 30 and older, the advantage of being screened with the HPV test in conjunction with their Pap test is that those women who are negative on both tests have a very low risk for persistent HPV infection or cervical cancer and probably don't need to be screened again for five years. In addition, four high-risk HPV tests have been approved by the FDA to screen for the HPV types most strongly associated with cervical cancer—HPV 16 and HPV 18. Ask your doctor about using one of these tests along with the Pap test.

  2. Take precautions for oral sex

    Most sexually transmitted infections, including HPV, can be spread via oral sex. To protect yourself, make sure your partner uses a condom if you're performing oral sex; if he's performing oral sex on you, or if you're having oral sex with a woman, use a dental dam, a flat piece of latex used during dental procedures, available in some medical supply stores. They provide a barrier between the mouth and the vagina or anus during oral sex. Household plastic wrap or a split and flattened, unlubricated condom can also be used. Also, don't brush or floss your teeth right before having oral sex. Either may tear the lining of your mouth, increasing your exposure to viruses.

  3. Practice the best protection

    The best protection against any type of sexually transmitted infection besides abstinence is a latex condom. However, it doesn't provide 100 percent protection against sexually transmitted diseases.

    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. 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.

  4. Get tested for STDs

    No one test screens for all sexually transmitted diseases. Some require a vaginal exam and Pap test; others a blood or urine test. And just because you have a negative test doesn't mean you don't have the disease. Chlamydia, for instance, may travel far up into your reproductive tract, so your doctor is unable to obtain an accurate culture. Or your body may not yet have developed enough antibodies to a virus like HIV to turn up in a blood test.

    Still, it's important to ask your health care provider to regularly test you for sexually transmitted diseases if you're sexually active in a relationship in which you or your partner is also sexually active with others.

    You can also get tested at your health department, community clinic or Planned Parenthood. Or call the CDC at 1-800-CDC-INFO (800-232-4636) for information on free or low-cost clinics in your area.

  5. Know whether you have an STD

    While some sexually transmitted diseases may have symptoms such as sores, ulcers or discharge, most have no symptoms. You can't always tell if you or a partner has an infection just by looking. So don't rely on a partner's self-reporting and assume that will prevent you from acquiring a sexually transmitted disease; many infected persons do not know they have a problem.

    Even if you have symptoms, they may be caused by something else, such as yeast infections, friction from sexual relations or allergies. 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 nurse practitioner or other health care professional 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.

Organizations and Support

Organizations and Support

For information and support on coping with HPV, 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 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 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 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 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 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

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

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

CDC - Human Papillomavirus
Website: http://www.cdc.gov/std/Spanish/STDFact-HPV-s.htm
Address: 1600 Clifton Road
Atlanta, GA 30333
Hotline: 1-888-246-2857
Phone: 404-639-3311

American Academy of Family Physicians
Website: http://familydoctor.org/online/famdoces/home/common/sexinfections/sti/389.html
Email: http://familydoctor.org/online/famdoces/home/about/contact.html

Last date updated: 
Thu, 2013-04-04

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 noncancerous masses of muscular tissue and collagen that can develop within the wall of the uterus. They are the most common benign tumor in premenopausal women. By the time women are 50 years old, 80 percent will have fibroids, but only 20 percent of women with fibroids will have any symptoms.

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.

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.

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 about 40 percent of fibroids increase in size with pregnancy.

At menopause, fibroids shrink because estrogen and progesterone levels decline. Using menopausal hormone therapy containing estrogen after menopause usually does not cause fibroids to grow. Growth of a fibroid after menopause is a reason to see your gynecologist to make sure nothing else is causing the growth.

Progesterone and growth hormone 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 may 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 heavy menstrual bleeding with associated bad menstrual cramps and infertility.
  • Subserosal fibroids grow from the uterine wall to the outside of the uterus. They can push on the bladder or bowel 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 extremely rarely 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 heavy menstrual bleeding—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 not be able to empty your bladder because the fibroid is in the way or you may get recurrent urinary tract infections.
  • Reproductive problems. Fibroids also are associated with reproductive problems, depending on the number of fibroids present in the uterus and on their size and specific location. While having fibroids can cause complications with pregnancy, most do not have any impact. Fibroids in a uterus do not create a high-risk pregnancy. The risks from fibroids may include a higher risk of miscarriage, infertility, premature labor and labor complications.

