Bumps and lumps

We get a lot of anxious patients worried when they find a variety of bumps/lumps on their bottoms and other locations.  Starting in the more southerly location, what should be the most concerning and what can wait to be evaluated?  Certainly anything causing severe pain we want to see sooner than later to get you relief.  This would include Bartholin's cysts/abscesses (usually the largest things we see and among the most painful).  They usually require surgical drainage to get better.

Herpes lesions, especially in large clusters, can be extremely uncomfortable and require medication for pain, for the viral infection and sometimes even urinary catheterization if a patient can't urinate normally due to the pain.  In the more severe herpes outbreaks, lymph nodes in the groin can also become enlarged and painful.

Sometimes sebaceous cysts or hair follicles can become infected and fill with pus (an "abscess") requiring incision and drainage in the office or treatment with topical or oral antibiotics.  Genital warts are usually more embarrassing than painful, but are most often treatable with topical medication.  Occasionally surgical excision or laser treatment is used for extensive disease.

Sometimes we encounter benign cysts, usually inside the vagina and often related to the way a laceration healed after childbirth.  Rarely we encounter tumors in the genital area.

Moving north,  the other area of concern for bumps/lumps is the breasts.  Fortunately many of the lumps we find (or that patients come to us with) are benign cysts or tumors that are commonly found in breasts.  We are always conscious of the fact, however, that even our younger patients aren't immune to breast cancers.  The characteristics of a breast lump that are reassuring are when they are tender, move around well with the rest of the surrounding breast tissue, have smooth edges,  and often wax and wane in different areas of the breasts (especially with the menstrual cycle).  Concerning signs of a breast lump are when it doesn't have smooth edges or move around easily, when it does NOT feel tender, when it is hard and when it keeps growing in the same place in the breast.  Obviously, a family history of breast cancer is also of concern, but the absence of a family history doesn't mean one isn't vulnerable to breast cancer.  Most patients with a palpable mass will get an imaging study of some kind (mammogram =/- Ultrasound) and the more concerning lesions occasionally merit an MRI.  Needle or surgical biopsies are sometimes needed to tell whether a lesion is benign or not.

Skin tags are very frequently seen and can often be removed in the office if they are getting in the way of clothing/jewelry/etc.  Darkly pigmented, irregular, irritated/bleeding or rapidly growing lesions should be evaluated by a dermatologist for possible skin cancer/precancer.  People with risk factors such as a history of sunburns, very fair skin, abundant moles, or family history of skin cancer should schedule regular skin checks with a dermatologist as well.  

When should my teenager come to the Gyn for the first time?

Another question I get all the time:  When should I bring in my teenage daughter for the first time?  In general the answer is between 15 and 16 years old, according the the experts in adolescent gynecology.    That doesn't necessarily mean they need to have a physical examination, which is what most of them are afraid of!  In the majority of cases, in fact, we just have a conversation about menstruation, safe sex, contraception, substance abuse, driving safety, and general personal responsibility for one's own health and welfare as they mature.  The first Pap doesn't have to be done until age 21 or within 3 years of first intercourse.  Oftentimes the child has already had her HPV vaccine series, but if not we can arrange for that.  STD testing is available when applicable, and we don't have a problem with prescribing hormonal contraceptives without a formal pelvic examination in the absence of any unusual personal/family history or symptoms.  I think the main reason to have your daughter come in is to establish a doctor-patient relationship and an avenue through which she can access care in the future with or without mom and dad's escort.  It gives her permission and encouragementto take care of herself now and forever.

Bleeding in Pregnancy

Nothing strikes fear into a woman's heart like discovering she's bleeding while pregnant.  The first thought is usually "is the baby alright?"  The answer to that depends on a variety of things including the amount of bleeding, the stage of pregnancy, the age of the mom, other medical conditions that may be present, and so on.

Bleeding in the first trimester is most concerning for miscarriage or occasionally for an ectopic pregnancy.  I tell my patients that call with early bleeding that only about half the time is bleeding an indication that the pregnancy will be lost, so to try not to panic right away.  If the bleeding is very heavy (more than a pad an hour) or associated with any severe pain or lightheadedness, we will often have patients go to the hospital emergency department for evaluation.  We also have a portable ultrasound machine in our office that can help determine the status of the pregnancy.

