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A multiple pregnancy is when you are pregnant with twins, triplets or more. Three babies or more is called a ‘higher order’ pregnancy, and it’s rare – occurring in just 1 in 50 multiple pregnancies. Find out more about the different types of multiple pregnancy here.

How do multiple pregnancies occur?

Multiple pregnancies occur when more than one embryo implants in your uterus (womb). This can happen if you release more than one egg during the menstrual cycle and each egg is fertilised by a sperm. Sometimes, a fertilised egg spontaneously splits into 2, resulting in identical embryos.

Multiple pregnancies are more common than they used to be, mainly because of the increasing use of in vitro fertilisation (IVF).

Fertility drugs often cause more than one egg to be released from the ovaries. IVF can result in a multiple pregnancy if more than one fertilised embryo is transferred to the uterus and develops. Sometimes, one of these eggs may split into twins after it is transferred.

Women aged 35 and older are more likely to release more than one egg during ovulation, so they are more likely to have a multiple pregnancy. You are also more likely to have a multiple pregnancy if you have a history of twins in your family.

Diagnosis of multiple pregnancy

Signs you may be expecting multiple babies include:

• You gain weight rapidly at the start of the pregnancy.
• You have severe morning sickness.
• More than one heartbeat is picked up during a prenatal examination.
• The uterus is larger than expected.

A multiple pregnancy is confirmed by an ultrasound scan, usually in the first trimester (the first 12 weeks). The ultrasound will confirm the type of multiple pregnancy, whether there is one placenta or 2, and how many amniotic sacs there are. These are all important factors for later in the pregnancy and it’s important to identify them as early as possible.

If you are carrying multiple babies, you will have to see your doctor more often than women who are expecting one baby. While most multiple pregnancies progress smoothly, there’s a higher chance of the babies being born prematurely, having a low birth weight, or for you to have other complications with your pregnancy.

Types of multiple pregnancy

The most common type of multiples are:

Fraternal twins

Two separate eggs are fertilised and implant in the uterus. The babies are siblings who share the same uterus — they may look similar or different, and may either be the same gender (2 girls or 2 boys) or of different genders. A pregnancy with fraternal twins is statistically the lowest risk of all multiple pregnancies since each baby has its own placenta and amniotic sac. You will sometimes hear fraternal twins referred to as ‘dizygotic’ twins, referring to 2 zygotes (fertilised eggs).

Identical twins

Identical twins are formed when a single fertilised egg is split in half. Each half (embryo) is genetically identical, so the babies share the same DNA. That means the babies will share many characteristics. However, because their appearance is influenced by the environment as well as by genes, sometimes identical twins can look quite different. Identical twins may share the same placenta and amniotic sac, or they may have their own placenta and amniotic sac. You will sometimes hear identical twins referred to as ‘monozygotic’, referring to one zygote (fertilised egg).

Triplets and ‘higher order multiples’ (HOMs)

Triplets, quadruplets, quintuplets, sextuplets or more can be a combination both of identical and fraternal multiples. For example, triplets can be either fraternal (trizygotic), forming from 3 individual eggs that are fertilised and implanted in the uterus; or they can be identical, when one egg divides into 3 embryos; or they can be a combination of both.

If you are having 3 babies or more, you will need a lot of support throughout your pregnancy.

Are identical twins or triplets always the same sex?

Because identical twins or triplets share genetic material, they are always the same sex. The sex of a baby is determined by the particular sperm cell that fertilizes the egg at conception. There are two kinds of sperm cells — those carrying an X chromosome or Y chromosome. The mother’s egg carries an X chromosome. If a sperm cell carrying an X chromosome fertilizes the egg, it will make a XX combination (female). If the sperm cell is carrying a Y chromosome, you end up with an XY pairing (male).

Identical multiples start as one egg and then split, so whatever chromosome combination is present at fertilization is the sex of all multiples.

What increases the chance of a multiple pregnancy?

There are several factors that can increase the risk of a multiple birth. You might be at a higher risk of getting pregnant with more than one baby at a time if you:

• Are older (women in their 30s are at a higher risk of multiples because the body starts to release multiple eggs at one time when you get older).
• Are a twin yourself or have twins in your family.
• Are using fertility drugs.

You might also be at a higher risk of a multiple pregnancy if you are taller than average or have a higher body weight.

Another risk factor for a multiple pregnancy is genetic. There is an increased possibility of a multiple pregnancy if you are a multiple yourself, or if multiples run in your family. This heredity trait is generally passed down through the maternal (mother’s) side of the family.

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The use of fertility drugs can be another reason you might have a multiple birth. Treatments for infertility can increase your risk of a multiple pregnancy because procedures, like in vitro fertilization (IVF), often involve transferring more than one fertilized egg into your womb. Your provider usually transfers more than one egg at a time to increase the odds of a successful pregnancy.

What are the signs of a multiple pregnancy?

The only way to know if you’re pregnant with more than one baby during your pregnancy is through an ultrasound exam with your healthcare provider. During this test, your provider can look at images of the inside of your uterus and confirm how many babies are in there.

You might experience more intense symptoms during a multiple pregnancy than with a single pregnancy. These can include:

• Severe nausea and vomiting (morning sickness).
• Rapid weight gain in the first trimester of pregnancy.
• Sore or very tender breasts.
• High human chorionic gonadotrophin (hCG) levels — this hormone is made during pregnancy and is what a pregnancy test picks up.
• High amounts of the protein alpha-fetoprotein in your blood.

Apart from an ultrasound, your provider might suspect multiples if there’s more than one heartbeat detected during a fetal Doppler scan.

What complications are linked to multiple births?

Anyone can experience complications during pregnancy — regardless of how many babies you’re carrying. However, most healthcare providers consider multiple pregnancies higher risk than single pregnancies. This doesn’t mean that every woman who carries more than one baby during a pregnancy is going to have problems. If you’re pregnant with multiples, your provider will want to watch you for possible complications that can happen when you carry more than one baby at once. Your provider will talk to you about each risk factor and frequently check with you to make sure you aren’t experiencing anything concerning.

Possible complications include:

• Premature labor and birth: The most common complication of multiple births is premature labor. If you’re pregnant for multiples, you are more likely to go into premature labor (before 37 weeks) than a woman carrying only one baby. The goal for many moms of multiples is to complete 37 weeks. This is considered term in a twin pregnancy and reaching this week of gestation increases the chance the babies will be born healthy and at a good weight. Babies that are born prematurely are at risk of another complication of multiple births — low birth weight.
• Preeclampsia or gestational hypertension (high blood pressure): High blood pressure is called hypertension. During pregnancy, your healthcare provider will watch your blood pressure carefully to make sure you don’t develop gestational hypertension (high blood pressure during pregnancy). This can lead to a dangerous condition called preeclampsia. Complications related to high blood pressure happen at twice the rate in women carrying multiples compared to women pregnant with only one baby. This complication also tends to happen earlier in pregnancy and be more severe in multiple pregnancies than single pregnancies.
• Gestational diabetes: You can develop diabetes during pregnancy. This happens because of the increased amount of hormones from the placenta. The size of the placenta can also be a factor in this condition. If you have two placentas, there’s an increased resistance to insulin.
• Placenta abruption: This condition happens when the placenta detaches (separates) from the wall of your uterus before delivery. This is an emergency situation. Placenta abruption is more common in women who are carrying multiples.
• Fetal growth restriction: This condition can also be called intrauterine growth restriction (IUGR) or small for gestational age (SGA). This condition happens when one or more of your babies is not growing at the proper rate. This condition might cause the babies to be born prematurely or at a low birth-weight. Nearly half of pregnancies with more than one baby have this problem.

Fraternal twins always have two placentas. The risks of pregnancies with fraternal twins are similar to those of pregnancies with only one baby. However, the number of possible risks are increased when compared to pregnancies with one baby.

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Pregnancy begins with a fertilized egg. Normally, the fertilized egg attaches to the lining of the uterus. An ectopic pregnancy occurs when a fertilized egg implants and grows outside the main cavity of the uterus.

An ectopic pregnancy most often occurs in a fallopian tube, which carries eggs from the ovaries to the uterus. This type of ectopic pregnancy is called a tubal pregnancy. Sometimes, an ectopic pregnancy occurs in other areas of the body, such as the ovary, abdominal cavity or the lower part of the uterus (cervix), which connects to the vagina.

An ectopic pregnancy can’t proceed normally. The fertilized egg can’t survive, and the growing tissue may cause life-threatening bleeding, if left untreated.

From fertilization to delivery, pregnancy requires a number of steps in a woman’s body. One of these steps is when a fertilized egg travels to the uterus to attach itself. In the case of an ectopic pregnancy, the fertilized egg doesn’t attach to the uterus. Instead, it may attach to the fallopian tube, abdominal cavity, or cervix.

While a pregnancy test may reveal a woman is pregnant, a fertilized egg can’t properly grow anywhere other than the uterus. According to the American Academy of Family Physicians (AAFP), ectopic pregnancies occur in about 1 out of every 50 pregnancies (20 out of 1,000).

