Women’ s Health
Women’s Health

Cervicitis is inflammation of the uterine cervix. Cervicitis in women has many features in common with urethritis in men and many cases are caused by sexually transmitted infections.Non-infectious causes of cervicitis can include intrauterine devices, contraceptive diaphragm, and allergic reactions to spermicides or latex condoms. The condition is often confused with vaginismus which is a much simpler condition and easily rectified with simple exercises.
Vaginitis, also known as vaginal infection and vulvovaginitis, is an inflammation of the vagina and possible vulva.It can result in discharge, itching and pain,and is often associated with an irritation or infection of the vulva. It is usually due to infection. The three main kinds of vaginitis are bacterial vaginosis (BV), vaginal candidiasis, and trichomoniasis. A woman may have any combination of vaginal infections at one time. Testing for vaginal infections is not a part of routine pelvic exams. If there is discomfort in the vulvovaginal area, women can request their health care providers evaluate for the presence of an infection.
 A woman may have vaginal itching or burning and may notice a discharge.The discharge may be excessive in amounts or abnormal in color(such as yellow, gray, or green).The following symptoms may indicate the presence of infection:

    irritation and/or itching of the genital area

    inflammation (irritation, redness, and swelling caused by the presence of extra immune cells) of the labia majora, labia minora, or perineal area

    vaginal discharge

    foul vaginal odor

    pain/irritation with sexual intercourse
 
Diagnosis is typically suspected based on a women's symptoms. Diagnosis is made with microscopy (mostly by vaginal wet mount) and culture of the discharge after a careful history and physical examination have been completed. The color, consistency, acidity, and other characteristics of the discharge may be predictive of the causative agent.
 Human papillomavirus infection is an infection by human papillomavirus (HPV).Most HPV infections cause no symptoms and resolve spontaneously. In some, they persist and result in warts or precancerous lesions. The precancerous lesions increase the risk of cancer of the cervix, vulva, vagina, penis, anus, mouth, or throat. Nearly all cervical cancer is due to HPV with two types, HPV16 and HPV18, accounting for 70% of cases. Between 60 and 90% of the other cancers are also linked to HPV. HPV6 and HPV11 are common causes of genital warts and respiratory papillomatosis.
Menopause, also known as the climacteric, is the time in most women's lives when menstrual periods stop permanently, and they are no longer able to bear children. Menopause typically occurs between 49 and 52 years of age. In those who have had surgery to remove their uterus but they still have ovaries, menopause may be viewed to have occurred at the time of the surgery or when their hormone levels fell. Following the removal of the uterus, symptoms typically occur earlier, at an average of 45 years of age.
 Before menopause, a woman's periods typically become irregular, which means that periods may be longer or shorter in duration or be lighter or heavier in the amount of flow. During this time, women often experience hot flashes; these typically last from 30 seconds to ten minutes and may be associated with shivering, sweating, and reddening of the skin. Hot flashes often stop occurring after a year or two.Other symptoms may include vaginal dryness, trouble sleeping, and mood changes. 
Menopause is usually a natural change. At the physiological level, menopause happens because of a decrease in the ovaries' production of the hormones estrogen and progesterone. While typically not needed, a diagnosis of menopause can be confirmed by measuring hormone levels in the blood or urine. Menopause is the opposite of menarche, the time when a girl's periods start.
 
During the transition to menopause, menstrual patterns can show shorter cycling (by 2–7 days); longer cycles remain possible. There may be irregular bleeding (lighter, heavier, spotting). Dysfunctional uterine bleeding is often experienced by women approaching menopause due to the hormonal changes that accompany the menopause transition. Spotting or bleeding may simply be related to vaginal atrophy, a benign sore (polyp or lesion), or may be a functional endometrial response. 
Other physical symptoms of menopause include lack of energy, joint soreness, stiffness, back pain, breast enlargement, breast pain, heart palpitations, headache, dizziness, dry, itchy skin, thinning, tingling skin, weight gain, urinary incontinence,urinary urgency, interrupted sleeping patterns, heavy night sweats, hot flashes.Psychological symptoms include anxiety, poor memory,inability to concentrate,depressive mood, irritability, mood swings, less interest in sexual activity.
 
