Women's Health

Despite the new frankness in films, one of the things we have yet to see is the woman pulling away from her lover as she notes blood on the sheets, or blood on her partner.  Bleeding after sex or “postcoital bleeding” (PCB) generates many questions from our readers here at WebMD. So even if Hollywood has not yet made a movie with a PCB scene, it seems important to address some of your questions about this topic.

• How common is bleeding after sex?

• What causes the bleeding in a non-pregnant woman?

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By Laura Corio, MD

I have been a doctor for 30 years and love it. My name is Laura Corio, MD and I have the privilege to be able to get up every morning, and enjoy what I do each day. Whether I am seeing patients in the office, doing surgery in the operating room, delivering a baby, or teaching medical students and residents, I am very pleased and happy to have such a great career. I am an obstetrician/gynecologist, practicing in New York City, New York.

I have lived in the tri-state area all my life. I went to medical school in Newark, NJ at CMDNJ, New Jersey Medical School. I then crossed the river, and went up to Mount Sinai Hospital in  New York City where I did my internship and residency in Ob/Gyn. I decided to stay at Sinai and teach, work and deliver babies. It has been a long relationship with Mount Sinai. (more…)

I had just finished an astounding book about a young woman who died of metastatic cervical cancer, when I saw an article in the December 2010 issue of Cancer Epidemiology Biomarkers & Prevention about an increase in HPV (human papilloma virus) rates after menopause. The impact of the book, and the scientific article, raised new questions for me about the true impact of HPV for women.

The book was The Immortal Life of Henrietta Lacks, written by Rebecca Skloot (Crown Publisher, 2010). Henrietta Lacks delivered a baby in September 1950, right after her thirtieth birthday. There was no mention at delivery, or her postpartum exam, of a cervical lesion. Yet three months later, she had a biopsy taken from her cervix of what the GYN described as “grape jello”. Within a year Henrietta had died from cervical cancer. (more…)

PCOS and Pregnancy Part Three

In the first part of our series on polycystic ovarian syndrome (PCOS) and pregnancy,  we asked the question, “How do I know if I have PCOS?“  Then we looked at the relationship between PCOS and difficulty getting pregnant. In this final part of the series, we examine possible treatments for PCOS that may help you to get pregnant. (more…)

PCOS and Pregnancy Part Two

In the first part of our series on polycystic ovarian syndrome (PCOS) and pregnancy,  we asked the question, “How do I know if I have PCOS?“  Now let’s look at the relationship between PCOS and difficulty getting pregnant. (more…)

I really want a baby!

Have you been told that you might have polycystic ovarian syndrome (PCOS)? If so, were you at all worried that you might not be able to have a baby? Many women know that PCOS can prompt unwanted facial hair growth, acne, and irregular periods. Additionally PCOS can make it difficult to conceive, increase rate of miscarriages, and increase the risk for type 2 diabetes. Here at the WebMD Women’s Health Community we have been getting increasing numbers of posts from women stating they are desperate for a baby, yet have been unable to conceive because they have PCOS. (more…)

Many women may be familiar with the problems of recurrent/frequent urinary tract infections (UTIs) , or even apparent UTI symptoms for which no bacterial infection can be found. This later condition, which one urologist likes to call “The UTI That Isn’t” can be especially frustrating. Let’s talk about the possible causes of “The UTI That Isn’t”. (more…)

Urinary tract infections (UTIs) are the third most common type of infection, surpassed in number only by respiratory and intestinal infections. Thus, many of us are all too familiar with the common symptoms of a UTI such as urgency, frequency, small amounts of urine voided, and pain with urination. Many of us may also be familiar with the problems of recurrent/frequent UTIs, or even apparent UTI symptoms for which no bacterial infection can be found. This later condition, which one urologist likes to call “The UTI That Isn’t” is a frustrating situation for women who have recurrent symptoms without good relief. (more…)

Recently I had a question from a MissE26. She was a 26 year old woman who related that, after three years of marriage to a man she deeply loved, they were still unable to have intercourse. Another 20 year old, Kate987, wrote about having increasingly severe painful penetration since first sex with her husband at age 16. Both described “this giant problem that is ruining everything.” Both women had been given the diagnosis of vaginismus.