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 four ways:

  • Magnetic resonance imaging (MRI). MRI uses a magnet (not x-ray) to make an image of the uterus. It is the most accurate way to determine the positions, sizes and number of fibroids you have.
  • 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.
  • Saline-infused sonography. 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.
  • 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 if you are trying to get pregnant to check if your tubes are open, but it is not very accurate when looking for fibroids..

Imaging tests, such as computed tomography (CT), may also be ordered but is not very accurate for the diagnosis of fibroids.

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, to rule out other conditions.

Treatment

Treatment

If you aren't experiencing symptoms caused by your fibroids, you usually do 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. The need for repeat treatments ranges from 10 percent to 25 percent, depending on the number and sizes of the fibroids initially treated. No treatment—except hysterectomy—can guarantee that new fibroids won't grow. The more fibroids you have, the more likely you are to have a recurrence 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. OCs do not make fibroids grow.

  • 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. Rare 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 procedure that involves placing a small catheter (a thin tube) into an artery in the groin 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. This technique is used to treat small fibroids within the uterus or heavy periods 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 few small incisions to insert an operative camera and surgical instruments. 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 recommend 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 cavity. 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.

    Blood loss may be slightly greater with a myomectomy than with hysterectomy, but surgeons use tourniquets and medications to control blood loss, so that transfusion rates are no greater than with hysterectomy.

  • Magnetic resonance guided focused ultrasound. A more recent fibroid treatment option, magnetic resonance guided focused ultrasound surgery (MRgFUS or FUS) is a noninvasive treatment that takes place inside an MRI machine. The machine guides the treatment, which consists of multiple waves of ultrasound energy that go through the abdominal wall and destroy the fibroid. The procedure requires sedation but is usually performed on an outpatient basis. In the weeks and months that follow, fibroids shrink and heavy menstrual flow decreases. Pregnancy isn't recommended after FUS, but it is possible to become pregnant following the procedure.

  • Radiofrequency ablation. Acessa is a new FDA-approved laparoscopic surgical procedure that uses radiofrequency energy to destroy fibroids. The energy heats the fibroid tissue and kills the cells, which are then reabsorbed by the lymphatic system, decreasing fibroid size and symptoms. The procedure is minimally invasive, performed under ultrasound guidance during an outpatient pelvic laparoscopy. The early results regarding the safety and effectiveness of Acessa are good. On average, women returned to normal activities in nine days. The long-term risk of fibroid recurrence has not yet been determined, though a 12-month follow-up in one study showed good results.

  • 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 not cancerous and they do not turn into cancer. 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. Up to 80 percent of women have fibroids, but not all of these women have symptoms. They are most commonly found in women in their 40s and early 50s.

    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. Fibroids usually grow slowly during the reproductive years, but may increase in size with pregnancy. At menopause, fibroids usually shrink, because estrogen and progesterone levels decline. Estrogen replacement therapy may rarely 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, depending on the number of fibroids in the uterus and their size and specific location. While fibroids can cause complications with pregnancy, most do not have any impact. Fibroids in a uterus do not create a high-risk pregnancy. The risk from fibroids may include a higher risk of miscarriage, infertility, premature labor and labor complications.

    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, magnetic resonance imagery (MRI), hysteroscopy, saline-infused sonography 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, and MRI is the most accurate.

    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 or shrunk, there is no guarantee that new fibroids won't develop. There are newer surgical procedures, such as myomectomy, robotic myomectomy, magnetic resonance guided focused ultrasound surgery, and radiofrequency ablation (Acessa procedure), that are showing success in treating fibroids while sometimes preserving fertility. Your health care professional will recommend which procedure is best for you.

    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, 2016-02-23

    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 the National Institutes of Health.

    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 only 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 (usually two to 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, the American Congress of Obstetricians and Gynecologists (ACOG), the North American Menopause Society (NAMS), and several other professional organizations say menopausal hormone therapy should not be used for primary or secondary prevention of coronary heart disease because there's not enough evidence to show long-term estrogen therapy or hormone replacement therapy improves cardiovascular outcome. However, ACOG and NAMS say women in early menopause who are in good cardiovascular health may consider estrogen plus progestin for their menopausal symptoms. Talk to your health care professional about your individual risks.

    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.

    In addition, 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 alone 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.