Bleeding later in pregnancy can often be associated with sexual intercourse or in more serious cases with preterm labor, placenta previa, or placental abruption.  Another common source of bleeding late in pregnancy is the cervical examinations we start doing around 35--36 weeks of pregnancy, although it is usually not very much and stops quickly.  Active labor is often accompanied by what we refer to as "bloody show" which is a mixture of blood and mucous that occurs when the cervix begins to dilate.

Whenever in doubt, we're of course always available to answer your questions and help you decide if the amount of bleeding you're experiencing needs to be immediately evaluated or not.  

You have a self-cleaning oven!

One of the most frequent  reasons to see a gynecologist is vaginal irritation.  While yeast infections, bacterial, and parasitic infections are commonly found, it is also very common to find no evidence of infection at all.  In those situations the first question I ask patients is "what is you personal hygiene regimen?"  The answer to that question is almost always the wrong one.

The right answer to the question should be "a little warm water", but it is usually some sort of soap, body wash, feminine cleanser, wipe, etc.  I respond by telling patients that for the most part they have a built in "self-cleaning oven" and that introducing all these cleansing techniques often does more harm than good.  As in the gastrointestinal tract, there is a mixture of normally-occurring microorganisms in the vagina that live together in a very delicate balance.  This balance can be affected by changes in pH, exposure to antibiotics/medications, chemicals, etc.  When the balance is off, symptoms such as discharge, odor and itching can result.

Many women, particularly fair-skinned women and older patients, can also have very sensitive skin around the vagina (the perineum) which can become red, itchy and irritated like an allergic reaction when exposed to soaps, pool chlorine, pads (especially scented ones), condoms, lubricants, etc.  As in other dermatologic disorders, sometimes it takes a little careful investigation to find out exactly what the source of the discomfort is.  Stopping the chemical irritants and waiting 4--8 weeks is often all that is necessary for balance to be restored, but intense itching can be symptomatically treated in the short run with antihistamines such as diphenhydramine or topical steroid creams such as 1% hydrocortisone cream.  Postmenopausal patients sometimes need topical estrogens to restore natural protections to the vaginal mucous membranes.

With regard to discharge, a certain amount of clear or light yellow mucous is a normal finding, particularly around the time of ovulation.  Some patients certainly experience more than others, and pregnant patients find that discharge naturally increases throughout pregnancy.  When you're not sure what normal is for you, your gynecology care provider can help you figure it out.  

Break-Through Bleeding, aka "BTB"

I asked my nurse today what she gets the most telephone questions about on a day-to-day basis and she said without hesitation:  Break-Through Bleeding!  What is BTB, anyway?  Generally we doctors refer to bleeding between periods as BTB or "metrorrhagia", heavy bleeding with the period as "menorrhagia", and both together as "menometrorrhagia".  Depending on your age, BTB can be caused by different things.  Probably the most common cause in our younger patients is starting a new (<3months), hormonal contraceptive  (pill/patch/ring/shot/etc).  While your body is getting used to having the exogenous hormones controlling the bleeding cycle, there can still be the occasional irregular shedding of uterine lining, leading to the bleeding.  This is more likely nowadays with the very low estrogen dose pills, which are a little more unforgiving if the pill is taken at different times of day.  Even perfect usage can be associated with some BTB at first though. BTB does not mean that the contraceptive is not working to prevent pregnancy, however.

More concerning is bleeding that occurs between periods without any exogenous hormone treatment.  A normal menstrual cycle is between 21--45 days in length.  I tell patients that I need them to tell me if they have bleeding episodes less than 21 days apart (counting from the first day of the period to the first day of the next period).  Sometimes we discover benign polyps or fibroids of the cervix or uterus.  Rarely, we diagnose pre-cancer or cancer of the uterus, however.  This is higher risk in patients at the end of their reproductive years of course, but I've also seen it in younger patients with long periods of absent periods followed by heavy or irregular bleeding episodes.  I like patients to let me know if they miss more than 3 menstrual periods in a row, as hormonal treatments can make them more regular and prevent mutations that could lead to abnormal cells in the uterine lining.

Sometimes we do an office biopsy ("EMB") for abnormal bleeding, sometimes an ultrasound, sometimes both.  Occasionally we do a procedure with a hysteroscope that allows us to see inside the uterus fiberoptically and identify pathology during a D and C procedure (dilitation and currettage).
If abnormal bleeding patterns persist despite all our best efforts and diagnosis and medical management, we do have surgical procedures that can decrease or eliminate menstrual bleeding.

