Female Genital Disorders

Anatomy or system affected: Genitals, reproductive system, uterus

Definition: All maladies affecting the reproductive organs of women

Causes: Endometriosis, hormonal imbalances, infection, disease, uterine fibroids, sexually transmitted diseases

Symptoms: Vary; can include abdominal pain, pain during menstruation or sexual intercourse, vaginal itching, vaginal discharge, burning upon urination

Duration: Acute or chronic, often with recurrent episodes

Treatments: Depends on cause; may include oral contraceptives, corticosteroids, hormone therapy, anti-inflammatory drugs, surgery, radiation therapy, chemotherapy, immunotherapy

Causes and Symptoms

Diseases and disorders of the female genitals and related internal organs encompass a huge number of different types of conditions that can range in severity from merely physically annoying to life-threatening. These disorders affect the vulva, vagina, uterus, ovaries, and Fallopian tubes. Many develop from unknown causes, and others have clear-cut origins, such as sexually transmitted diseases. Some have immediately recognizable symptoms, while others are silent until the disease has progressed to a serious stage. Early recognition of symptoms or abnormalities and proper treatment can alleviate pain and save lives.

Endometriosis is a chronic, recurring disease in which the tissue that lines the uterus may be found growing in sites outside the uterus. The endometrial tissue, frequently called endometrial implants, may be found in a variety of extrauterine sites. Endometrial tissue is hormonally responsive, and the symptoms of endometriosis are cyclic. The endometrial tissue responds to the same hormonal cues that signal the sloughing off of the uterine lining during menstruation ; however, the blood from the endometrial tissue cannot leave the abdominal cavity, leading to inflammation. As the inflammation subsides, it is replaced with scar tissue. This process will repeat with each menstrual cycle, and the scarring can result in infertility, organ malfunction, or adhesions that bind organs together. Some women with endometriosis experience no symptoms, while many experience severe abdominal pain before, during, and after their menstrual periods. Endometrial tissue can be definitively diagnosed only with laparoscopy. The cause of endometriosis is unknown, but some evidence suggests an inherited tendency to develop endometriosis.

Vaginitis is a general term for infections of the vagina. The three most common vaginal infections are yeast infections, usually caused by the fungus Candida albicans; trichomonaisis, caused by a small parasite, Trichomonas vaginalis ; and bacterial vaginosis, which is caused by an imbalance of the normal bacteria in the vagina. Diagnosis of the causative organism is critical in choosing the correct treatment, and also for addressing issues of sexual transmission. Yeast vaginitis is not sexually transmitted. Bacterial vaginosis is not transmitted by a partner but may have some sexual association based on pH changes that can occur with sexual activity. Trichomoniasis is sexually transmitted, and partners must be treated to eradicate the infection.

Uterine fibroids are benign tumors made mainly of muscle tissue that can grow inside the uterus or along its outer surface. They grow slowly and are dependent on the hormone estrogen for continued growth. They are usually not problematic, but if they become very large they may cause extremely heavy bleeding during menstruation and can interfere with pregnancy and childbirth. Their cause is unknown, but they will shrink or disappear after menopause.

Uterine prolapse occurs when the pelvic muscles lose tone and are no longer able to support the pelvic organs, causing the uterus to “fall” into the vagina. Prolapse may occur only inside the vagina with straining, such that the uterus “drops” from its position high in the vagina; may occur within the vagina without straining; or may be a rare condition in which the cervix and even the uterus protrudes outside the vagina. This disorder is most common in women of older age and is often precipitated by one or more difficult births. Obesity is also implicated as a risk factor.

Ovarian cysts form when an egg developing inside a follicle within the ovary does not ovulate but instead keeps growing. Small cysts will be painless, but larger ones (up to 7.5 centimeters in diameter) may cause abdominal pain. Most cysts will go away on their own, but some can rupture and cause severe pain.

The hallmark of cancer is uncontrolled cell growth. Cancer may prove fatal by causing destruction of a particular organ at the site of origin or by spreading throughout the body and damaging other organs and systems. All the organs of the female reproductive system can be affected by cancer. Cervical cancer begins in superficial layers of the cervix but may spread rapidly through the vagina and throughout the body. Cervical cancer can be detected in its early, most curable stages by a Pap test. Endometrial cancer affects the glands that line the uterus. It can occur at any age, but the most common age of onset is sixty. Abnormal bleeding accompanies this disorder, which is diagnosed by examination of a biopsy of uterine tissue. Sarcomas of the uterus are malignant tumors of muscle tissue frequently confused with benign fibroids. This rare cancer is aggressive and difficult to treat. Ovarian cancer constitutes about 25 percent of female reproductive tract cancers, is difficult to detect and cure, and therefore has a high mortality rate. There are no early symptoms, and the cancer seems to occur frequently in those with a family history of the disease. Cancers of the Fallopian tubes and vagina are very rare, but vaginal cancer occurs with greater frequency in women whose mothers were treated with the synthetic estrogen diethylstilbestrol (DES) during the 1940s through the 1960s with the intent of preventing miscarriages. Cancer of the vulva, a form of skin cancer, is relatively easy to treat and has a high cure rate.

Sexually transmitted diseases (STDs) , now more properly referred to as sexually transmitted infections (STIs), can involve any part of the female genital system. Common STIs of bacterial origin include gonorrhea and chlamydia , which are major precursors to Pelvic inflammatory disease (PID) and syphilis . Untreated, these diseases can lead to serious complications. Common STDs with a viral cause include genital herpes , genital warts, and acquired immunodeficiency syndrome (AIDS). The causative agent of trichomoniasis vaginalis is a protozoan. STIs are transmitted through direct sexual contact with an infected person, and each has its own set of symptoms and diagnostic criteria.