    Estratest. 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 (systemic). 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 an FDA-approved bio-identical estradiol in a transdermal gel; Estrasorb is a transdermal estradiol lotion.

    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 is a plant-derived, synthetic conjugated estrogen product in tablet form.

    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), and dienestrol (Ortho dienestrol).

    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?

      According to the American Cancer Society, taking estrogen alone is not linked to a higher risk of breast cancer. In fact, in certain groups of women, such as those with no family history of breast cancer or no personal history of benign breast disease, estrogen may lead to a slightly lower risk of breast cancer.

      The story is a little different for women taking a combination of estrogen and progestin, however. The Women's Health Initiative found taking estrogen and progestin replacement therapy was linked to a higher risk of breast cancer. Specifically, for every 10,000 women who took estrogen and progestin hormone replacement therapy each year, there were eight more cases of breast cancers than there were in women who hadn’t taken the hormones. And the longer a woman took estrogen and progestin replacement, the higher her risk. However, this risk drops within three years of stopping the hormones but remains slightly elevated compared to women who never used combination hormone therapy. The ACS also reports breast cancers in women taking estrogen and progestin replacement therapy tend to be larger and possibly more advanced once they are found.

      HT can also increase breast density and make mammograms less reliable.
    6. How does estrogen affect cardiovascular health?

      ACOG and NAMS say menopausal hormone therapy should not be used for the primary or secondary prevention of heart disease because there isn't enough evidence to show long-term estrogen or estrogen plus progestin therapy improves cardiovascular outcomes. However, ACOG says women in early menopause who are in good cardiovascular health may consider estrogen plus progestin for menopausal symptoms. Talk to your doctor about your individual risk.

    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: 
    Tue, 2015-07-28

    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 structures, most commonly in the pelvis, such as on the ovaries, bowel, fallopian tubes or bladder. Rarely it implants in other places, such as the liver, lungs, diaphragm and surgical sites.

    It is a common cause of pelvic pain and infertility. It affects about 5 million women in the United States.

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

    The most common symptoms are painful menstrual periods and/or chronic 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.

    When endometriosis tissue grows outside of the uterus, it 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 essentially trapped.

    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."

    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.

    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 local 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 diagnose 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 occasionally suggest endometriosis, particularly ovarian endometriotic cysts called "endometrioma," or rule out other conditions, none can definitively confirm the condition.

    At this point, there is no established 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.

    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, and intrauterine 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.

      • Progestin-containing intrauterine device. Several studies have shown that an intrauterine device (IUD) containing a synthetic type of progesterone (progestin) can also reduce the painful symptoms and extent of disease associated with endometriosis. If effective, the IUD can be left in the uterus for three to five years and can be removed if a woman wants to conceive. There are currently three FDA-approved brands—Mirena, Skyla, and Liletta—and each has different characteristics; Mirena can be left in place the longest. It should not be used in women with multiple sexual partners, those with an abnormal uterus (fibroids) or those with prior sexually transmitted disease. Side effects include cramping and breakthrough bleeding.

      • Aromatase inhibitors. This class of drugs inhibits the actions of one of the enzymes that 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 electrical, ultrasound-generated or laser energy 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 has only been one comparative study of medical and surgical therapies to see which approach is better. This trial demonstrated improved outcomes with GnRH agonist and add-back therapy alone or after surgery in comparison to surgery alone. Each approach has advantages and disadvantages. Often, your plan of care will be a combination of treatments with medical therapy recommended either before or after surgery.

    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. Few if any alternative treatments have undergone rigorous scientific evaluation.

    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 about 5 percent of reproductive-age women.

    2. About 5 million women in the United States have been diagnosed with endometriosis.

    3. Endometriosis develops when cells similar to 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 recommend medical therapy after surgical therapy? If so, what therapies do you use?

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

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

    8. 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?

    9. 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?

    10. Does endometriosis affect my ability to have children?

    11. 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?

    12. 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, ultrasound energy, coagulation)?

    13. 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 and implants in various sites, most commonly in the pelvis. 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. Eliminate trans fats

      Some 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.

    2. 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.

    3. 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.

    4. 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.

    5. 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 plan ahead with 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: 
    Tue, 2016-01-19

    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?

    4. Do I need the HPV test?

    5. How will I be informed of the results?

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

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

    8. 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?

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

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

    11. 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?

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

    13. 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