Long term effects of menopause are a possible but contentious increased risk of atherosclerosis, acute myocardial infarction and other cardiovascular diseases and an increased risk of osteopenia and osteoporosis.
 The term "postmenopausal" describes women who have not experienced any menstrual flow for a minimum of 12 months, assuming that they have a uterus and are not pregnant or lactating. In women without a uterus, menopause or postmenopause can be identified by a blood test showing a very high FSH level. Thus postmenopause the time in a woman's life that take place after her last period or, more accurately, after the point when her ovaries become inactive.
 
In post-menopausal women, however, any genital bleeding is an alarming symptom that requires an appropriate study to rule out the possibility of malignant diseases.Symptoms that may appear during menopause and continue through postmenopause include:

 painful intercourse

 vaginal dryness

 atrophic vaginitis — thinning of the membranes of the vulva, the vagina, the cervix, and the outer urinary tract, along with considerable shrinking and loss in elasticity of all of the outer and inner genital areas.
 
Menstrual disorders

Disorders of ovulation include oligoovulation and anovulation:
Oligoovulation is infrequent or irregular ovulation (usually defined as cycles of ≥36 days or <8 cycles a year).Anovulation is absence of ovulation when it would be normally expected (in a post-menarchal, premenopausal woman). Anovulation usually manifests itself as irregularity of menstrual periods, that is, unpredictable variability of intervals, duration, or bleeding. Anovulation can also cause cessation of periods (secondary amenorrhea) or excessive bleeding (dysfunctional uterine bleeding).
 
Disorders of cycle length

Polymenorrhea is the medical term for cycles with intervals of 21 days or fewer.
Irregular menstruation is where there is variation in menstrual cycle length of more than approximately eight days for a woman. The term metrorrhagia is often used for irregular menstruation that occurs between the expected menstrual periods.
 
Oligomenorrhea is the medical term for infrequent, often light menstrual periods (intervals exceeding 35 days).
Amenorrhea is the absence of a menstrual period in a woman of reproductive age. Physiologic states of amenorrhoea are seen during pregnancy and lactation (breastfeeding). Outside of the reproductive years there is absence of menses during childhood and after menopause.
 
Disorders of flow
Abnormal uterine bleeding is a general category that includes any bleeding from menstrual or nonmenstrual causes.
Hypomenorrhea is abnormally light menstrual periods. Menorrhagia (meno = month, rrhagia = excessive flow/discharge) is an abnormally heavy and prolonged menstrual period. Metrorrhagia is bleeding at irregular times, especially outside the expected intervals of the menstrual cycle. If there is excessive menstrual and uterine bleeding other than that caused by menstruation, menometrorrhagia (meno = prolonged, metro = uterine, rrhagia = excessive flow/discharge) may be diagnosed. Causes may be due to abnormal blood clotting, disruption of normal hormonal regulation of periods or disorders of the endometrial lining of the uterus. Depending upon the cause, it may be associated with abnormally painful periods.
 
Dysmenorrhea
Dysmenorrhea (or dysmenorrhoea), cramps or painful menstruation, involves menstrual periods that are accompanied by either sharp, intermittent pain or dull, aching pain, usually in the pelvis or lower abdomen.
Premenstrual syndrome (PMS) refers to physical and emotional symptoms that occur in the one to two weeks before a woman’s period. Symptoms often vary between women and resolve around the start of bleeding. Common symptoms include acne, tender breasts, bloating, feeling tired, irritability, and mood changes. Often symptoms are present for around six days. A woman’s pattern of symptoms may change over time. Symptoms do not occur during pregnancy or following menopause.
 
Diagnosis requires a consistent pattern of emotional and physical symptoms occurring after ovulation and before menstruation to a degree that interferes with normal life. Emotional symptoms must not be present during the initial part of the menstrual cycle. A daily list of symptoms over a few months may help in diagnosis. Other disorders that cause similar symptoms need to be excluded before a diagnosis is made.
 