Letting it All Out: Nausea and vomiting in pregnancy

I enjoyed seeing just how many euphemisms there are for vomiting on this webpage:  http://jakersdelight.blogspot.com/2009/08/vomit-euphemisms.html.  Every pregnant woman knows, however, that there's nothing funny about the nausea (aka "morning sickness") that affects most women at some point during pregnancy.  Some of us can suffer for half or more of the pregnancy, while most women peak at 7--12 weeks then find that the symptoms decrease and then disappear.  So what's to be done about it?  Well,  if there's just nausea but no vomiting it is certainly reasonable to try just modifying one's diet to foods that seem to agree with them (which will be different for everyone, but typically bland foods low in fat and higher in carbs work for many).  Vitamin B6 or pyridoxine, 100mg daily, can also be helpful.  Some women also try "sea-bands" and accupuncture to help themselves.  Sipping lemonade or sucking on lemon drops can take away some of that bad taste women frequently complain about.  Being careful during tooth brushing not to stimulate too much retching is also a challenge, but a fluoride mouthwash can help you keep up with your oral hygiene.

I tell my patients that some weight loss is not as concerning in the beginning as is dehydration.  If a patient calls with an inability to hold down fluids for more than 12 hrs, I usually have them come to the hospital for IV hydration in order to help break the cycle of nausea and vomiting that can often ensue from getting dehydrated.  This is true both for pregnancy-related nausea and vomiting, as well as gastroenteritis or food poisoning.  Late in pregnancy the dehydration can also cause preterm contractions, which is another reason we like to intervene sooner than later.

Medications that we use for nausea in pregnancy include promethazine or Phenergan, Reglan, and Zofran.  Promethazine can be sedating and Zofran can cause constipation, so being prepared for side effects is a good thing.  In extreme cases we occassionally hospitalize patients and even more rarely send them home with long-term intravenous nutrition formulas for home infusion.  Having severe nausea can also lead to depression, so we monitor these patients closely for those signs and symptoms too.

The good news is that the reason many women suffer with nausea is that the level of their hormones is nice and high, often an indicator of a normally developing pregnancy.  All pregnancies are associated with a plateau in these levels around 10 wks or so, and that's why most women can expect their symptoms to wane shortly thereafter.

"I'm feeling so HORMONAL lately!" Mood Swings in Women

Many patients will come to the office saying they're feeling "hormonal" at various times.  When pressed, what I almost always learn is that what they are really saying is that they are feeling depressed, anxious, irritable or generally moody. While certain times of the menstrual cycle (a week before the onset of menses to about 2 days into the period) can produce transient mood changes, I'm always careful not to allow my patients to blame all of their emotional changes simply on their hormone fluctuations.  Mood problems are very common in both men and women (23--46% chance) and can wax and wane over one's lifetime for a variety of reasons.  Some people are more prone than others to disturbances in their moods, and looking at your family history can often give a clue as to whether there are some vulnerabilities that may have been passed down the family tree.  This includes not only formally diagnosed conditions such as depression, anxiety, bipolar disorder, etc. but also a tendency toward substance abuse (often associated with self-medication of mood disorders).

20% of pregnant women may experience mood disorders and up to 80% of postpartum patients experience some level of "the blues".  Fortunately less than 1--2% suffer postpartum psychosis.  We monitor all our pregnant and postpartum patients for such symptoms.  Often patients who are struggling to conceive a pregnancy or who have had prior poor pregnancy outcomes are vulnerable to mood changes and require special attention.

PMS is often manageable with excercise, lifestyle changes, dietary modifications, and sometimes medications (hormonal and non-hormonal) given part or all of the month.  Mood changes associated with the transition to menopause (the "peri-menopause") are frequently related to the hot flashes, night sweats and disruption of normal sleep patterns.  Addressing those symptoms so that a woman gets good rest can go a long way toward helping restore a more stable mood.  Low dose hormonal contraceptives can also help regulate fluctuations in hormones during this transition as well, making periods more predictable.  This is an option even for those who have had tubal ligations or other long term/permanent contraceptive methods of birth control.

After the menopause transition, mood problems are no more common than in the general population, but certainly managing chronic health conditions, changing levels of independence, and the grief of losing a spouse or other friends and family members can produce changes in mental health that should be addressed regularly by one's physician or mental health professional.

http://www.34-menopause-symptoms.com/mood-swings.htm