What Is Vaginismus?
Most simply described, “Vaginismus is an involuntary spasm of the muscles surrounding the vagina. The spasms close the vagina” (National Institutes of Health, 2010). Such spasms can make it difficult or impossible to insert a finger, tampon, yeast cream applicator, penis — or to do a GYN pelvic exam.

There are six different classification systems used world wide to identify sexual medicine conditions. Vaginismus is described in each. I personally prefer this version (Basson, 2004):

The persistent or recurrent difficulties of the woman to allow vaginal entry of a penis, a finger, and/or any object, despite the woman’s expressed wish to do so. There is often (phobic) avoidance, involuntary pelvic muscle contraction, and anticipation/fear/experience of pain. Structural or other physical abnormalities must be ruled out/addressed.

It seems essential that easily identified physical obstructions to penetration be evaluated (e.g., intact or very firm hymen, septate vagina). Also important to identify would be problems like chronic yeast infections, lichen planus, vaginal atrophy from lack of estrogen, or prolonged pain at an episiotomy site which could make penetration painful. MissE26 mentions, “I have had a hymenectomy over a year ago.” Kate987 said, “I’ve been tested for everything in the book, infections, STDs, diseases, all negative. I’ve also had a pelvic sonogram that came back normal.”

How Is It Diagnosed?
Interestingly, vaginismus is one of two GYN conditions which is as likely to be diagnosed by a psychiatrist as by a GYN MD (the other is PMDD). Vaginismus is included in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) as a sexual pain disorder. A psychiatrist or psychologist may make the diagnosis by asking the woman specific questions about persistent or recurrent difficulties for at least six months with inability to have vaginal intercourse and/or pain for the majority of sex attempts.

By contrast, a GYN, or a specially trained pelvic floor physical therapist (PT), may give the diagnosis after an exam and patient history. As secondary outcome, Reissing and colleagues (2004) compared diagnostic abilities between two GYN MDs and two pelvic floor PTs. They were asked to evaluate for vaginal muscle spasms among women with vaginismus, women with vulvodynia (painful vulva), and women without pain. Overall, the vaginismus women had an increased number of painful vaginal muscle spasms, but not an increased frequency of spasms compared to the vulvodynia women. The PTs had a better record for detecting vaginal spasms compared to the GYNs. This suggests that vaginal muscle spasms may not be the only factor in the problems from vaginismus.

Further support for this can be inferred from studies using electromyography measurements (use of needles or a vaginal probe to record levels of muscle tension). Usually women with vaginismus are compared to women with vulvodynia and or women without pain. Of eight studies, four studies found increased levels of muscle tension among vaginismus sufferers and four did not find increased muscle tension.

Thus, simply measuring muscle tension may not give the most accurate diagnosis. Rather it may by a combination of symptoms reported by the woman coupled with exam data. During an actual exam there are a number of classic reactions which can give the examiner the impression of vaginismus (e.g., closing of the thighs, arching back or very tightly closed muscles around the vaginal opening). In reading widely on this topic, I was amazed to find two descriptions of exams of women with vaginismus which matched my own experiences. The first description was written in 1942 by Dr. Joan Malleson, the second by Dr. William Masters in 1970-both gynecologists.

One group from the Netherlands (Klaassen & Ter Kuile, 2009) has published test results for a questionnaire called the Vaginal Penetration Cognition Questionnaire, or VPCQ. This questionnaire attempts to identify non-physical correlates linked to vaginismus. Again, this supports the idea of vaginismus being evaluated best by looking at physical symptoms and their emotional sequelae.

How Many Women Have Vaginismus?
Prevalence rates vary widely from 4%-42% (Hope, 2010). This huge variation reflects both what groups of women are being questioned, and how vaginismus is defined. For example, one might expect higher rates among women being seen in a psychiatry department for sexual problems. Among 54 such Turkish women seeking psychiatric care for sexual pain, almost 76% were diagnosed with vaginismus (Dogan, 2009). When 301 healthy women in Ghana were given the same questionnaire used in the Turkish study, 68% had some difficulties with vaginismsus. Yet only 6% had very severe penetration problems (Amidu, 2010).