More than 200 different symptoms have been associated with PMS. Common emotional and non-specific symptoms include stress, anxiety, difficulty with sleep, headache, feeling tired, mood swings, increased emotional sensitivity, and changes in interest in sex.
 
Physical symptoms associated with the menstrual cycle include bloating, lower back pain, abdominal cramps, constipation/diarrhea, swelling or tenderness in the breasts, cyclic acne, and joint or muscle pain, and food cravings. The exact symptoms and their intensity vary significantly from woman to woman, and even somewhat from cycle to cycle and over time. Most women with premenstrual syndrome experience only a few of the possible symptoms, in a relatively predictable pattern
 
There is no laboratory test or unique physical findings to verify the diagnosis of PMS. The three key features are:
 
The woman’s chief complaint is one or more of the emotional symptoms associated with PMS (most typically irritability, tension, or unhappiness). The woman does not have PMS if she only has physical symptoms (such as cramps or bloating).
Symptoms appear predictably during the luteal (premenstrual) phase, reduce or disappear predictably shortly before or during menstruation, and remain absent during the before ovulation.
The symptoms must be severe enough to disrupt or interfere with the woman’s everyday life.
 
Urinary infections
A urinary tract infection (UTI) is an infection that affects part of the urinary tract. When it affects the lower urinary tract it is known as a bladder infection (cystitis) and when it affects the upper urinary tract it is known as kidney infection (pyelonephritis). Symptoms from a lower urinary tract include pain with urination, frequent urination, and feeling the need to urinate despite having an empty bladder. Symptoms of a kidney infection include fever and flank pain usually in addition to the symptoms of a lower UTI. Rarely the urine may appear bloody. In the very old and the very young, symptoms may be vague or non-specific.
 
The most common cause of infection is Escherichia coli, though other bacteria or fungi may rarely be the cause. Risk factors include female anatomy, sexual intercourse, diabetes, obesity, and family history. Although sexual intercourse is a risk factor, UTIs are not classified as sexually transmitted infections (STIs). Kidney infection, if it occurs, usually follows a bladder infection but may also result from a blood-borne infection. Diagnosis in young healthy women can be based on symptoms alone. In those with vague symptoms, diagnosis can be difficult because bacteria may be present without there being an infection. In complicated cases or if treatment fails, a urine culture may be useful.
 
Lower urinary tract infection is also referred to as a bladder infection. The most common symptoms are burning with urination and having to urinate frequently (or an urge to urinate) in the absence of vaginal discharge and significant pain. These symptoms may vary from mild to severe and in healthy women last an average of six days. Some pain above the pubic bone or in the lower back may be present. People experiencing an upper urinary tract infection, or pyelonephritis, may experience flank pain, fever, or nausea and vomiting in addition to the classic symptoms of a lower urinary tract infection. Rarely the urine may appear bloody or contain visible pus in the urine
 
Polycystic ovary syndrome (PCOS) is a set of symptoms due to elevated androgens (male hormones) in women. Signs and symptoms of PCOS include irregular or no menstrual periods, heavy periods, excess body and facial hair, acne, pelvic pain, difficulty getting pregnant, and patches of thick, darker, velvety skin.Associated conditions include type 2 diabetes, obesity, obstructive sleep apnea, heart disease, mood disorders, and endometrial cancer.
Common signs and symptoms of PCOS include the following:
 Menstrual disorders: PCOS mostly produces oligomenorrhea (few menstrual periods) or amenorrhea (no menstrual periods), but other types of menstrual disorders may also occur.
 Infertility:This generally results directly from chronic anovulation (lack of ovulation).
High levels of masculinizing hormones: The most common signs are acne and hirsutism (male pattern of hair growth), but it may produce hypermenorrhea (heavy and prolonged menstrual periods), androgenic alopecia (increase hair thinning or diffuse hair loss), or other symptoms. Approximately three-quarters of women with PCOS (by the diagnostic criteria of NIH/NICHD 1990) have evidence of hyperandrogenemia.
 
 Metabolic syndrome:This appears as a tendency towards central obesity and other symptoms associated with insulin resistance. Serum insulin, insulin resistance, and homocysteine levels are higher in women with PCOS.
 