An untreated ectopic pregnancy can be a medical emergency. Prompt treatment reduces your risk of complications from the ectopic pregnancy, increases your chances for future, healthy pregnancies, and reduces future health complications.

causes

A tubal pregnancy — the most common type of ectopic pregnancy — happens when a fertilized egg gets stuck on its way to the uterus, often because the fallopian tube is damaged by inflammation or is misshapen. Hormonal imbalances or abnormal development of the fertilized egg also might play a role.

The cause of an ectopic pregnancy isn’t always clear. In some cases, the following conditions have been linked with an ectopic pregnancy:

• inflammation and scarring of the fallopian tubes from a previous medical condition, infection, or surgery
• hormonal factors
• genetic abnormalities
• birth defects
• medical conditions that affect the shape and condition of the fallopian tubes and reproductive organs

Your doctor may be able to give you more specific information about your condition.

symptoms

Nausea and breast soreness are common symptoms in both ectopic and uterine pregnancies. The following symptoms are more common in an ectopic pregnancy and can indicate a medical emergency:

• sharp waves of pain in the abdomen, pelvis, shoulder, or neck
• severe pain that occurs on one side of the abdomen
• light to heavy vaginal spotting or bleeding
• dizziness or fainting
• rectal pressure

You should contact your doctor or seek immediate treatment if you know that you’re pregnant and have any of these symptoms.

You may not notice any symptoms at first. However, some women who have an ectopic pregnancy have the usual early signs or symptoms of pregnancy — a missed period, breast tenderness and nausea.

If you take a pregnancy test, the result will be positive. Still, an ectopic pregnancy can’t continue as normal.

As the fertilized egg grows in the improper place, signs and symptoms become more noticeable.

Early warning of ectopic pregnancy

Often, the first warning signs of an ectopic pregnancy are light vaginal bleeding and pelvic pain.

If blood leaks from the fallopian tube, you may feel shoulder pain or an urge to have a bowel movement. Your specific symptoms depend on where the blood collects and which nerves are irritated.

Emergency symptoms

If the fertilized egg continues to grow in the fallopian tube, it can cause the tube to rupture. Heavy bleeding inside the abdomen is likely. Symptoms of this life-threatening event include extreme lightheadedness, fainting and shock.

When to see a doctor

Seek emergency medical help if you have any signs or symptoms of an ectopic pregnancy, including:

• Severe abdominal or pelvic pain accompanied by vaginal bleeding
• Extreme lightheadedness or fainting
• Shoulder pain

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Diagnosis

If you suspect you may have an ectopic pregnancy, see your doctor immediately. Ectopic pregnancies can’t be diagnosed from a physical exam. However, your doctor may still perform one to rule out other factors.

Another step to diagnosis is a transvaginal ultrasound. This involves inserting a special wand-like instrument into your vagina so that your doctor can see if a gestational sac is in the uterus.

Your doctor may also use a blood test to determine your levels of hCG and progesterone. These are hormones that are present during pregnancy. If these hormone levels start to decrease or stay the same over the course of a few days and a gestational sac isn’t present in an ultrasound, the pregnancy is likely ectopic.

If you’re having severe symptoms, such as significant pain or bleeding, there may not be enough time to complete all these steps. The fallopian tube could rupture in extreme cases, causing severe internal bleeding. Your doctor will then perform an emergency surgery to provide immediate treatment.

A pelvic exam can help your doctor identify areas of pain, tenderness, or a mass in the fallopian tube or ovary. However, your doctor can’t diagnose an ectopic pregnancy by examining you. You’ll need blood tests and an ultrasound.

Pregnancy test

Your doctor will order the human chorionic gonadotropin (HCG) blood test to confirm that you’re pregnant. Levels of this hormone increase during pregnancy. This blood test may be repeated every few days until ultrasound testing can confirm or rule out an ectopic pregnancy — usually about five to six weeks after conception.

Ultrasound

A transvaginal ultrasound allows your doctor to see the exact location of your pregnancy. For this test, a wandlike device is placed into your vagina. It uses sound waves to create images of your uterus, ovaries and fallopian tubes, and sends the pictures to a nearby monitor.

Abdominal ultrasound, in which an ultrasound wand is moved over your belly, may be used to confirm your pregnancy or evaluate for internal bleeding.

Other blood tests

A complete blood count will be done to check for anemia or other signs of blood loss. If you’re diagnosed with an ectopic pregnancy, your doctor may also order tests to check your blood type in case you need a transfusion.

risk factors

All sexually active women are at some risk for an ectopic pregnancy. Risk factors increase with any of the following:

• maternal age of 35 years or older
• history of pelvic surgery, abdominal surgery, or multiple abortions
• history of pelvic inflammatory disease (PID)
• history of endometriosis
• conception occurred despite tubal ligation or intrauterine device (IUD)
• conception aided by fertility drugs or procedures
• smoking
• history of ectopic pregnancy
• history of sexually transmitted diseases (STDs), such as gonorrhea or chlamydia
• having structural abnormalities in the fallopian tubes that make it hard for the egg to travel

If you have any of the above risk factors, talk to your doctor. You can work with your doctor or a fertility specialist to minimize the risks for future ectopic pregnancies.

Complications

An ectopic pregnancy can cause your fallopian tube to burst open. Without treatment, the ruptured tube can lead to life-threatening bleeding.

Treatment

A fertilized egg can’t develop normally outside the uterus. To prevent life-threatening complications, the ectopic tissue needs to be removed. Depending on your symptoms and when the ectopic pregnancy is discovered, this may be done using medication, laparoscopic surgery or abdominal surgery.

Medication

An early ectopic pregnancy without unstable bleeding is most often treated with a medication called methotrexate, which stops cell growth and dissolves existing cells. The medication is given by injection. It’s very important that the diagnosis of ectopic pregnancy is certain before receiving this treatment.

After the injection, your doctor will order another HCG test to determine how well treatment is working, and if you need more medication.

Laparoscopic procedures

Salpingostomy and salpingectomy are two laparoscopic surgeries used to treat some ectopic pregnancies. In these procedure, a small incision is made in the abdomen, near or in the navel. Next, your doctor uses a thin tube equipped with a camera lens and light (laparoscope) to view the tubal area.

In a salpingostomy, the ectopic pregnancy is removed and the tube left to heal on its own. In a salpingectomy, the ectopic pregnancy and the tube are both removed.

Which procedure you have depends on the amount of bleeding and damage and whether the tube has ruptured. Also a factor is whether your other fallopian tube is normal or shows signs of prior damage.

Emergency surgery

If the ectopic pregnancy is causing heavy bleeding, you might need emergency surgery. This can be done laparoscopically or through an abdominal incision (laparotomy). In some cases, the fallopian tube can be saved. Typically, however, a ruptured tube must be removed.

Home care

Your doctor will give you specific instructions regarding the care of your incisions after surgery. The chief goals are to keep your incisions clean and dry while they heal. Check them daily for infection signs, which could include:

• bleeding that won’t stop
• excessive bleeding
• foul-smelling drainage from the site
• hot to the touch
• redness
• swelling

You can expect some light vaginal bleeding and small blood clots after surgery. This can occur up to six weeks after your procedure. Other self-care measures you can take include:

• don’t lift anything heavier than 10 pounds
• drink plenty of fluids to prevent constipation
• pelvic rest, which means refraining from sexual intercourse, tampon use, and douching
• rest as much as possible the first week postsurgery, and then increase activity in the next weeks as tolerated

Always notify your doctor if your pain increases or you feel something is out of the ordinary.

Prevention

Prediction and prevention aren’t possible in every case. You may be able to reduce your risk through good reproductive health maintenance. Have your partner wear a condom during sex and limit your number of sexual partners. This reduces your risk for STDs, which can cause PID, a condition that can cause inflammation in the fallopian tubes.

Maintain regular visits with your doctor, including regular gynecological exams and regular STD screenings. Taking steps to improve your personal health, such as quitting smoking, is also a good preventive strategy.

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Uterine fibroids are noncancerous growths of the uterus that often appear during childbearing years. Also called leiomyomas (lie-o-my-O-muhs) or myomas, uterine fibroids aren’t associated with an increased risk of uterine cancer and almost never develop into cancer.

Fibroids range in size from seedlings, undetectable by the human eye, to bulky masses that can distort and enlarge the uterus. You can have a single fibroid or multiple ones. In extreme cases, multiple fibroids can expand the uterus so much that it reaches the rib cage and can add weight.

Many women have uterine fibroids sometime during their lives. But you might not know you have uterine fibroids because they often cause no symptoms. Your doctor may discover fibroids incidentally during a pelvic exam or prenatal ultrasound.

Fibroids are abnormal growths that develop in or on a woman’s uterus. Sometimes these tumors become quite large and cause severe abdominal pain and heavy periods. In other cases, they cause no signs or symptoms at all. The growths are typically benign, or noncancerous. The cause of fibroids is unknown.

Fibroids are also known by the following names:

• leiomyomas
• myomas
• uterine myomas
• fibromas

According to the Office on Women’s Health, up to 80 percentTrusted Source of women have them by the age of 50. However, most women don’t have any symptoms and may never know they have fibroids.

types

The type of fibroid a woman develops depends on its location in or on the uterus.

