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Not in the mood? Why sexual desire can dwindle

From CBS News, September 25, 2013

While people often reminisce about their youthful romps, the bedroom door can slam shut...

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Rebecca Booth MD

"When women are given the tools to better understand the unique challenges that face them and their health they are empowered to make decisions that improve not only their own health, but that of their loved ones and their community. Clearly communicating the options for the most minimally invasive surgical procedures to treat common problems for women should be a vital part of the mission of all of those involved in the care of women."

Rebecca Booth, MD

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Abnormal Uterine Bleeding

Abnormal uterine bleeding can be characterized as either too much or too little bleeding. The most common type of abnormal uterine bleeding (also called dysfunctional uterine bleeding) is menorrhagia. Menorrhagia is experienced when there is excessive and possibly prolonged uterine bleeding. Although the amount of menstrual flow is somewhat subjective, women with menorrhagia often have a difficult time doing their daily activities. They may soil their clothes and bleed through protection. Some women may even become anemic due to excessive menstrual blood loss. Different types of abnormal uterine bleeding include:
Menorrhagia: Heavy or prolonged bleeding
Metrorrhagia: Any irregular bleeding between periods
Polymenorrhea: Bleeding is typically closer than 21 days
Oligomenorrhea: Periods are skipped or very light
Postmenopausal Bleeding: Bleeding that occurs a year after the last menstrual cycle at menopause

Causes for Abnormal Uterine Bleeding

  • Hormonal Changes
  • Uterine Fibroids
  • Adenomyosis
  • Abnormal Pregnancy (i.e., miscarriage, ectopic)
  • Uterine Polyps
  • Birth Control Methods
  • Pelvic Inflammatory Disease
  • Hematologic Disorders
  • Liver, Kidney or Thyroid Deisease

Symptoms
Generally, menorrhagia or menstrual bleeding is considered excessive when women bleed through sanitary protection in an hour. Prolonged bleeding occurs when a period lasts longer than seven days.

The symptoms of menorrhagia may resemble other menstrual or medical problems. It is best to see your provider for the appropriate diagnosis.

Diagnosis
The evaluation evaluating menorrhagia and other abnormal uterine bleeding problems includes a complete history and pelvic exam.
Tests that may be recommended include:
  • Blood Tests (check for anemia and hormaonal levels)
  • Pap Test (screen for cerix cancer)
  • Ultrasound (evaluate anatomic abnormalities such as fibroids and polyps)
  • Biopsy (endometrial) An endometrial biopsy removes tissue from the lining of the uterus. This is typically performed in the office.
  • Hysteroscopy A visual examination of the canal of the cervix and the interior of the uterus using a viewing instrument (hysteroscope) inserted through the vagina.
  • Dilation and Curettage (D&C) This is a minor gynecological surgery which involves the widening the cervical canal with a dilator and scraping the uterine cavity with a curette.


Treatment Options for Menorrhagia

Treatment for menorrhagia and other types of abnormal uterine bleeding are decided between the patient and the healthcare provider once the workup for possible underlying causes is complete. The best treatment is determined based on several factors including the reason for your bleeding along with your age and interest in future pregnancy.
  • Iron supplementation. This treatment is used if the condition is coupled with anemia. A blood disorder caused by a deficiency of red blood cells.
  • Tranexamic Acid. A man-made from of an amino acid called lysine that works to slow bleeding by stabilizing blood clot formation. This medication is only taken when the heavy bleeding is occurring.
  • Prostaglandin inhibitors. These are nonsteroidal anti-inflammatory medications, including ibuprofen and aspirin, which not help decrease the cramping, but also the amount of blood flow.
  • Oral contraceptives. Thins lining of the uterus and suppresses ovulation.
  • Progesterone. Hormone treatment that can thin the lining and reduce bleeding.
  • Levonorgestrel-releasing Intrauterine system (Mirena IUD). The IUD can be used for cycle control and/or for birth control.
  • Endometrial ablation. A procedure to destroy the lining of the uterus (endometrium)
  • Hysterectomy. A surgical removal of the uterus.