Recently, scientists have begun to recognize that vaginismus can be partial as well as complete. In the instance of partial vaginismus, the woman still has a non-voluntary contraction of the vaginal muscles but at least partial penetration can occur. Binik (2009), in an excellent review of published studies, posits that women who have vaginal pain after intercourse may in fact have partial vaginismus. If this is true then one would wonder if the pain of repeated partial intercourse would predispose the woman to complete contraction of the muscles of the vaginal opening. This could be akin to the body “protecting itself” from the likelihood of further discomfort.

When Does Vaginismus Begin?
Sometimes this problem has been present from the very beginning of sexual life. As MissE26 confided, “I did know beforehand that I had a sort of fear of penetration, but I didn’t think it would actually prevent me.”

In other situations the inability to have intercourse arises later. Kate987 explained, “When I was younger I thought it would go away, and I was too embarrassed to ask anyone, including my gyno. Now that we are married, needless to say, it has gotten much worse.”

It is often written that vaginismus arises following past sexual trauma, abuse, psychological disorders (e.g., anxiety, marital discord), or a history of pain with intercourse (National Institutes of Health, 2010). Yet many of the women with vaginismus do not have any of these “predisposing” factors. Miss E26 asserts: “I feel the need to state a couple things that have come up in my past cries for help…1. I’ve never been sexually molested. 2. I do love and am attracted to my husband 3. I am attracted to men (again, specifically my husband).” Kate987 confirms: “I have never been sexually abused and I don’t have any mental trauma about sex or anything.”

Can Vaginismus Be Treated?
Everyone from Dr. Joan Malleson in 1942 through Drs. Jindal & Jindal in November 2010 write that vaginismus can be successfully treated. Treatment strategies can include:

• Education: One thousand married virgins were interviewed in 1964 by Balzer as to the reasons for nonconsumation of the marriage. He asserted that most problems would have been resolved had the woman had “adequate scientific knowledge at their disposal” (Chisholm, 1972).With today’s sex saturated media, and the availability of information via the Internet, it is hard to believe that women would need basic sex education. Yet information specific to situations such as vaginismus may enable a couple to find specialized treatment.

• Pelvic muscle training: Variations of training for relaxation of pelvic muscles is a mainstay in vaginismus treatment. This can be accomplished by use of biofeedback of muscle tension, or ability of the woman to relax until any muscle spasm resolves. Sensate focus has also been used successfully.  Jindal & Jindal (2010) reported that 60 of 76 women with primary vaginismus had symptomatic resolution of their penetration pain.

• Vaginal dilators: Plastic dilators in graduated sizes have been a common treatment for decades. These may be sent home with the woman and her partner or they may be used in the presence of a pelvic floor PT. One small study of ten women with lifelong vaginismus (Ter Kuile, 2009) were seen for six hours during a one week training session by a PT. Two follow up sessions were held over the following five weeks. At the end of treatment, nine of the ten women reported successful intercourse. The research team attributed their success to the contributions of the female PT.

• Counseling: According to the National Institutes for Health success rates can be very high if treatment is rendered by a specialist in sex therapy. A sex therapist usually incorporates specialized counseling (including the partner) along with dilators and/or referrals to pelvic floor physical therapists. Dogan and Dogan (2008) published a study on sexual function of the partners of 32 women with vaginismus. According to strict criteria, 65% of the males had one or more sexual dysfunctions with the two most common being premature ejaculation (50%) and erectile dysfunction (28%). Thus partners may need information and counseling as well.

In my clinical experience the best results have been from a combined treatment approach which utilizes both a sex therapist and a pelvic floor PT. There are also specialized clinics for the treatment of vaginismus.