Intramural fibroids

Intramural fibroids are the most common type of fibroid. These types appear within the muscular wall of the uterus. Intramural fibroids may grow larger and can stretch your womb.

Subserosal fibroids

Subserosal fibroids form on the outside of your uterus, which is called the serosa. They may grow large enough to make your womb appear bigger on one side.

Pedunculated fibroids

Subserosal tumors can develop a stem, a slender base that supports the tumor. When they do, they’re known as pedunculated fibroids.

Submucosal fibroids

These types of tumors develop in the middle muscle layer, or myometrium, of your uterus. Submucosal tumors aren’t as common as the other types.

causes

Doctors don’t know the cause of uterine fibroids, but research and clinical experience point to these factors:

• Genetic changes. Many fibroids contain changes in genes that differ from those in normal uterine muscle cells.
• Hormones. Estrogen and progesterone, two hormones that stimulate development of the uterine lining during each menstrual cycle in preparation for pregnancy, appear to promote the growth of fibroids. Fibroids contain more estrogen and progesterone receptors than normal uterine muscle cells do. Fibroids tend to shrink after menopause due to a decrease in hormone production.
• Other growth factors. Substances that help the body maintain tissues, such as insulin-like growth factor, may affect fibroid growth.
• Extracellular matrix (ECM). ECM is the material that makes cells stick together, like mortar between bricks. ECM is increased in fibroids and makes them fibrous. ECM also stores growth factors and causes biologic changes in the cells themselves.

• Pregnancy Pregnancy increases the production of estrogen and progesterone in your body. Fibroids may develop and grow rapidly while you’re pregnant.

Doctors believe that uterine fibroids develop from a stem cell in the smooth muscular tissue of the uterus (myometrium). A single cell divides repeatedly, eventually creating a firm, rubbery mass distinct from nearby tissue.

The growth patterns of uterine fibroids vary — they may grow slowly or rapidly, or they may remain the same size. Some fibroids go through growth spurts, and some may shrink on their own.

Many fibroids that have been present during pregnancy shrink or disappear after pregnancy, as the uterus goes back to a normal size.

Symptoms

Your symptoms will depend on the number of tumors you have as well as their location and size. For instance, submucosal fibroids may cause heavy menstrual bleeding and trouble conceiving.

If your tumor is very small or you’re going through menopause, you may not have any symptoms. Fibroids may shrink during and after menopause. This is because women undergoing menopause are experiencing a drop in their levels of estrogen and progesterone, hormones that stimulate fibroid growth.

Symptoms of fibroids may include:

• heavy bleeding between or during your periods that includes blood clots
• pain in the pelvis or lower back
• increased menstrual cramping
• increased urination
• pain during intercourse
• menstruation that lasts longer than usual
• pressure or fullness in your lower abdomen
• swelling or enlargement of the abdomen

Many women who have fibroids don’t have any symptoms. In those that do, symptoms can be influenced by the location, size and number of fibroids.

In women who have symptoms, the most common signs and symptoms of uterine fibroids include:

• Heavy menstrual bleeding
• Menstrual periods lasting more than a week
• Pelvic pressure or pain
• Frequent urination
• Difficulty emptying the bladder
• Constipation
• Backache or leg pains

Rarely, a fibroid can cause acute pain when it outgrows its blood supply, and begins to die.

Fibroids are generally classified by their location. Intramural fibroids grow within the muscular uterine wall. Submucosal fibroids bulge into the uterine cavity. Subserosal fibroids project to the outside of the uterus.

When to see a doctor

See your doctor if you have:

• Pelvic pain that doesn’t go away
• Overly heavy, prolonged or painful periods
• Spotting or bleeding between periods
• Difficulty emptying your bladder
• Unexplained low red blood cell count (anemia)

Seek prompt medical care if you have severe vaginal bleeding or sharp pelvic pain that comes on suddenly.

Diagnosis

Uterine fibroids are frequently found incidentally during a routine pelvic exam. Your doctor may feel irregularities in the shape of your uterus, suggesting the presence of fibroids.

If you have symptoms of uterine fibroids, your doctor may order these tests:

• Ultrasound. If confirmation is needed, your doctor may order an ultrasound. It uses sound waves to get a picture of your uterus to confirm the diagnosis and to map and measure fibroids. A doctor or technician moves the ultrasound device (transducer) over your abdomen (transabdominal) or places it inside your vagina (transvaginal) to get images of your uterus.
• Lab tests. If you have abnormal menstrual bleeding, your doctor may order other tests to investigate potential causes. These might include a complete blood count (CBC) to determine if you have anemia because of chronic blood loss and other blood tests to rule out bleeding disorders or thyroid problems.

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Other imaging tests

If traditional ultrasound doesn’t provide enough information, your doctor may order other imaging studies, such as:

• Magnetic resonance imaging (MRI). This imaging test can show in more detail the size and location of fibroids, identify different types of tumors and help determine appropriate treatment options. An MRI is most often used in women with a larger uterus or in women approaching menopause (perimenopause).
• Hysterosonography. Hysterosonography (his-tur-o-suh-NOG-ruh-fee), also called a saline infusion sonogram, uses sterile saline to expand the uterine cavity, making it easier to get images of submucosal fibroids and the lining of the uterus in women attempting pregnancy or who have heavy menstrual bleeding.
• Hysterosalpingography. Hysterosalpingography (his-tur-o-sal-ping-GOG-ruh-fee) uses a dye to highlight the uterine cavity and fallopian tubes on X-ray images. Your doctor may recommend it if infertility is a concern. This test can help your doctor determine if your fallopian tubes are open or are blocked and can show some submucosal fibroids.
• Hysteroscopy. For this, your doctor inserts a small, lighted telescope called a hysteroscope through your cervix into your uterus. Your doctor then injects saline into your uterus, expanding the uterine cavity and allowing your doctor to examine the walls of your uterus and the openings of your fallopian tubes.

Risk factors

There are few known risk factors for uterine fibroids, other than being a woman of reproductive age. Factors that can have an impact on fibroid development include:

• Race. Although any woman of reproductive age can develop fibroids, black women are more likely to have fibroids than are women of other racial groups. In addition, black women have fibroids at younger ages, and they’re also likely to have more or larger fibroids, along with more-severe symptoms.
• Heredity. If your mother or sister had fibroids, you’re at increased risk of developing them.
• Other factors. Onset of menstruation at an early age; obesity; a vitamin D deficiency; having a diet higher in red meat and lower in green vegetables, fruit and dairy; and drinking alcohol, including beer, appear to increase your risk of developing fibroids.

Complications

Although uterine fibroids usually aren’t dangerous, they can cause discomfort and may lead to complications such as a drop in red blood cells (anemia), which causes fatigue, from heavy blood loss. Rarely, a transfusion is needed due to blood loss.

Pregnancy and fibroids

Fibroids usually don’t interfere with getting pregnant. However, it’s possible that fibroids — especially submucosal fibroids — could cause infertility or pregnancy loss.

Fibroids may also raise the risk of certain pregnancy complications, such as placental abruption, fetal growth restriction and preterm delivery.

Treatment

There’s no single best approach to uterine fibroid treatment — many treatment options exist. If you have symptoms, talk with your doctor about options for symptom relief.

Watchful waiting

Many women with uterine fibroids experience no signs or symptoms, or only mildly annoying signs and symptoms that they can live with. If that’s the case for you, watchful waiting could be the best option.

Fibroids aren’t cancerous. They rarely interfere with pregnancy. They usually grow slowly — or not at all — and tend to shrink after menopause, when levels of reproductive hormones drop.

Medications

Medications for uterine fibroids target hormones that regulate your menstrual cycle, treating symptoms such as heavy menstrual bleeding and pelvic pressure. They don’t eliminate fibroids, but may shrink them. Medications include:

• Gonadotropin-releasing hormone (GnRH) agonists. Medications called GnRH agonists treat fibroids by blocking the production of estrogen and progesterone, putting you into a temporary menopause-like state. As a result, menstruation stops, fibroids shrink and anemia often improves. GnRH agonists include leuprolide (Lupron, Eligard, others), goserelin (Zoladex) and triptorelin (Trelstar, Triptodur Kit). Many women have significant hot flashes while using GnRH agonists. GnRH agonists typically are used for no more than three to six months because symptoms return when the medication is stopped and long-term use can cause loss of bone. Your doctor may prescribe a GnRH agonist to shrink the size of your fibroids before a planned surgery or to help transition you to menopause.
• Progestin-releasing intrauterine device (IUD). A progestin-releasing IUD can relieve heavy bleeding caused by fibroids. A progestin-releasing IUD provides symptom relief only and doesn’t shrink fibroids or make them disappear. It also prevents pregnancy.
• Tranexamic acid (Lysteda, Cyklokapron). This nonhormonal medication is taken to ease heavy menstrual periods. It’s taken only on heavy bleeding days.
• Other medications. Your doctor might recommend other medications. For example, oral contraceptives can help control menstrual bleeding, but they don’t reduce fibroid size. Nonsteroidal anti-inflammatory drugs (NSAIDs), which are not hormonal medications, may be effective in relieving pain related to fibroids, but they don’t reduce bleeding caused by fibroids. Your doctor may also suggest that you take vitamins and iron if you have heavy menstrual bleeding and anemia.