Treatment and Therapy

A variety of treatments are available for endometriosis, depending on the severity of the disorder. Over-the-counter or prescription anti-inflammatory drugs may give immediate relief from pain, but the condition itself is frequently treated with hormone therapy. Birth control pills that are high in the hormone progestin and low in estrogen can help shrink endometriosis. Danazol, a synthetic male hormone, suppresses the production of estrogen by the ovaries, thereby helping to eliminate the condition, but it has undesirable side effects. In some cases, surgical removal of the tissue is necessary. In laparoscopy, an instrument is inserted through tiny abdominal incisions and used to remove the tissue. In the most severe cases, a complete hysterectomy (removal of the uterus and ovaries) is performed.

Vaginitis needs to be diagnosed either by direct microscopic visualization through a wet prep along with a test of pH of the discharge, or by other serologic laboratory technologies. Culture is rarely employed. Medications for vaginal yeast infection are available over the counter as vaginal creams or suppositories or by prescription as vaginal creams or as a one-dose antifungal oral medication. Medication for Trichomonas vaginalis is generally with oral metronidazole (Flagyl), and partners must be treated as well. Medication for bacterial vaginosis can be oral or intravaginal with metronidazole or clindamycin, or with oral tinidazole.

If no major discomfort is experienced by the woman when uterine fibroids are first detected, usually no treatment beyond regular observation is necessary. For those experiencing pain or difficulty in conception or pregnancy, the fibroids may be surgically removed in an operation called a myomectomy; in severe cases, a hysterectomy is performed. A laparoscope can be used to remove tumors on the outside of the uterus, or a hysteroscope can be inserted through the cervix, which uses a laser to burn away internal fibroids. Uterine artery embolization, in which the arteries that supply the fibroids are blocked, is another surgical option; this is less invasive than a hysterectomy and has similar success rates. Various medications are also available to treat the symptoms of uterine fibroids as well as block their growth. For example, synthetic hormones called gonadotropin-releasing hormone analogs block the ovaries’ production of estrogen, which leads to shrinking of the fibroids and the possible avoidance of surgery. .

A prolapsed uterus is frequently treated by hysterectomy, but other therapies are possible. Kegel exercises, designed to strengthen the muscles of the pelvic floor, are effective if done regularly for an extended period of time. A pessary, a ring-shaped device that fits around the cervix and props up the uterus, is another alternative, though an inconvenient one. Major surgery to resuspend the uterus is a surgical alternative to hysterectomy.

Ovarian cysts will usually be resorbed into the ovary within one to three menstrual cycles. Proper monitoring by a physician is needed to determine if the cysts have cleared. If the cyst does not disappear within three months, or if it increases in size, ultrasound and/or laparoscopy will be used to determine if a different type of ovarian tumor is present, which would necessitate surgical removal.

Cancer treatment is highly specialized for the particular variety of the disease, its severity, and consideration of the affected individual. Typical treatments include surgical removal of the tumor and/or affected organ, radiation therapy, chemotherapy, and immunotherapy (the reinforcement of the immune system, generally administered after radiation or chemotherapy). When diagnosed in premalignant stages, cervical abnormalities may be treated by cryosurgery (freezing and killing the abnormal cells) or laser destruction of the abnormal cells. Advanced cervical cancer is treated by hysterectomy. Endometrial cancer is treated with total hysterectomy, including the uterus, ovaries, and Fallopian tubes, and if the cancer has spread, radiation and/or chemotherapy. The only known cure for uterine sarcoma is total hysterectomy, and removal of both the ovaries and the Fallopian tubes is performed for ovarian cancer. The tumors of vaginal cancer are eliminated surgically or with laser treatment.

Sexually transmitted diseases of bacterial origin can be treated successfully with antibiotics. Drug therapy can also eliminate trichomoniasis. There are no cures for the virally transmitted STDs. Certain drugs can reduce the frequency of outbreaks of genital herpes, and genital warts may be removed by freezing, burning, or surgery. No cure exists for AIDS, although drugs are available to prolong life.

Perspective and Prospects

The diagnosis and treatment of female genital disorders and diseases have evolved from a state of some being considered psychosomatic to being the focus of a field that spurs the continued development and improvement of diagnostic and treatment technologies. It is also a field that has been a major force in the mass screening of diseases and in public health issues. Many conditions, such as endometriosis, have historically been misdiagnosed and the associated pain dismissed as imagined—to the dismay of the suffering woman. This and other conditions, such as prolapsed uterus and fibroids, were typically treated with the drastic surgery of hysterectomy. Women have demanded that more research into the causes of these disorders, and alternatives to hysterectomy, be developed. Laparoscopy has replaced hysterectomy in many cases, preserving the uterus and childbearing capacity.

The treatment of all female cancers has benefited from research into the cause and treatment of these disorders. For decades, the Pap test has been routinely used with American women on an annual basis, and it has been responsible for saving thousands of lives through early detection of abnormal cervical cells that may progress to a cancerous state. Public education about the necessity of early cancer detection has helped to improve the survival chances of individuals with cancer, and sensitive blood tests can detect some cancers at their most treatable stages, long before any symptoms occur. Discovery of the hereditary nature of female genital cancers has established routine monitoring of those at risk for the disease, again resulting in early detection. New, better radiation and chemotherapy treatments, as well as improved immune system support, benefit all cancer patients. The connection between certain “cancer-fighting” foods and good health has led to a revision of Americans’ eating habits.

While some sexually transmitted diseases are easily cured with antibiotics if caught early, those of viral origin are not and may have fatal consequences. Information provided through such diverse means as television and grade-school programs has educated people about this problem and the best ways to protect themselves from becoming victims of an incurable STD. Continuing research into diagnostic methods and treatment regimes in this area will lead to improved health for everyone.

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