Adenomyosis

Adenomyosis is a relatively common condition, resulting from growth of the endometrial or uterine lining glands in the wall of the uterus. Generally, the glands of the uterine lining are limited only to the uterine cavity. Adenomyosis, unike endometriosis, is restricted to the wall of the uterus and the two conditions are discovered in the same patient less than 20% of the time. They are two different diseases however, both adenomyosis and endometriosis have the presence of endometrial glands in areas where they should not ordinarily grow. Adenomyosis usually occurs in women between ages 35 to 50. The majority of the women who have symptoms from it have had more than one vaginal delivery and the incidence seems to increase with multiple deliveries. The most common symptoms are menstrual cramps and very heavy menstrual periods. Also commonly seen is a lower pelvic fullness, low back pain, pain with intercourse (generally deep penetration) and sometimes pain with pelvic exam or Pap smear. Also, commonly seen is pre- and post-menstrual period spotting. Often on exam, the physician will note that the uterus is slightly enlarged and sometimes double the size it ordinarily would be. Ultrasound can suggest this diagnosis in many cases. Although depending on the involvement of the uterine wall, the pelvic ultrasound may appear normal. In cases where adenomyosis can be seen on ultrasound, generally what is seen is a disturbance throughout the wall of the uterus. In the past, the diagnosis was only made after hysterectomy, but now with advanced vaginal ultrasonography and careful attention to patient's symptoms, many OB/GYN's feel the diagnosis can be made prior to surgery. Treatment ranges from hormonal treatments, such as progestins or birth control pills. Other treatments include suppression of the menstrual cycle with medication, such as Depo-Lupron. Depo-Provera is helpful for some patients. Surgical approaches can include endometrial ablation. In this procedure, the lining ofthe uterus is ablated, which may help the symptoms of heavy periods, but may also at the same time trap some of the glands in the wall of the uterus so that pain and painful sex continues. The most definitive treatment is hysterectomy.

Many patients with adenomyosis have only minor symptoms that can be controlled with simple over-the-counter medications, such as nonsteroidal anti-inflammatory agents like Anaprox, Aleve, Nuprin or Advis. Some patients, however, are incapacitated by their symptoms and need treatment. If you feel you are suffering from these symptoms, you and your doctor should work out a careful plan to approach them, as there are many options available.

Fibroids

What are fibroids?
Fibroids or leiomyoma are benign tumors of the uterus made of muscle. These growths can occur in different parts of the uterus, including inside the cavity of the uterus, on the outside of the uterus or within the wall of the uterus. Fibroids can range in size from less than a centimeter to larger than a grapefruit.

How common are fibroids? What causes them?
Fibroids are very common and occur in 25-80% (NIH statistic) of women. It is unknown what specifically causes fibroids.

Fibroids are thought to grow in response to the female hormone, estrogen. Therefore, they are most frequently seen in women of reproductive age. Some women who have fibroids report that other women in their families also have this condition. There is, indeed, thought to be a hereditary component. Also, African American women are more likely than Caucasion women to have uterine fibroids.

How do I know if I have fibroids?
Most commonly, fibroids do not cause any symptoms or health problems. Sometimes they are discovered incidentally during a woman's annual GYN exam. If fibroids arise in particular parts of the uterus or grow to a larger size, they can cause problems including abnormal or heavy periods, anemia, difficulty becoming pregnant, back pain, painful intercourse, bloating or fullness in the belly or difficulty urinating.

How are fibroids treated?
If fibroids are diagnosed in a woman who has no symptoms, they usually do not require treatment. However, if a women is suffering from any of the symptoms listed above, she may require treatment.

The approach to treating symptomatic fibroids depends on what the woman's symptoms are and where/how large her fibroids are.

Many doctors start with less invasive therapies first. Painful periods related to fibroids can sometimes be treated with anti-inflammatory medications like ibuprofen or naproxen. Also, some doctors may prescribe a birth control pill or a medication called lupron to decrease hormone levels and thereby decrease growth of the fibroids and bleeding.

For other women, surgery may be the best option. In women who have pain or heavy periods related to fibroids and want to potentially become pregnant in the future, a myomectomy, or removal of the fibroids with preservation of the uterus, can be an option. A myomectomy is a major surgery. It is possible to do a myomectomy using small incisions and laparoscopy or robotic surgery. In younger women who have myomectomies, fibroids may grow back in the future.

If the fibroids are located within the uterine cavity, a myomectomy can be performed through a tiny scope inserted into the cervix and uterus. This is called a 'hysteroscopic' myomectomy.

Another procedure, called uterine fibroid embolization (or UFE), is sometimes recommended for women who have heavy periods due to their fibroids and wish to avoid surgery. This type of procedure is performed by a special doctor called an Interventional Radiologist. It involves injecting a material into the blood vessels that supply the fibroids, thereby decreasing blood flow. Women who desire pregnancy in the future are not candidates for this procedure.

Finally, hysterectomy is an option for treatment of fibroids. A hysterectomy is a major surgery during which the uterus is removed. Depending on the size of a woman's fibroids, hysterectomy can be performed through small incisions (laparoscopically), through the vagina and in rare cases, must be performed using a large incision if the fibroids are very big.