Noninvasive procedure

MRI-guided focused ultrasound surgery (FUS) is:

• A noninvasive treatment option for uterine fibroids that preserves your uterus, requires no incision and is done on an outpatient basis.
• Performed while you’re inside an MRI scanner equipped with a high-energy ultrasound transducer for treatment. The images give your doctor the precise location of the uterine fibroids. When the location of the fibroid is targeted, the ultrasound transducer focuses sound waves (sonications) into the fibroid to heat and destroy small areas of fibroid tissue.
• Newer technology, so researchers are learning more about the long-term safety and effectiveness. But so far data collected show that FUS for uterine fibroids is safe and effective.

Minimally invasive procedures

Certain procedures can destroy uterine fibroids without actually removing them through surgery. They include:

• Uterine artery embolization. Small particles (embolic agents) are injected into the arteries supplying the uterus, cutting off blood flow to fibroids, causing them to shrink and die. This technique can be effective in shrinking fibroids and relieving the symptoms they cause. Complications may occur if the blood supply to your ovaries or other organs is compromised. However, research shows that complications are similar to surgical fibroid treatments and the risk of transfusion is substantially reduced.
• Radiofrequency ablation. In this procedure, radiofrequency energy destroys uterine fibroids and shrinks the blood vessels that feed them. This can be done during a laparoscopic or transcervical procedure. A similar procedure called cryomyolysis freezes the fibroids. With laparoscopic radiofrequency ablation, also called Lap-RFA, your doctor makes two small incisions in the abdomen to insert a slim viewing instrument (laparoscope) with a camera at the tip. Using the laparoscopic camera and a laparoscopic ultrasound tool, your doctor locates fibroids to be treated. After locating a fibroid, your doctor uses a specialized device to deploy several small needles into the fibroid. The needles heat up the fibroid tissue, destroying it. The destroyed fibroid immediately changes consistency, for instance from being hard like a golf ball to being soft like a marshmallow. During the next three to 12 months, the fibroid continues to shrink, improving symptoms. Because there’s no cutting of uterine tissue, doctors consider Lap-RFA a less invasive alternative to hysterectomy and myomectomy. Most women who have the procedure get back to regular activities after 5 to 7 days of recovery. The transcervical — or through the cervix — approach to radiofrequency ablation also uses ultrasound guidance to locate fibroids.
• Laparoscopic or robotic myomectomy. In a myomectomy, your surgeon removes the fibroids, leaving the uterus in place. If the fibroids are few in number, you and your doctor may opt for a laparoscopic or robotic procedure, which uses slender instruments inserted through small incisions in your abdomen to remove the fibroids from your uterus. Larger fibroids can be removed through smaller incisions by breaking them into pieces (morcellation), which can be done inside a surgical bag, or by extending one incision to remove the fibroids. Your doctor views your abdominal area on a monitor using a small camera attached to one of the instruments. Robotic myomectomy gives your surgeon a magnified, 3D view of your uterus, offering more precision, flexibility and dexterity than is possible using some other techniques.
• Hysteroscopic myomectomy. This procedure may be an option if the fibroids are contained inside the uterus (submucosal). Your surgeon accesses and removes fibroids using instruments inserted through your vagina and cervix into your uterus.
• Endometrial ablation. This treatment, performed with a specialized instrument inserted into your uterus, uses heat, microwave energy, hot water or electric current to destroy the lining of your uterus, either ending menstruation or reducing your menstrual flow. Typically, endometrial ablation is effective in stopping abnormal bleeding. Submucosal fibroids can be removed at the time of hysteroscopy for endometrial ablation, but this doesn’t affect fibroids outside the interior lining of the uterus. Women aren’t likely to get pregnant following endometrial ablation, but birth control is needed to prevent a pregnancy from developing in a fallopian tube (ectopic pregnancy).

With any procedure that doesn’t remove the uterus, there’s a risk that new fibroids could grow and cause symptoms.

Traditional surgical procedures

Options for traditional surgical procedures include:

• Abdominal myomectomy. If you have multiple fibroids, very large fibroids or very deep fibroids, your doctor may use an open abdominal surgical procedure to remove the fibroids. Many women who are told that hysterectomy is their only option can have an abdominal myomectomy instead. However, scarring after surgery can affect future fertility.
• Hysterectomy. This surgery — the removal of the uterus — remains the only proven permanent solution for uterine fibroids. But hysterectomy is major surgery. Hysterectomy ends your ability to bear children. If you also elect to have your ovaries removed, the surgery brings on menopause and the question of whether you’ll take hormone replacement therapy. Most women with uterine fibroids may be able to choose to keep their ovaries.

Morcellation during fibroid removal

Morcellation — a process of breaking fibroids into smaller pieces — may increase the risk of spreading cancer if a previously undiagnosed cancerous mass undergoes morcellation during myomectomy. There are several ways to reduce that risk, such as evaluating risk factors before surgery, morcellating the fibroid in a bag or expanding an incision to avoid morcellation.

All myomectomies carry the risk of cutting into an undiagnosed cancer, but younger, premenopausal women generally have a lower risk of undiagnosed cancer than do older women.

Also, complications during open surgery are more common than the chance of spreading an undiagnosed cancer in a fibroid during a minimally invasive procedure. If your doctor is planning to use morcellation, discuss your individual risks before treatment.

The Food and Drug Administration (FDA) advises against the use of a device to morcellate the tissue (power morcellator) for most women having fibroids removed through myomectomy or hysterectomy. In particular, the FDA recommends that women who are approaching menopause or who have reached menopause avoid power morcellation. Older women in or entering menopause may have a higher cancer risk, and women who are no longer concerned about preserving their fertility have additional treatment options for fibroids.

If you’re trying to get pregnant or might want to have children

Hysterectomy and endometrial ablation won’t allow you to have a future pregnancy. Also, uterine artery embolization and radiofrequency ablation may not be the best options if you’re trying to optimize future fertility.

Have a full discussion of the risks and benefits of these procedures with your doctor if you want to preserve the ability to become pregnant. Before deciding on a treatment plan for fibroids, a complete fertility evaluation is recommended if you’re actively trying to get pregnant.

If fibroid treatment is needed — and you want to preserve your fertility — myomectomy is generally the treatment of choice. However, all treatments have risks and benefits. Discuss these with your doctor.

Risk of developing new fibroids

For all procedures except hysterectomy, seedlings — tiny tumors that your doctor doesn’t detect during surgery — could eventually grow and cause symptoms that warrant treatment. This is often termed the recurrence rate. New fibroids, which may or may not require treatment, also can develop.

Also, some procedures — such as laparoscopic or robotic myomectomy, radiofrequency ablation, or MRI-guided focused ultrasound surgery (FUS) — may only treat some of the fibroids present at the time of treatment.

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Pelvic floor prolapse is the herniation of the pelvic organs through the perineum. Depending on the pelvic organ involved, pelvic prolapse further categorizes into:

1. Anterior compartment containing urinary bladder(cystocele)
2. Middle compartment containing uterine or vaginal prolapse (uterus or vagina)
3. Posterior compartment containing either the small bowel loops (enterocele) or rectum (rectocele).

Pelvic prolapse is very common among multiparous women over 50 (affects approximately 50% of women over age 50). Symptoms include fecal or urinary incontinence, uterine prolapse, constipation, or incomplete defecation. Pelvic prolapse can negatively impact the patient’s body image and sexuality. Pelvic prolapse treatments range from non-surgical approaches like Kegel exercise and pessary to various surgical procedures. 

Definition/Description

Pelvic organ prolapse is the descent of a pelvic organ into or outside of the vaginal canal or anus. It mainly results from pelvic floor dysfunction.

There are several types:

• Cystocele: prolapse of the bladder into the vagina
• Urethrocele: prolapse of the urethra
• Uterine prolapse
• Vaginal vault prolapse: prolapse of the vagina
• Enterocele: small bowel prolapse
• Rectocele: rectum prolapse

Etiology

Pelvic organ prolapse has a multifactorial etiology. It is likely caused by a combination of physiological, anatomical, reproductive, genetic and lifestyle factors that interact and contribute to dysfunction of the pelvic floor. 

Symptoms

A variety of symptoms may be present including:

• Vaginal bulging
• Feeling of pelvic pressure or heaviness
• Pelvic pain
• Urinary or fecal incontinence or obstruction
• Altered daily activities, sexual function and quality of life
• Risk Factors

causes

The factors causing pelvic organ prolapse are different between patients. Risk factors include the following:

Primary Pelvic Organ Prolapse

• Pregnancy and labour
• Obesity/BMI
• Respiratory problems involving a chronic, long-term cough
• Cancer of the pelvic organs
• Hysterectomy (surgical removal of the uterus)
• Genetics (possibly) due to weaker connective tissues
• History of vaginal delivery increases the risk 5.56 times
• Hypertension and Diabetes Mellitus combined increase the risk by 1.9 times
• Increased birth weight
• Age
• Parity (i.e. the number of times a woman has given birth to a fetus with a gestational age of greater than or equal to 24 weeks, alive or stillborn)

Pelvic Organ Prolapse Recurrence (after native tissue repair)

• Preoperative stage 3 or 4 pelvic organ prolapse (i.e. a more severe prolapse)

Diagnosis

Diagnosis of pelvic organ prolapse begins with your medical history and a physical exam of your pelvic organs. This can help your health care provider determine the type of prolapse, such as bladder, rectum or uterine.