In conclusion, there are some very obvious reasons to get treatment for vaginismus such as the desire to have a child. Pain with attempted intercourse can certainly have an impact on the relationship. As Kate987 explains, “Since I’ve been dealing with this for so long, I’m truly terrified of the thought of intercourse, although we still try. But it always ends with me in tears and my husband frustrated.” Vaginismus has the potential to impair a woman’s quality of life. As MissE26 attests: “I have an issue that has become more and more of a thorn in my side over the years, to the point that is affecting my quality of life, marriage and at some times even my emotional state of mind…”

So if you have problems with vaginal penetration know that you are not alone. Successful treatments exist. Support opportunities also exist. You can find additional information or support at:

• Vaginismus Awareness Network
• Vaginismus Treatments Done Differently
• Vaginismus Community

A “structural” cause of heavy menstrual bleeding means that excessive bleeding is due to actual problems within the cavity or walls of the uterus. Some examples of this would include: infections of the lining of the uterus, fibroids of the uterus, endometriosis of the muscular wall of the uterus (“adenomyosis”), polyps of the uterine lining, or even uterine cancer. Overall, among heavy bleeders between the ages of thirty and fifty, only 40% of women will have a completely normal uterus. The other 60% may have one of the following culprits responsible for excessive bleeding.

Infections
An infection in the lining of the uterus (“endometritis“) creates inflammation. The elements involved in an inflammatory response destabilize the uterine lining. This leads to both increased bleeding, and more breakthrough bleeding. Chronic infections of the uterine lining have been found in 22% of patients participating in an in vitro fertilization program, 14% of patients with unexplained infertility, and in some 23% of patients with first trimester miscarriages (Cravelo, 1997).

The most common causes of endometritis have been proposed to be chlamydia or ureaplasma (Cravello, 1997). Yet in a much larger study of 438 women with chronic endometritis the most frequently cultured pathogen was common bacteria (58%), with ureaplasma (10%) and chlamydia (2.7%) being less frequent (Cicinelli, 2008). Surprisingly most women do not get treatment. M. Smith and colleagues (2010) found that only 3% of 105 women with chronic endometritis received antibiotics or other treatments.

Certainly if a woman has a known pelvic infection (i.e., PID) she should get the recommended dose of antibiotics to prevent a chronic infection in the lining of her uterus. Given the difficulty of getting a culture from inside the uterus (as opposed to putting a Q-tip to opening of the cervical canal) a woman may be given antibiotics in an attempt to stop abnormal bleeding without having a positive lab result.

Fibroids
Fibroids of the uterus can be found in several locations: inside the cavity of the uterus (“submucosal”), inside the walls of the uterus (“intramural”), on the outside surface of the uterus (“subserosal”), or even hanging on a stalk from one of the walls of the uterus (“pedunculated”). They are created when a normal uterine muscle cell is transformed by growth factors into a fibroid cell (Blake, 2007). Thus it can be said that fibroids are a benign overgrowth of uterine muscle tissue.

There are two postulated mechanisms whereby fibroids can promote heavy bleeding. The initial link between fibroids and bleeding was thought to be the mechanical presence of these large, and often multiple, masses. The uterus would be unable to contract down firmly to help stop bleeding. This would be especially true for fibroids inside the cavity and in the wall of the uterus.

It was then noticed that bleeding problems could be present no matter where the fibroids were located. The second explanation came to include new findings about how fibroids seemed to change blood flow. Both the blood vessels on the surface of the fibroids and the blood vessels in the walls of the uterus had higher specific volumes compared to normal uterine tissue samples (Sapozhnikov, 1897). Also small blood vessels in the wall of the uterus show increased blood flow into the blood vessels surrounding fibroids (ESHRE, 2007).

Who is most likely to have fibroids? By age 45, more than 60% of white females will have fibroids present; the incidence is higher still for African American females. There is a strong genetic predisposition to having fibroids so having a family history of fibroids increases one’s risk. Some medical conditions seem to be predisposing factors. These diagnoses include: being obese, having polycystic ovarian syndrome, diabetes, high blood pressure, and never having had a pregnancy (Okolo, 2008).

A more recent study (Huang, 2010) suggests another predisposing condition — endometriosis. Of 131 women who were given hysterectomies or myomectomies (surgical removal of fibroids while leaving the uterus in place), 113 were found to have endometriosis as well. That means only 18 had just fibroids. This could imply that endometriosis of the wall of the uterus (“adenomyosis“) may be a contributing factor to abnormally heavy bleeding.

