Wednesday, August 19, 2009

Vaginal Wind: An Embarrassing Event

Some women have experienced passage of air or wind from the vagina that can create an audible noise, and may be embarrassing. It can happening during sporting activities, sexual intercourse or sometimes just from squatting.

Pelvic floor weakness, usually from childbirth, is the main culprit here. Air can get drawn or sucked into the vagina during any of the above mentioned activities, especially if the vaginal opening is wider or looser than what it had been previously. After the air is drawn in it becomes trapped in the upper vagina behind one of the vaginal walls that may be loose, such as from a mildly dropped bladder. Then during repositioning of the body, the air is pushed out the vagina creating a noise and sensation.

Pelvic floor muscle weakness is common. Many women already perform Kegel muscle exercises to help decrease the severity and incidence of urinary incontinence/leakage they experience. Similar pelvic floor muscle retraining can re-strengthen this part of the body. In addition, squeezing the thighs closed against a beach ball, or pushing the thighs out against resistance at the gym, also helps the pelvic floor.

Weighted vaginal cones are different sized smooth cones that are placed in the vagina around which the woman squeezes in order to retain the cone. You begin with larger sizes and work your way down.

Sometimes placing a large tampon in the vagina while working out, simply blocks movement of air. It may also support the urethra just enough to prevent urinary incontinence as well during a workout, and trap urine within it prevent wetting of underwear or workout clothes.
Significant pelvic floor weakness can be surgically corrected if significant. When the bladder, top of the vagina or rectum push into the vagina, causing pressure, or even push out the vagina, then it’s time to have a formal examination.

Thursday, August 13, 2009

Vaginal Health for Post-Menopausal Women PART 2

Loss of Estrogen with menopause can also lead to urinary incontinence and bladder symptoms. The two most common types of urinary incontinence are Stress Urinary Incontinence (SUI), and Urge Urinary Incontinence (UUI). Atrophy itself doesn’t directly lead to incontinence, but atrophy does increase the likelihood of development and both types of leakage are more symptomatic in the woman with atrophy. Other contributing factors to incontinence include: birth trauma, previous surgery such as hysterectomy, radiation, obesity, repetitive straining (constipation, heavy exercise), medication use, and age.

Review of the medical literature has shown that Estrogen replacement (topical preferred), is beneficial in treating atrophy, particularly symptoms of dryness, itching, burning, pain with intercourse, recurrent UTIs, and urinary urgency and frequency.

The usual dose is 1 gm inserted into the vagina at bedtime between 2-3 times per week. Usually there is a run-in period for 1-2 weeks when first beginning when it is inserted every night or every other night. Of course, any history of breast cancer, cervical or endometrial cancer is clearly contraindicated. Sometimes even vaginal estrogen topical cream can lead to transient flushing, breast tenderness or other symptoms when first starting up. The overall absorption of estrogen into the bloodstream after topical application is inconsequential, and circulating blood levels of Estrogen are unchanged even after 6 months of typical use (1 gram topical every other night). Occasionally it can lead to a burning sensation itself in the vagina, and thus it is not for everyone.

Generally, about 2-12 weeks are needed for resolution of symptoms, however, some women find that once therapy is initiated, it should be continued as long as it is tolerated or desired. Symptoms usually return about 4-6 weeks after it is discontinued. Topical Estrogen alone DOES NOT treat stress or urge incontinence, but Estrogen in conjunction with other therapies can improve urge incontinence. Usually, stress incontinence is best treated by a sling procedure once Kegel muscles exercises have failed, or if severe. Lastly, Estrogen therapy is not effective in treating pelvic organ prolapse, such as a dropped bladder (cystocele).

Monday, August 10, 2009

Vaginal Health in Post-Menopausal Women: Part 1

What is it about menopause that leads to deterioration of vaginal health? Most answers revolve around Estrogen levels getting lower but how does the latter lead to the former?

The environment of the vagina has normal bacterial flora, just like the mouth or intestines, that serve certain good purposes. These normal vaginal bacteria keep the tissue healthy and protect against infection. Lactobacilli are the normal bacteria in the vagina. They produce lactic acid which keeps the vagina slightly acidic, preventing bacteria around the anus or other parts of the body from “invading”. However, Lactobacili require a healthy vagina high in Estrogen to thicken the vaginal lining to allow these to survive.

Atrophy, or thinning of tissue, occurs with loss of Estrogen following menopause. The degree of atrophy depends on multiple factors which helps explain a wide variety of symptoms. Up to 50% of menopausal women experience symptoms of genital atrophy, and with women living longer and healthy, vaginal atrophy symptoms can lead to dramatic effects on quality of life.

What are some symptoms of atrophy?
Vaginal: burning, watery discharge, dryness, uncomfortable intercourse, itching.
Bladder: recurrent UTIs, frequency, urgency, burning with urination, waking at night frequently to urinate.

Bacteria can exist in the bladder in 20% of 70 year old women, and increases up to 50% by age 80. Close to 10% of women over the age of 60 will suffer from recurrent UTIs, which is defined as more than 2 UTIs per year. Once Estrogen levels drop, Lactobacilli fail to grow in the vagina, leading to a loss of acidity, which then allows harmful bacteria to propagate in the vagina and lead to infections.

Saturday, August 1, 2009

Pessaries- What are they and when do you use them?

Until surgical methods matured, Pessaries were the only form of treating pelvic organ prolapse (POP), such as cystocele, rectocele, uterine prolapse and stress incontinence. A pessary is classically a round ring that is placed into the vagina to reduce the prolapse. It derives from the Greek word pesos, meaning stone. Modern Pessaries can take many shapes: rings, cubes, horns, rings with knobs, and semi-circle forms. Since the lifetime risk for a woman in the US for undergoing POP surgery is 11%, pessary is often discussed as one of the non-invasive treatment options either for mild-moderate prolapse or in women who may not be good surgical candidates.

Pessaries must be properly fit to the woman’s pelvis and must be comfortable. Often, 2 or 3 fittings are necessary in order to see which size is appropriate. Not many practitioners are skilled in fitting Pessaries, but usually, a GYN nurse practitioner is the most common health care professional who does the fittings.

Care must taken when using a pessary. Women who have them inserted must be comfortable removing and placing them by themselves. They must be removed before intercourse. Local estrogen cream is necessary to keep the vaginal tissue from becoming irritated from the pessary. It can be left in during the day and removed at night. Side effects include: discharge, odor, vaginal skin irritation with bleeding, spontaneous expulsion, obstructive urination, and discomfort. Rare cases of vaginal erosion or ulceration can occur if women forget they have a pessary in place. If the woman cannot herself remove it, she must at least visit her practitioner on a frequent basis to have it removed and cleaned.