Some tests might also be needed. Ask your health care provider to explain why each test is being done. Tests for pelvic organ prolapse might include:

• Bladder function tests. Some tests are as simple as finding out whether your bladder leaks when it’s put back into place at the time of your physical exam. Other tests might measure how well your bladder empties. Seeing these results can help you and your doctor determine the most appropriate type of management for prolapse.
• Pelvic floor strength tests. Your doctor will test the strength of your pelvic floor and sphincter muscles at the time of your physical examination. This tests the strength of muscles and ligaments that support the vaginal walls, uterus, rectum, urethra and bladder.
• Magnetic resonance imaging (MRI). An MRI will use a magnetic field and radio waves to create detailed images of your pelvis. This is useful only in complex cases.
• Ultrasound. This imaging method will use high-frequency sound waves to produce images of your kidneys, bladder and the muscles around your anus. An ultrasound is useful only in complex cases.

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Treatment/Management

As prolapse treatment options expand to include more conservative choices, greater awareness and education is needed among women and professionals about these as a first line treatment and preventive measure (alongside a multi-professional team approach).

Women presenting with prolapse symptoms need to be

• listened to by the health care team,
• offered information about treatment choices
• supported to make a decision that is right for them.

A qualitative research developed a conceptual model that explores the experience of living with a POP, and the model indicated that: the physical losses of POP are linked to loss of identity; women conceptualized POP as part of womanhood, and a vicious cycle of taboo, silence, and misunderstanding about POP and its treatment. And further, POP is not taken seriously in healthcare.

Treatment for pelvic organ prolapse usually involves either conservative management (for mild prolapse or women who are not good surgical candidates) or surgery. Conservative treatments include pelvic floor muscle training and the use of devices (pessaries).

Physiotherapy

Physical therapists play a major role in the nonsurgical management of POP. Along with pessary support, pelvic-floor muscle training (PFMT) is cited in highly credible reviews as a main nonsurgical option for women with POP.

For all the information re retraining these muscles see the physiotherapy section of Pelvic Floor Dysfunction and Kegel’s Exercises

In a study by Panman et al in 2016, examining the two-year effects of pelvic floor muscle retraining, it was demonstrated that in women aged 55 and greater with symptomatic mild pelvic organ prolapse, pelvic floor muscle retraining results in a significant decrease in pelvic floor symptoms when compared to watchful waiting (note: statistically significant but below the minimal clinically important difference). Additionally, it was found that pelvic floor muscle retraining was more effective in women who experienced increased pelvic floor symptom distress at baseline. Conversely, the same study found no difference in sexual functioning, quality of life, function of the pelvic floor muscles or degree of prolapse.

A randomised control trial compared the effect of intravaginal vibratory stimulation (IVVS) with intravaginal electrical stimulation (IVES) in women with pelvic floor dysfunctions, unable to voluntarily contract the pelvic floor muscles. The results showed improvement with both techniques, with IVVS superior to IVES in improving pelvic floor muscle strength.

Pelvic floor muscle retraining included: (Kegel exercises diagram in illustration)

• Explanation and description of the pelvic floor
• Instruction regarding how to contract and relax pelvic floor muscles
  • If unable to perform this task, use feedback through digital palpation
  • If insufficient control demonstrated, use myofeedback or electrical stimulation

• General exercise program provided, subsequently modified for individual needs
• Taught correct technique for contracting pelvic floor muscles before and during increases in abdominal pressure
• Received information about washroom habits and lifestyle
• If pelvic floor muscles were overactive, focus was on relaxation rather than contraction
• Face-to-face contact with physiotherapist as well as encouragement to maintain practice at home 3-5 times per week, 2-3 times per day

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The uterus (womb) is a muscular structure that’s held in place by pelvic muscles and ligaments. If these muscles or ligaments stretch or become weak, they’re no longer able to support the uterus, causing prolapse.

Uterine prolapse occurs when the uterus sags or slips from its normal position and into the vagina (birth canal).

Uterine prolapse may be incomplete or complete. An incomplete prolapse occurs when the uterus is only partly sagging into the vagina. A complete prolapse occurs when the uterus falls so far down that some tissue protrudes outside of the vagina.

Uterine prolapse occurs when pelvic floor muscles and ligaments stretch and weaken and no longer provide enough support for the uterus. As a result, the uterus slips down into or protrudes out of the vagina.

Uterine prolapse can occur in women of any age. But it often affects postmenopausal women who’ve had one or more vaginal deliveries.

Mild uterine prolapse usually doesn’t require treatment. But if uterine prolapse makes you uncomfortable or disrupts your normal life, you might benefit from treatment.

• Muscle weakness or relaxation may allow your uterus to sag or come completely out of your body in various stages:
  • First degree: The cervix drops into the vagina.
  • Second degree: The cervix drops to the level just inside the opening of the vagina.
  • Third degree: The cervix is outside the vagina.
  • Fourth degree: The entire uterus is outside the vagina. This condition is also called procidentia. This is caused by weakness in all of the supporting muscles.
• Other conditions are usually associated with prolapsed uterus. They weaken the muscles that hold the uterus in place:
  • Cystocele: A herniation (or bulging) of the upper front vaginal wall where a part of the bladder bulges into the vagina. It’s also called a prolapsed bladder. This may lead to urinary frequency, urgency, retention, and incontinence (loss of urine).
  • Enterocele: The herniation of the upper rear vaginal wall where a small bowel portion bulges into the vagina. Standing leads to a pulling sensation and backache that is relieved when you lie down.
  • Rectocele: The herniation of the lower rear vaginal wall where the rectum bulges into the vagina. This makes bowel movements difficult, to the point that you may need to push on the inside of your vagina to empty your bowel.

Causes

Uterine prolapse results from the weakening of pelvic muscles and supportive tissues. Causes of weakened pelvic muscles and tissues include:

• Pregnancy
• Difficult labor and delivery or trauma during childbirth
• Delivery of a large baby
• Being overweight or obese
• Lower estrogen level after menopause
• Chronic constipation or straining with bowel movements
• Chronic cough or bronchitis
• Repeated heavy lifting

Symptoms

Women who have a minor uterine prolapse may not have any symptoms. Moderate to severe prolapse may cause symptoms, such as:

• the feeling that you’re sitting on a ball
• vaginal bleeding
• increased discharge
• problems with sexual intercourse
• the uterus or cervix protruding out of the vagina
• a pulling or heavy feeling in the pelvis
• constipation or difficulty passing stool
• recurring bladder infections or difficulty emptying your bladder

If you develop these symptoms, you should see your doctor and get treatment right away. Without proper attention, the condition can impair your bowel, bladder, and sexual function.

Mild uterine prolapse generally doesn’t cause signs or symptoms. Signs and symptoms of moderate to severe uterine prolapse include:

• Sensation of heaviness or pulling in your pelvis
• Tissue protruding from your vagina
• Urinary problems, such as urine leakage (incontinence) or urine retention
• Trouble having a bowel movement
• Feeling as if you’re sitting on a small ball or as if something is falling out of your vagina
• Sexual concerns, such as a sensation of looseness in the tone of your vaginal tissue

Often, symptoms are less bothersome in the morning and worsen as the day goes on.

When to see a doctor

See your doctor to discuss your options if signs and symptoms of uterine prolapse become bothersome and disrupt your normal activities

Risk factors

Factors that can increase your risk of uterine prolapse include:

• One or more pregnancies and vaginal births
• Giving birth to a large baby
• Increasing age
• Obesity
• Prior pelvic surgery
• Chronic constipation or frequent straining during bowel movements
• Family history of weakness in connective tissue
• Being Hispanic or white

Complications

Uterine prolapse is often associated with prolapse of other pelvic organs. You might experience:

• Anterior prolapse (cystocele). Weakness of connective tissue separating the bladder and vagina may cause the bladder to bulge into the vagina. Anterior prolapse is also called prolapsed bladder.
• Posterior vaginal prolapse (rectocele). Weakness of connective tissue separating the rectum and vagina may cause the rectum to bulge into the vagina. You might have difficulty having bowel movements.

Severe uterine prolapse can displace part of the vaginal lining, causing it to protrude outside the body. Vaginal tissue that rubs against clothing can lead to vaginal sores (ulcers.) Rarely, the sores can become infected

diagnosis

Your doctor can diagnose uterine prolapse by evaluating your symptoms and performing a pelvic exam. During this exam, your doctor will insert a device called a speculum that allows them to see inside of the vagina and examine the vaginal canal and uterus. You may be lying down, or your doctor may ask you to stand during this exam.

Your doctor may ask you to bear down as if you’re having a bowel movement to determine the degree of prolapse.

Your health care provider can diagnose uterine prolapse with a medical history and physical examination of the pelvis.