Herpes

As many as 1 in 5 sexually active people have the Herpes virus. Not everyone is aware that they have it and can transmit it to a sexual partner. Most people are surprised to learn that Herpes is a very common virus. It is a viral infection and can be treated with medication (anti-viral) when there is an active oral or genital lesion. Although the symptoms are treatable, the virus remains present and can cause recurrent "sores" and possible spread to a partner.

The diagnosis of genital herpes can be devastating for some people because even though the symptoms of a lesion or "sore" can be treated, once a person has the Herpes Simplex Virus (HSV) it is not completely curable and remains dormant allowing it to recur and be passed on to a partner. It is most concerning for pregnant women and it is very important to have suppressive therapy (anti-viral medication) in the last 4 weeks of pregnancy so that there are not active genital lesions at the time of a vaginal birth. A newborn is at risk for a serious infection that could be fatal if not treated. If there are active lesions at the time of labor than a cesarean section is recommended so that the baby does not become infected with the herpes virus.

Hysterectomy

What is a hysterectomy?
Hysterectomy is the surgical removal of the uterus.
This can be a total hysterectomy which is the removal of the uterus and the cervix, or a subtotal hysterectomy (supracervical) which is the removal of the top part of the uterus and the cervix is left in place. Other organs such as the ovaries and tubes may also be removed at the time of a hysterectomy. For women who are premenopausal, having a hysterectomy means that they are no longer capable of achieving a pregnancy and they should stop having menstrual periods.

Hysterectomy Background
There are around 600,000 hysterectomies performed each year in the US, making it the second most common procedure in child bearing women. To put this into perspective, one in three women in the United States will undergo a hysterectomy by age 60.

The most common conditions requiring hysterectomy are fibroid tumors, adenomyosis, endometriosis and uterine prolapse.

Reasons for Hysterectomy
Fibroid Tumors. These are benign muscle tumors of the uterus that are very common in women. They account for as many as 40 percent of the hysterectomy procedures. They can cause many problems including; pelvic pain, abnormal bleeding, infertility, urinary frequency or retention.

Adenomyosis. This is a condition where endometrial glands that should be present in the lining of the uterus (the endometrium) are found in the muscle of the uterus. (the myometrium) Adenomyosis may cause symptoms of heavy or irregular menstrual bleeding and can be associated with pain.

Endometriosis. The endometrial cells grow outside the lining of the uterus and may attach to other organs in the pelvis or on the surface of the peritoneum which is the layer that lines the inside of the body cavity. The endometrial cells are responsive to hormones secreted throughout the menstrual cycle and will focally bleed and cause inflammation. This may result in pain and scarring of the tissue. Patients may complain of abnormal bleeding, painful periods, painful sex and infertility.

Cancer. Only 10 percent of the hysterectomies performed each year are due to one of the gynecologic cancers. Cancer of the ovary, cervix, uterus or fallopian tubes.

Uterine Prolapse. This is a condition that is most common in postmenopausal women. Uterine prolapse occurs when the uterus has lost some degree of support and may push into the vagina and even come outside the vagina. There are varying degrees of severity and the vaginal walls are also at risk for weakness. Treatments can range from physical therapy and pessary device to pelvic reconstructive surgery that may require a hysterectomy. A pessary device is inserted in the vagina and functions as a brace to hold the uterus and vaginal walls in place. Minimal to moderate degrees of prolapse may be improved with physical therapy to strengthen the pelvic floor.

Oophorectomy

Oophorectomy is the removal of ovaries to decrease the risk of ovarian cancer and is frequently done together with a hysterectomy.

Osteopenia

Osteopenia, or low bone mass, seen on a dexagram is a reduction in bone mass below the normal range, but yet not low enough to be in the range of osteoporosis. This is defined by the World Health Organization as being -1 standard deviation below that of a 30 year old -1 up to -2.5 standard deviation. This equates to about 10-25% below the normal value found in a 30 year old woman. Below 25%, the diagnosis of osteoporosis kicks in. The World Health Organization recommends patients with osteopenia be further evaluated to using various clinical risk factors regarding the need for intervention and therapy via medication to prevent fracturing. Anyone at risk for osteoporosis is also at risk for osteopenia.

Osteoporosis

Osteoporosis is a skeletal disorder that is characterized by a loss of bone mass, a deterioration of bone microarchitecture and a decline in bone quality which leads to an increased vulnerability to bone fractures. Osteoporosis has a five fold greater prevalence in women than men. There is also a wide variation in hip and fracture rates in women based on race and ethnicity. In the United States Caucasian women have the highest rate of hip fracture while African- American women have the lowest rate. Mexican-American women fall in-between these two groups. Although Asian women often have bone density measurements lower than Caucasian women, interestingly enough they have fewer vertebral and hip fractures than Caucasians.