Adenomyosis
Adenomyosis represents a spectrum of changes whereby glandular and connective tissues from the lining of the uterus are found inside the muscular walls of the uterus. The nearby smooth muscles of the walls seem to thicken (Gordts, 2008). Adenomyosis is a common cause of diffuse enlargement of the uterus when fibroids are not seen. In some women there may be tenderness of the uterus as well.

It is less clear how adenomyosis increases the frequency of heavy bleeding. One possible explanation states that the muscular walls of the uterus have an impaired ability to contract to help stop heavy bleeding. Prostaglandins have also been blamed for the increased bleeding of adenomyosis. More recently increased numbers of blood vessels have been found that seem to be growing in the muscular wall of the uterus when adenomyosis is present (Hickey, 2000).

It has been proposed that undetected adenomyosis may be responsible for unsuccessful attempts at treating heavy bleeding such as failed endometrial ablations, or resections, (Basak, 2009). Unfortunately, the most definitive diagnosis is made after hysterectomy when the pathologist examines the tissues of the uterus. An MRI is the best diagnostic imaging method; ultrasound does not visualize adenomyosis with reliability. The incidence of adenomyosis has been found to range from 15% (Ben Hamouda, 2007) to 48% (Weiss, 2009).

Polyps
Polyps are composed of glands (like uterine lining tissue) in a fibrous tissue matrix which also contains blood vessels (Brechin, 1999). Therefore, like adenomyosis and uterine lining tissue, polyps are hormonally stimulated by estrogen. This prolonged exposure to estrogen likely accounts for the increasing numbers of uterine lining polyps seen in women as they age into their 30’s and 40’s.

Polyps can be single or multiple, with a size range from a pencil lead to a human thumb. The size differential may govern whether a polyp regresses without treatment. In one small study of 64 women without bleeding problems, four out of the seven that had polyps showed polyps regressing at the time of a second saline infusion ultrasound two and a half years later. Polyps that did not resolve tended to be larger in size and went on to cause bleeding abnormalities (Dewaay, 2002)

Polyps can prompt bleeding between menstrual periods or spotting after sex. Like the lining of the uterus or the cervical canal, the glands that make up the lining can produce a fragile, easy to bleed surface. The increased number of blood vessels, coupled with the fragile uterine lining tissue stretched over the surface of the polyp, likely contributes to increased bleeding. Additionally, polyps have increased numbers of activated mast cells compared to surrounding uterine lining (Al-Jefout, 2009). Mast cells can secrete histamine (dilates tiny veins) and heparin (keeps blood from clotting).

The over riding concern is whether polyps may contain abnormal, cancerous or precancerous cells. This is similar to the concern we have about a too thick lining of the uterus containing abnormal cells. Lee and colleagues (2010) reviewed studies containing a total of 1552 women who had polyps removed and sent to a pathologist. They concluded that both complaints of vaginal bleeding and being postmenopausal increased the risks of a polyp being cancerous or precancerous. Yet absolute numbers were small. Vaginal bleeders accounted for 4.1% of worrisome polyps and non-bleeders for 2.1%. Of women with polyps, the prevalence of cancerous or precancerous polyps in postmenopausal women was 5.4% compared with 1.7% in premenopausal women.

Like adenomyosis, polyps are not reliably diagnosed with simple vaginal ultrasound scans. On an ultrasound polyps may appear to be an irregularly thickened lining inside the uterus. Two of the better ways to diagnose polyps are a saline infusion ultrasound and a hysteroscope. When sterile saline is put into the uterine cavity, polyps will appear to “float” in the water — rather like sea grass on the ocean shore. In a comparison study, regular ultrasound was able to correctly identify polyps about 65% of the time while the use of saline increased the rate to 91% (Yildizhan, 2008). A flexible, fiber optic light scope (hysteroscope) can be inserted inside the uterus to get a direct look for polyps. Any polyps or other tissues of concern can be removed with micro-cutting tools at the time of the procedure.

And again, there are treatments for each of the causes of heavy bleeding we have discussed. So if you or someone you know has episodes of heavy blood loss rather than a normal period, talk to your doctor  — there are ways to stop going with the flow.

Read the series “Let It Bleed: Causes of Heavy Periods”

• Hormonal Causes
• Structural Causes