• The doctor may need to examine you in standing position and while you are lying down and ask you to cough or strain to increase the pressure in your abdomen.
• Specific conditions, such as ureteral obstruction due to complete prolapse, may need an intravenous pyelogram (IVP) or renal sonography. Dye is injected into your vein, and a series of X-rays are taken to view its progress through your bladder.
• Ultrasound may be used to rule out other pelvic problems. In this test, a wand is passed over your abdomen or inserted into your vagina to create images with sound waves.
• Pelvic magnetic resonance imaging (MRI) is sometimes done if you have more than one prolapsed organ or to help plan surgery.

Prevention

To reduce your risk of uterine prolapse, try to:

• Perform Kegel exercises regularly. These exercises can strengthen your pelvic floor muscles — especially important after you have a baby.
• Treat and prevent constipation. Drink plenty of fluids and eat high-fiber foods, such as fruits, vegetables, beans and whole-grain cereals.
• Avoid heavy lifting and lift correctly. When lifting, use your legs instead of your waist or back.
• Control coughing. Get treatment for a chronic cough or bronchitis, and don’t smoke.
• Avoid weight gain. Talk with your doctor to determine your ideal weight and get advice on weight-loss strategies, if you need them.

treatment

Treatment isn’t always necessary for this condition. If the prolapse is severe, talk with your doctor about which treatment option is appropriate for you.

Nonsurgical treatments include:

• losing weight to take stress off pelvic structures
• avoiding heavy lifting
• doing Kegel exercises, which are pelvic floor exercises that help strengthen the vaginal muscles
• wearing a pessary, which is a device inserted into the vagina that fits under the cervix and helps push up and stabilize the uterus and cervix

The use of vaginal estrogen has been well-studied and shows improvement in vaginal tissue regeneration and strength. While using vaginal estrogen to help augment other treatment options may be helpful, on its own it doesn’t reverse the presence of a prolapse.

Surgical treatments include uterine suspension or hysterectomy. During uterine suspension, your surgeon places the uterus back into its original position by reattaching pelvic ligaments or using surgical materials. During a hysterectomy, your surgeon removes the uterus from the body through the abdomen or the vagina.

Surgery is often effective, but it’s not recommended for women who plan on having children. Pregnancy and childbirth can put an immense strain on pelvic muscles, which can undo surgical repairs of the uterus.

Treatment of uterine prolapse is largely dependent on the extent to which a patient is experiencing symptoms. Treatments include surgical and non-surgical options, the choice of which will depend on general health, the severity of the condition and plans for a future pregnancy.

Proper diagnosis and management of uterine prolapse can majorly impact a patient’s quality of life and can have long-term physical and mental health effects. Healthcare practitioners should thoroughly counsel patients with uterine prolapse so they can make informed decisions and choose the treatment that is right for them.

Options include:

• Pelvic floor exercises
• Vaginal pessary
• Vaginal surgery.

1. Pelvic floor muscle training:

• Typically taught to patients in association with a physiotherapist. They have been shown to result in subjective improvement in symptoms by patients as well as objective improvement in the The Pelvic Organ Prolapse Quantification (POP-Q) system score by examiners.

2. Vaginal pessaries:

• Objects often made of silicone that are inserted into the vagina to provide support for the prolapsed pelvic organs.
• Vaginal pessaries can be an effective way of reducing the symptoms of a prolapse, but they will not be appropriate for everyone. Together with pelvic floor exercises, they may provide a non-surgical solution to manage a uterine prolapse.
• Vaginal pessaries provide a solution in 84% of cases of advanced pelvic organ prolapse with mild adverse events in 31% of cases. 
• Patients must be fitted for a pessary and commonly try several pessaries before finding the appropriate one. The examiner should be able to sweep a single finger between the pessary and vaginal walls. The patient should be able to walk, bend, and urinate comfortably without shifting the pessary. Complications of pessary placement include vaginal irritation/ulceration, discharge, pain, bleeding, and odor.
• Regular reassessments of pessary fit should be performed to ensure that the pessary is not rubbing against the walls of the vagina, as this can lead to irritation of the vaginal mucosa and predispose patients to infection. Patients with dementia or poor follow up are not good candidates for pessary placement as they require frequent cleaning and regular reassessment of position to prevent complications.

Surgical management

• Decision should be made after a detailed discussion with the patient regarding the desire for future vaginal intercourse, effects on body image, cultural views, alternative treatments, and potential complications.
• In moderate to severe cases, the prolapse may have to be surgically repaired. In laparoscopic surgery, instruments are inserted through the navel. The uterus is pulled back into its correct position and reattached to its supporting ligaments. The operation can also be performed with an abdominal incision.
• Surgery may fail and the prolapse can recur if the original cause of the prolapse, such as obesity, coughing or straining, is not addressed.

Physiotherapy

Physical therapists play a major role in the nonsurgical management of Uterine prolapse. Along with pessary support, pelvic-floor muscle training (PFMT) is cited in highly credible reviews as a main nonsurgical option for women with Uterine prolapse.

For all the information re retraining these muscles see the physiotherapy section of Pelvic Floor Dysfunction and Kegel’s Exercises

In a study by Panman et al in 2016, examining the two-year effects of pelvic floor muscle retraining, it was demonstrated that in women aged 55 and greater with symptomatic mild pelvic organ prolapse, pelvic floor muscle retraining results in a significant decrease in pelvic floor symptoms when compared to watchful waiting (note: statistically significant but below the minimal clinically important difference). Additionally, it was found that pelvic floor muscle retraining was more effective in women who experienced increased pelvic floor symptom distress at baseline. Conversely, the same study found no difference in sexual functioning, quality of life, function of the pelvic floor muscles or degree of prolapse.

A randomised control trial compared the effect of intravaginal vibratory stimulation (IVVS) with intravaginal electrical stimulation (IVES) in women with pelvic floor dysfunctions, unable to voluntarily contract the pelvic floor muscles. The results showed improvement with both techniques, with IVVS superior to IVES in improving pelvic floor muscle strength.

Pelvic floor muscle retraining included: (Kegel exercises diagram in illustration)

• Explanation and description of the pelvic floor
• Instruction regarding how to contract and relax pelvic floor muscles
  • If unable to perform this task, use feedback through digital palpation
  • If insufficient control demonstrated, use myofeedback or electrical stimulation

• General exercise program provided, subsequently modified for individual needs
• Taught correct technique for contracting pelvic floor muscles before and during increases in abdominal pressure
• Received information about washroom habits and lifestyle
• If pelvic floor muscles were overactive, focus was on relaxation rather than contraction
• Face-to-face contact with physiotherapist as well as encouragement to maintain practice at home 3-5 times per week, 2-3 times per day 

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Normal puberty begins between eight and 14 years of age in girls and between nine and 14 years of age in boys. Pubic hair distribution is used to stage puberty, along with breast size and contour in girls and testicular volume in boys. Some children experience constitutional sexual precocity, but precocity is likely to be pathologic if it occurs in very young children, if there is contrasexual development or if the sequence of normal pubertal milestones is disrupted. Delayed puberty may be constitutional, but pathologic causes should be considered. The etiology of a pubertal disorder can often be determined with the use of a focused medical history, a directed physical examination and appropriate diagnostic tests. Treatment for disorders of puberty is determined by the underlying cause.

Puberty is a process leading to physical and sexual maturation that involves the development of secondary sexual characteristics as well as growth, changes in body composition and psychosocial maturation.

Girls: key physical changes in puberty

If you have a daughter, these are the main external physical changes in puberty that you can expect.

Around 10-11 years

• Breasts will start developing. This is the first visible sign that puberty is starting. It’s normal for the left and right breasts to grow at different speeds. It’s also common for the breasts to be a bit tender as they develop. If your child wants a bra, a soft crop top or sports bra can be a good first choice.
• Your daughter will have a growth spurt, and she’ll get taller. Some parts of her body – like her head, face and hands – might grow faster than her limbs and torso. This might leave her looking out of proportion for a while. On average girls grow 5-20 cm. They usually stop growing at around 16-17 years.
• Your daughter’s body shape will change. For example, her hips will widen.
• Your daughter’s external genitals (vulva) and pubic hair will start to grow. Her pubic hair will get darker and thicker over time.

Around 12-14 years (about two years after breast development starts)

• Hair will start growing under your daughter’s arms.
• Your daughter will get a clear or whitish discharge from her vagina for several months before her periods start. If the discharge bothers your daughter, you could suggest she uses a panty liner. If your daughter says she has itching, pain or a bad or strong odour, check with a GP.
• Periods will start. This is when the lining of the uterus (womb), including blood, is shed every month. Your daughter might get pain before and during her period, like headaches or stomach cramps. Her periods might be irregular at first.

Boys: key physical changes in puberty

If you have a son, these are the main external physical changes in puberty that you can expect.

Around 11-13 years

• The external genitals (penis, testes and scrotum) will start to grow. It’s normal for one testis to grow faster than the other. You can reassure your son that men’s testes usually aren’t the same size.
• Pubic hair will start to grow. It will get darker and thicker over time.

Around 12-14 years

• Your son will have a growth spurt. He’ll get taller and his chest and shoulders will get broader. Some parts of his body – like his head, face and hands – might grow faster than his limbs and torso. This might leave him looking out of proportion for a while. On average boys grow 10-30 cm. They usually stop growing at around 18-20 years.
• It’s common for boys to have minor breast development. If your son is worried by this, you can let him know it’s normal and usually goes away by itself. If it doesn’t go away or if your son’s breasts seem to be growing a lot, he could speak to his GP.