Pass the Pearls asks Dr. Rebecca Terry, a gynecologist with Women First of Louisville who also specializes in treating and preventing osteoporosis in women these questions. She is a contributor to our site and serves on the Pass the Pearls editorial board.

What are the symptoms of osteoporosis? How is osteoporosis treated? Osteoporosis has been called the silent epidemic in America. This is because there is no pain associated with it and no outwardly visible signs. Bone mass and quality decrease and a fracture occurs often without any warning symptoms. Before osteoporosis treatment is started secondary causes for osteoporosis besides aging are excluded by blood testing and evaluation of medical problems or any medications that can cause bone loss. There are many treatment options for osteoporosis including the largest category called the bisphosphonate drugs. These include the brand names of Fosamax, Actonel, Boniva, and Reclast along with others. These are given either orally or they can be given via IV infusion. Often times at least a 3-5% increase in bone density is seen after two years of therapy. Another category is a partial estrogen agonist or antagonist. This includes Evista. These drugs mimic the actions of estrogen on bone and improve bone mass. Another drug used more recently on the market is Prolia. It is given as an injection under the skin every six months and helps to prevent the formation of the small cells that actually break down our bones to release calcium. Forteo is a medication that is given as an injection just under the skin daily for two years in patients who have a failure to respond to categories of drugs I have listed. It is also often used in patients who have had skeletal fractures because it tends to act more rapidly to improve bone density. It cannot be used in patients with a history of extensive irradiation to the bone for cancer or other conditions. The final therapeutic intervention most commonly used is estrogen. Estrogen is important as it prevents bone loss from occurring and helps to prevent any further bone loss from occurring and lowers fracture risk.

Polycystic Ovarian Syndrome (PCOS)

What is PCOS?
PCOS stands for polycystic ovarian syndrome. This is a condition caused by a hormonal imbalance leading to high levels of testosterone. Because of these changes, women with PCOS are at higher risk for cancer of the lining of the uterus, infertility, high blood pressure and diabetes.

What causes PCOS?
The cause of PCOS is not entirely clear. The condition stems from high levels of male hormone or androgens. Why this occurs in some women is not known although some authorities believe it is due to overproduction of testosterones within the ovary. There is some evidence suggesting there may be a genetic component involved in developing PCOS. In addition, obesity and insulin resistance also contribute.

What are the symptoms of PCOS?
Symptoms of PCOS include irregular or infrequent menstrual cycles, infertility and signs of high testosterone levels such as increased hair growth on face or body or acne. PCOS is often associated with obesity and insulin resistance.

How is PCOS diagnosed?
PCOS is diagnosed based on a woman's symptoms and lab tests including testosterone level. In some cases, ultrasound of the ovaries may be performed to aid with making the diagnosis.

How is PCOS treated?
Treatment for PCOS differs depending on the presenting complaints. In women who are suffering from irregular or absent menstrual cycles, one of the main goals is to ensure that the lining of the uterus is shed periodically to prevent pre-cancer or cancer. These women may be placed on birth control pills to regulate hormone levels and keep the uterine lining healthy.

For women who are diagnosed with PCOS and desire pregnancy, a medication that can increase the likelihood of ovulation can be used.

Some women with PCOS also have signs of pre-diabetes. These women may be given a medication, metformin, which can increase their body's ability to utilize sugar efficiently.

Women who have PCOS and are overweight or obese can benefit from healthy diet, exercise and weight loss. Many women who attain a healthy weight may notice their menstrual periods 'self-regulating' and are more likely to ovulate (or release an egg) each month, increasing their chances of conceiving.

Urinary Incontinence

Do you leark urine?
This is question that all women should be asked at their annual examinations.

Some women believe that it is just part of getting older and that they have to live with the often times embarrassing quality of life issue for women.

The two most common types of incontinence are treated differently so it is important to differentiate what conditions exist when the leaking occurs. Some women have both types of incontinence and they are diagnosed with a "mixed" picture and may need a combination of treatment. Urge incontinence is most often treated with medication (Most of us have seen the "gotta go" ads by pharmaceutical companies). Stress urinary incontinence (SUI) is better treated with physical therapy or surgery.