Osteoporosis
 
Osteoporosis is a disease where decreased bone strength increases the risk of a broken bone. It is the most common reason for a broken bone among the elderly. Bones that commonly break include the back bones, the bones of the forearm, and the hip. Until a broken bone occurs there are typically no symptoms. Bones may weaken to such a degree that a break may occur with minor stress or spontaneously. Chronic pain and a decreased ability to carry out normal activities may occur following a broken bone.
 
Osteoporosis may be due to lower than normal peak bone mass and greater than normal bone loss. Bone loss increases after menopause due to lower levels of estrogen. Osteoporosis may also occur due to a number of diseases or treatments including alcoholism, anorexia, hyperthyroidism, surgical removal of the ovaries, and kidney disease. Certain medications increase the rate of bone loss including some antiseizure medications, chemotherapy, proton pump inhibitors, selective serotonin reuptake inhibitors, and steroids. Not enough exercise and smoking are also risk factors. Osteoporosis is defined as a bone density of 2.5 standard deviations below that of a young adult. This is typically measured by dual-energy X-ray absorptiometry at the hip.
 
Osteoporosis itself has no symptoms; its main consequence is the increased risk of bone fractures. Osteoporotic fractures occur in situations where healthy people would not normally break a bone; they are therefore regarded as fragility fractures. Typical fragility fractures occur in the vertebral column, rib, hip and wrist.
Fractures are the most dangerous aspect of osteoporosis. Debilitating acute and chronic pain in the elderly is often attributed to fractures from osteoporosis and can lead to further disability and early mortality. These fractures may also be asymptomatic. The most common osteoporotic fractures are of the wrist, spine, shoulder and hip. The symptoms of a vertebral collapse (“compression fracture”) are sudden back pain, often with radicular pain (shooting pain due to nerve root compression) and rarely with spinal cord compression or cauda equina syndrome. Multiple vertebral fractures lead to a stooped posture, loss of height, and chronic pain with resultant reduction in mobility.
Fractures of the long bones acutely impair mobility and may require surgery. Hip fracture, in particular, usually requires prompt surgery, as serious risks are associated with it, such as deep vein thrombosis and pulmonary embolism, and increased mortality.Fracture risk calculators assess the risk of fracture based upon several criteria, including BMD, age, smoking, alcohol usage, weight, and gender.
 
In general, immobilization causes bone loss (following the ‘use it or lose it’ rule). For example, localized osteoporosis can occur after prolonged immobilization of a fractured limb in a cast. This is also more common in active people with a high bone turn-over (for example, athletes). Other examples include bone loss during space flight or in people who are bedridden or use wheelchairs for various reasons.
    Hypogonadal states can cause secondary osteoporosis. In females, the effect of hypogonadism is mediated by estrogen deficiency. It can appear as early menopause (<45 years) or from prolonged premenopausal amenorrhea (>1 year). Bilateral oophorectomy (surgical removal of the ovaries) and premature ovarian failure cause deficient estrogen production. In males, testosterone deficiency is the cause (for example, andropause or after surgical removal of the testes).Endocrine disorders that can induce bone loss include Cushing’s syndrome, hyperparathyroidism, hyperthyroidism, hypothyroidism, diabetes mellitus type 1 and 2,acromegaly, and adrenal insufficiency. In pregnancy and lactation can cause reversible bone loss.
    Malnutrition, parenteral nutrition and malabsorption can lead to osteoporosis. Nutritional and gastrointestinal disorders that can predispose to osteoporosis include undiagnosed and untreated coeliac disease (both symptomatic and asymptomatic people), Crohn’s disease ulcerative colitis,cystic fibrosis,[surgery(after gastrectomy, intestinal bypass surgery or bowel resection) and severe liver disease (especially primary biliary cirrhosis). People with lactose intolerance or milk allergy may develop osteoporosis due to restrictions of calcium-containing foods. Individuals with bulimia can also develop osteoporosis. Those with an otherwise adequate calcium intake can develop osteoporosis due to the inability to absorb calcium and/or vitamin D. Other micronutrients such as vitamin K or vitamin B12 deficiency may also contribute.
    People with rheumatologic disorders such as rheumatoid arthritis, ankylosing spondylitis, systemic lupus erythematosus and polyarticular juvenile idiopathic arthritis are at increased risk of osteoporosis, either as part of their disease or because of other risk factors (notably corticosteroid therapy). Systemic diseases such as amyloidosis and sarcoidosis can also lead to osteoporosis.
    Renal insufficiency can lead to renal osteodystrophy.
    Hematologic disorders linked to osteoporosis are multiple myeloma and other monoclonal gammopathies, lymphoma and leukemia, mastocytosis,hemophilia, sickle-cell disease and thalassemia.
    People with scoliosis of unknown cause also have a higher risk of osteoporosis. Bone loss can be a feature of complex regional pain syndrome. It is also more frequent in people with Parkinson’s disease and chronic obstructive pulmonary disease.
    People with Parkinson’s disease have a higher risk of broken bones. This is related to poor balance and poor bone density. In Parkinson’s disease there may be a link between the loss of dopaminergic neurons and altered calcium metabolism (and iron metabolism) causing a stiffening of the skeleton and kyphosis.
 