Around 13-15 years

• Hair will start growing on other parts of your son’s body – under his arms, on his face and on the rest of his body. His leg and arm hair will thicken. Some young men will grow more body hair into their early 20s.
• Your son will start producing more testosterone, which stimulates the testes to produce sperm.
• Your son will start getting erections and ejaculating (releasing sperm). During this period, erections often happen for no reason at all. Just let your son know that this is normal and that people don’t usually notice. Ejaculation during sleep is often called a ‘wet dream’.

Around 14-15 years
The larynx (‘Adam’s apple’ or voice box) will become more obvious. Your son’s larynx will get larger and his voice will ‘break’, eventually becoming deeper. Some boys’ voices move from high to low and back again, even in one sentence. This will stop in time.

Other physical changes in puberty: inside and out

Brain
Changes in the teenage brain affect your child’s behaviour and social skills. Your child will begin to develop improved self-control and skills in planning, problem-solving and decision-making. This process will continue into your child’s mid-20s.

Bones, organs and body systems
Many of your child’s organs will get bigger and stronger. Lung performance improves, limbs grow, and bones increase in thickness and volume.

Clumsiness
Because children grow so fast during puberty, their centres of gravity change and their brains might take a while to adjust. This might affect your child’s balance. You might see a bit more clumsiness for a while, and your child might be more likely to be injured.

Physical strength
Muscles increase in strength and size during this period. Your child’s hand-eye coordination will get better over time, along with motor skills like ball-catching and throwing.

Weight
Your child will gain weight and need more healthy food. Teenagers’ stomachs and intestines increase in size, and they need more energy, proteins and minerals. Foods with plenty of calcium and iron are important for bone growth and blood circulation.

Sleep patterns
Sleep patterns change, and many children start to stay awake later at night and sleep until later in the day. Also, the brain re-sets the body clock during puberty. Children going through puberty need more sleep than they did just before puberty started.

Sweat
A new type of sweat gland in the armpit and genital area develops during puberty. Skin bacteria feed on the sweat this gland produces, which can lead to body odour. Hygiene is important.

Skin and hair
Glands in the skin on the face, shoulders and back start to become more active during puberty, producing more oil. This can lead to skin conditions like acne. If you’re concerned about your child’s skin, first check whether the pimples or acne are worrying your child too. If they are, consider speaking with your GP.

Children might find their hair gets oilier, and they need to wash it more. This is normal.

Teeth
Children will get their second molars at around 13 years. Third molars – ‘wisdom teeth’ – might appear between 14 and 25 years. These teeth can appear in singles, pairs, as a full set of four wisdom teeth – or not at all. Healthy teeth and gums are vital to your teenage child’s health, so teenage dental care is important.

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Puberty and children with additional needs

Children with additional needs are likely to go through the physical changes of puberty in the same way as other children.

Some children might have delayed physical development because of chronic health problems, which might cause a delay in the onset of puberty. How your child manages puberty emotionally might also be affected by additional needs. A health professional can answer any questions you might have about this.

Pubertal Milestones in Girls

Tanner stage	Breasts*	Standard	Pubic hair*	Standard	Growth	Other
1	Prepubertal, elevation of papilla only		Prepubertal, villus hair only	—	Basal: about 5.0 to 6.0 cm (2.0 to 2.4 in) per year	Adrenarche Ovarian growth
2	Breast bud appears under enlarged areola (11.2 years)		Sparse growth of slightly pigmented hair along the labia (11.9 years)		Accelerated: about 7.0 to 8.0 cm (2.8 to 3.2 in) per year	Clitoral enlargement Labia pigmentation Uterus enlargement
3	Breast tissue grows beyond areola without contour separation (12.4 years)		Hair is coarser, curled and pigmented; spreads across the pubes (12.7 years)		Peak velocity: about 8.0 cm (3.2 in) per year (12.5 years)	Axillary hair (13.1 years) Acne (13.2 years)
4	Projection of areola and papilla forms a secondary mound (13.1 years)		Adult-type hair but no spread to medial thigh (13.4 years)		Deceleration: < 7.0 cm (2.8 in) per year	Menarche (13.3 years) Regular menses (13.9 years)
5	Adult breast contour with projection of papilla only (14.5 years)		Adult-type hair with spread to medial thigh but not up linea alba (14.6 years)		Cessation at about 16 years	Adult genitalia

Pubertal Milestones in Boys

Tanner stage	Standard	Genitalia*	Pubic hair*	Growth	Other
1		Prepubertal Testes: < 2.5 cm (1.0 in)	Prepubertal, villus hair only	Basal: about 5.0 to 6.0 cm (2.0 to 2.4 in) per year	Adrenarche
2		Thinning and reddening of scrotum (11.9 years) Testes: 2.5 to 3.2 cm (1.0 to 1.28 in)	Sparse growth of slightly pigmented hair at base of penis (12.3 years)	Basal: about 5.0 to 6.0 cm (2.0 to 2.4 in) per year	Decrease in total body fat
3		Growth of penis, especially length (13.2 years) Testes: 3.3 to 4.0 cm (1.32 to 1.6 in)	Thicker, curlier hair spreads to the mons pubis (13.9 years)	Accelerated: about 7.0 to 8.0 cm (2.8 to 3.2 in) per year	Gynecomastia (13.2 years) Voice break (13.5 years) Muscle mass increase
4		Growth of penis and glands, darkening of scrotum (14.3 years) Testes: 4.1 to 4.5 cm (1.64 to 1.8 in)	Adult-type hair but no spread to medial thigh (14.7 years)	Peak velocity: about 10.0 cm (4.0 in) per year (13.8 years)	Axillary hair (14.0 years) Voice change (14.1 years) Acne (14.3 years)
5		Adult genitalia (15.1 years) Testes: > 4.5 cm (1.8 in)	Adult-type hair with spread to medial thighs but not up linea alba (15.3 years)	Deceleration and cessation (about 17 years)	Facial hair (14.9 years) Muscle mass continues to increase after Stage 5

Causes & Risk Factors of abnormal puberty

Causes may include:

• Heredity
• Hormonal disorders – including polycystic ovary syndrome (POS)
• Genetic disorders
• Problems in the pituitary or thyroid glands that produce the hormones necessary for body growth and development
• Chromosome disorders that interfere with normal growth processes
• Eating disorders
• Excessive exercise
• Tumors
• Infections
• Chemotherapy
• Other underlying medical condition or injury 

Symptoms & Types of abnormal puberty

Symptoms may include:

• Lack of breast development by age 13
• Lack of pubic hair by age 14
• More than 5 years between breast development and first period
• Period hasn’t started by age 16
• Breast growth, period, pubic hair and other signs of puberty occur before age 7 or 8

Types of Puberty Disorders:

• Delayed puberty – puberty hasn’t started by age 13
• Precocious puberty – puberty begins too early, before age 7 or 8 in girls
• Contrasexual pubertal development – development of male characteristics in females
• Premature thelarche – breast development without any other signs of puberty
• Premature menarch – periods start without any other signs of puberty
• Premature adrenarche – appearance of pubic hair without any other signs of puberty

Diagnosis & Tests for abnormal puberty

Diagnosis starts with a detailed medical history and a thorough physical exam, including pelvic and breast exams when necessary.

Diagnostic testing may include:

• X-ray of the hand/wrist – to determine bone age
• Blood tests – to measure hormone levels and check for chromosomal abnormalities and other conditions
• MRI (magnetic resonance imaging) or CT scan – to rule out abnormalities in the brain or pituitary gland
• Thyroid testing
• Ultrasound – to examine the health of the ovaries and adrenal glands

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Precocious puberty is when a child’s body begins changing into that of an adult (puberty) too soon. When puberty begins before age 8 in girls and before age 9 in boys, it is considered precocious puberty.

Puberty includes rapid growth of bones and muscles, changes in body shape and size, and development of the body’s ability to reproduce.

The cause of precocious puberty often can’t be found. Rarely, certain conditions, such as infections, hormone disorders, tumors, brain abnormalities or injuries, may cause precocious puberty. Treatment for precocious puberty typically includes medication to delay further development.

Symptoms

Precocious puberty signs and symptoms include development of the following before age 8 in girls and before age 9 in boys.

• Breast growth and first period in girls
• Enlarged testicles and penis, facial hair and deepening voice in boys
• Pubic or underarm hair
• Rapid growth
• Acne
• Adult body odor

When to see a doctor

Make an appointment with your child’s doctor for an evaluation if your child has any of the signs or symptoms of precocious puberty.

Causes

To understand what causes precocious puberty in some children, it’s helpful to know what causes puberty to begin. The brain starts the process with the production of a hormone called gonadotropin-releasing hormone (GnRH).

When this hormone reaches the pituitary gland — a small bean-shaped gland at the base of your brain — it leads to the production of more hormones in the ovaries for females (estrogen) and the testicles for males (testosterone).

Estrogen is involved in the growth and development of female sexual characteristics. Testosterone is responsible for the growth and development of male sexual characteristics.