Urge Incontinence
Urge incontinence is the type of incontinence associated with urgency and frequent urination. Women experience a strong/frequent "urge" to urinate, with very little control to prevent a leak. With Urge incontinence the bladder contracts on its own without a signal from the brain. When the bladder fills up with a certain volume of urine there is very little time between the urge and getting to the bathroom. Women who experience urge incontinence often start to leak while they are trying to make it to the restroom.

Stress Incontinence
Stress incontinence occurs when urine leaks as a result of an increase in abdominal pressure. Stress incontinent symptoms usually occur at times of activity or movement (ie, coughing, sneezing, laughing, exercising, or quick changes in position like sitting to standing.) There is a weakness in the bladder angle or hypermobility of the urethra that leads to stress urinary incontinence. This can occur as a result of pregnancy and delivery, but also is relatively common in female atheletes.

Thankfully, there are treatment options available, and can range from behavioral treatments and physical therapy to medications (more effectively used for Urge incontinence), or minimally invasive surgical option (used to support the urethral in cases of Stress incontinence.)

Vaginal Yeast Infection

Most women will experience that itchy, irritating feeling around the vaginal opening, symptoms of a yeast infection, at least once in a lifetime. Vaginal yeast infections are one of the more common reasons why women seek care from their OB/GYN. Most women harbor yeast, a fungal organism, somewhere in their vaginal canal. While usually in small amounts, certain situations allow for overgrowth. The body's main defense against yeast infections occurring in the vagina is pH balance. The pH balance is maintained by normal bacteria referred to as lactobacillus, also known as acidophilus. This variety of bacteria creates an acid pH, which prevents the healthy vagina from harboring fungal organisms such as yeast and also odorous bacteria. Many factors influence the vaginal pH balance, for example, antibiotics tend to reduce the population of acidophilus resulting in a higher pH in the vagina and an environment that can harbor unfriendly organisms. Dietary habits such as high intake of sugar or carbohydrates result in higher than average levels of blood sugar causing fungal organisms to thrive. Pregnancy encourages the growth of yeast because of alterations that estrogen causes in the vagina. Other conditions that encourage yeast growth include diabetes, a depressed immune system and heredity also play somewhat of a part.

The symptoms of yeast infections can start out very subtly. Often a woman will notice only intermittent itching. This is more notable around her period at which time her vaginal pH is elevated. Usually the symptoms wax and wane and may resolve spontaneously, but in the majority of patients that are seen in the physician's office, the most common complaint is itching. Often a discharge is present, but not always. Usually there is no significant odor. There are many medications now available over the counter to treat yeast infections. Usually these treatments will reduce the symptoms of itching and significantly reduce the population of yeast in the vagina. Occasionally a resistant strain of yeast is present and must require prescription medication for good results.

Prevention of recurrent yeast infections is the most important approach to avoid them. This can be done by several measures, one of which is dietary. Women who are prone toward yeast infections should be very careful about avoiding sugar or diets high in carbohydrates such as the "white stuff": white potatoes, white rice, white pasta, and white bread. Soft drinks are a common cause of elevation of blood sugar. We, in the business of gynecology, often see more yeast infections around holiday times such as Christmas and Easter when candy, fudge, etc., are in abundance. Another approach is to increase dietary intake of products high in acidophilus such as cultured yogurt, particularly plain yogurt, acidophilus milk and capsules or powders available in most health food stores. I usually recommend the refrigerated varieties, as they tend to have more live cultures.

Women who are prone toward yeast infections should be cautious about antibiotic use, using them only when necessary and remembering to increase dietary intake of acidophilus food products when taking antibiotics. Other approaches should include efforts to reduce irritation of the vagina or vulva. I suggest patients wear only 100% cotton underwear, not just cotton crotch. Pantyhose should be vented to allow for good air circulation or try thigh high pantyhose as an alternative. Most pairs of pantyhose can be vented easily with a small slit inside the seams of the crotch. Wet athletic wear and bathing suits should be removed as soon as exercise or swimming is finished, changing into dry cotton underwear. The use of vaginal douches is not recommended as this may actually water down the acid pH. Yeast infections are not sexually transmitted diseases, but on occasion partners will both have inflammation of their genital areas. In men "jock itch" is one such condition and again is not sexually transmitted, but may be treated with antifungals available over the counter. Women who have symptoms of yeast infections should be seen by a physician or health care professional for an accurate diagnosis. Recurrent yeast infections may require blood work to assess whether there are other risk factors such as diabetes. While yeast infections are a great annoyance to most patients, research has not revealed any overall negative health effects from long term mild infections, other than discomfort.

In summary, vaginal yeast infections are extremely common, usually treatable and may be entirely preventable with dietary changes and other healthy habits.




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