Certain medications have been associated with an increase in osteoporosis risk; only steroids and anticonvulsants are classically associated, but evidence is emerging with regard to other drugs.
 
    Steroid-induced osteoporosis (SIOP) arises due to use of glucocorticoids – analogous to Cushing’s syndrome and involving mainly the axial skeleton. The synthetic glucocorticoid prescription drug prednisone is a main candidate after prolonged intake. Some professional guidelines recommend prophylaxis in patients who take the equivalent of more than 30 mg hydrocortisone (7.5 mg of prednisolone), especially when this is in excess of three months. Alternate day use may not prevent this complication.
    Barbiturates, phenytoin and some other enzyme-inducing antiepileptics – these probably accelerate the metabolism of vitamin D
    L-Thyroxine over-replacement may contribute to osteoporosis, in a similar fashion as thyrotoxicosis does.This can be relevant in subclinical hypothyroidism.
    Several drugs induce hypogonadism, for example aromatase inhibitors used in breast cancer, methotrexate and other antimetabolite drugs, depot progesterone and gonadotropin-releasing hormone agonists.
    Anticoagulants – long-term use of heparin is associated with a decrease in bone density, and warfarin (and related coumarins) have been linked with an increased risk in osteoporotic fracture in long-term use
    Proton pump inhibitors – these drugs inhibit the production of stomach acid; this is thought to interfere with calcium absorption.[69] Chronic phosphate binding may also occur with aluminium-containing antacids.
    Thiazolidinediones (used for diabetes) – rosiglitazone and possibly pioglitazone, inhibitors of PPARγ, have been linked with an increased risk of osteoporosis and fracture.
    Chronic lithium therapy has been associated with osteoporosis.
    The diagnosis of osteoporosis can be made using conventional radiography and by measuring the bone mineral density (BMD). The most popular method of measuring BMD is dual-energy X-ray absorptiometry. In addition to the detection of abnormal BMD, the diagnosis of osteoporosis requires investigations into potentially modifiable underlying causes; this may be done with blood tests. Depending on the likelihood of an underlying problem, investigations for cancer with metastasis to the bone, multiple myeloma, Cushing’s disease and other above-mentioned causes may be performed.
Conventional radiography is useful, both by itself and in conjunction with CT or MRI, for detecting complications of osteopenia (reduced bone mass; pre-osteoporosis), such as fractures; for differential diagnosis of osteopenia; or for follow-up examinations in specific clinical settings, such as soft tissue calcifications, secondary hyperparathyroidism, or osteomalacia in renal osteodystrophy. However, radiography is relatively insensitive to detection of early disease and requires a substantial amount of bone loss (about 30%) to be apparent on X-ray images.
 
The main radiographic features of generalized osteoporosis are cortical thinning and increased radiolucency. Frequent complications of osteoporosis are vertebral fractures for which spinal radiography can help considerably in diagnosis and follow-up.