Why this process begins early in some children depends on whether they have central precocious puberty or peripheral precocious puberty.

Central precocious puberty

The cause for this type of precocious puberty often can’t be identified.

In central precocious puberty, the puberty process starts too soon. The pattern and timing of the steps in the process are otherwise normal. For the majority of children with this condition, there’s no underlying medical problem and no identifiable reason for the early puberty.

In rare cases, central precocious puberty may be caused by:

• A tumor in the brain or spinal cord (central nervous system)
• A defect in the brain present at birth, such as excess fluid buildup (hydrocephalus) or a noncancerous tumor (hamartoma)
• Radiation to the brain or spinal cord
• Injury to the brain or spinal cord
• McCune-Albright syndrome — a rare genetic disease that affects bones and skin color and causes hormonal problems
• Congenital adrenal hyperplasia — a group of genetic disorders involving abnormal hormone production by the adrenal glands
• Hypothyroidism — a condition in which the thyroid gland doesn’t produce enough hormones

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Peripheral precocious puberty

Estrogen or testosterone in your child’s body causes this type of precocious puberty.

The less common peripheral precocious puberty occurs without the involvement of the hormone in your brain (GnRH) that normally triggers the start of puberty. Instead, the cause is release of estrogen or testosterone into the body because of problems with the ovaries, testicles, adrenal glands or pituitary gland.

In both girls and boys, the following may lead to peripheral precocious puberty:

• A tumor in the adrenal glands or in the pituitary gland that releases estrogen or testosterone
• McCune-Albright syndrome, a rare genetic disorder that affects the skin color and bones and causes hormonal problems
• Exposure to external sources of estrogen or testosterone, such as creams or ointments

In girls, peripheral precocious puberty may also be associated with:

• Ovarian cysts
• Ovarian tumors

In boys, peripheral precocious puberty may also be caused by:

• A tumor in the cells that make sperm (germ cells) or in the cells that make testosterone (Leydig cells).
• A rare disorder called gonadotropin-independent familial sexual precocity, which is caused by a defect in a gene, can result in the early production of testosterone in boys, usually between ages 1 and 4.

Risk factors

Factors that increase a child’s risk of precocious puberty include:

• Being a girl. Girls are much more likely to develop precocious puberty.
• Being African-American. Precocious puberty appears to affect African-Americans more often than children of other races.
• Being obese. Children who are significantly overweight have a higher risk of developing precocious puberty.
• Being exposed to sex hormones. Coming in contact with an estrogen or testosterone cream or ointment, or other substances that contain these hormones (such as an adult’s medication or dietary supplements), can increase your child’s risk of developing precocious puberty.
• Having other medical conditions. Precocious puberty may be a complication of McCune-Albright syndrome or congenital adrenal hyperplasia — conditions that involve abnormal production of the male hormones (androgens). In rare cases, precocious puberty may also be associated with hypothyroidism.
• Having received radiation therapy of the central nervous system. Radiation treatment for tumors, leukemia or other conditions can increase the risk of precocious puberty.

Complications

Possible complications of precocious puberty include:

• Short height. Children with precocious puberty may grow quickly at first and be tall, compared with their peers. But, because their bones mature more quickly than normal, they often stop growing earlier than usual. This can cause them to be shorter than average as adults. Early treatment of precocious puberty, especially when it occurs in very young children, can help them grow taller than they would without treatment.
• Social and emotional problems. Girls and boys who begin puberty long before their peers may be extremely self-conscious about the changes occurring in their bodies. This may affect self-esteem and increase the risk of depression or substance abuse.

Prevention

Some of the risk factors for precocious puberty, such as sex and race, can’t be avoided. But, there are things you can do to reduce your child’s chances of developing precocious puberty, including:

• Keeping your child away from external sources of estrogen and testosterone — such as prescription medications for adults in the house or dietary supplements containing estrogen or testosterone
• Encouraging your child to maintain a healthy weight

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Rhesus (Rh) factor is an inherited protein found on the surface of red blood cells. If your blood has the protein, you’re Rh positive. If your blood lacks the protein, you’re Rh negative.

Rh positive is the most common blood type. Having an Rh negative blood type is not an illness and usually does not affect your health. However, it can affect your pregnancy. Your pregnancy needs special care if you’re Rh negative and your baby is Rh positive (Rh incompatibility). A baby can inherit the Rh factor from either parent.

Your health care provider will recommend a blood type and Rh factor screening test during your first prenatal visit. This will identify whether your blood cells carry the Rh factor protein.

What’s an Rh Factor?

An Rh factor is a protein found on some red blood cells (RBCs). Not everyone carries this protein, though most do. They are Rh-positive. People who don’t carry the protein are Rh-negative.

What if Parents Don’t Have the Same Rh Factor?

When a mother-to-be and father-to-be are not both positive or negative for Rh factor, it’s called Rh incompatibility.

For example:

• If a woman who is Rh negative and a man who is Rh positive conceive a baby, the fetus may have Rh-positive blood, inherited from the father. (About half of the children born to an Rh-negative mother and Rh-positive father will be Rh-positive.)

Rh incompatibility usually isn’t a problem if it’s the mother’s first pregnancy. That’s because the baby’s blood does not normally enter the mother’s circulatory system during the pregnancy.

During the birth, though, the mother’s and baby’s blood can mix. If this happens, the mother’s body recognizes the Rh protein as a foreign substance. It then might begin making antibodies (proteins that act as protectors if foreign cells enter the body) against the Rh protein.

Rh-negative pregnant women can be exposed to the Rh protein that might cause antibody production in other ways too. These include:

• blood transfusions with Rh-positive blood 
• miscarriage
• ectopic pregnancy

Why it’s done

During pregnancy, problems can occur if you’re Rh negative and the baby you’re carrying is Rh positive. Usually, your blood doesn’t mix with your baby’s blood during pregnancy. However, a small amount of your baby’s blood could come in contact with your blood during delivery or if you experience bleeding or abdominal trauma during pregnancy. If you’re Rh negative and your baby is Rh positive, your body might produce proteins called Rh antibodies after exposure to the baby’s red blood cells.

The antibodies produced aren’t a problem during the first pregnancy. The concern is with your next pregnancy. If your next baby is Rh positive, these Rh antibodies can cross the placenta and damage the baby’s red blood cells. This could lead to life-threatening anemia, a condition in which red blood cells are destroyed faster than the baby’s body can replace them. Red blood cells are needed to carry oxygen throughout the body.

If you’re Rh negative, you might need to have another blood test — an antibody screen — during your first trimester, during week 28 of pregnancy and at delivery. The antibody screen is used to detect antibodies to Rh positive blood. If you haven’t started to produce Rh antibodies, you’ll likely need an injection of a blood product called Rh immune globulin. The immune globulin prevents your body from producing Rh antibodies during your pregnancy.

If your baby is born Rh negative, no additional treatment is needed. If your baby is born Rh positive, you’ll need another injection shortly after delivery.

If you’re Rh negative and your baby might be or is Rh positive, your health care provider might recommend an Rh immune globulin injection after situations in which your blood could come into contact with the baby’s blood, including:

• Miscarriage
• Abortion
• Ectopic pregnancy — when a fertilized eggs implants somewhere outside the uterus, usually in a fallopian tube
• Removal of a molar pregnancy — a noncancerous (benign) tumor that develops in the uterus
• Amniocentesis — a prenatal test in which a sample of the fluid that surrounds and protects a baby in the uterus (amniotic fluid) is removed for testing or treatment
• Chorionic villus sampling — a prenatal test in which a sample of the wispy projections that make up most of the placenta (chorionic villi) is removed for testing
• Cordocentesis — a diagnostic prenatal test in which a sample of the baby’s blood is removed from the umbilical cord for testing
• Bleeding during pregnancy
• Abdominal trauma during pregnancy
• The external manual rotation of a baby in a breech position — such as buttocks first — before labor
• Delivery

If the antibody screen shows that you’re already producing antibodies, an injection of Rh immune globulin won’t help. Your baby will be carefully monitored. He or she might be given a blood transfusion through the umbilical cord during the pregnancy or immediately after delivery if necessary.

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Mother’s Rh factor	Father’s Rh factor	Baby’s Rh factor	Precautions
Rh positive	Rh positive	Rh positive	None
Rh negative	Rh negative	Rh negative	None
Rh positive	Rh negative	Could be Rh positive or Rh negative	None
Rh negative	Rh positive	Could be Rh positive or Rh negative	Rh immune globulin injections

What you can expect

An Rh factor test is a basic blood test. The blood sample is usually taken during the first prenatal visit and sent to a lab for analysis. No special preparation is necessary.

Results

If you’re Rh positive, no action is needed.

If you’re Rh negative and your baby is Rh positive, there’s a potential for your body to produce antibodies that could be harmful during a subsequent pregnancy. If you have vaginal bleeding at any time during pregnancy, contact your health care provider immediately. Also, talk with your health care provider about scheduling an Rh immune globulin injection during your pregnancy and remind your health care team of your Rh status during labor.

When Is a Baby at Risk?

Rh antibodies are harmless until the mother’s second or later pregnancies. If she is ever carrying another Rh-positive child, her Rh antibodies will recognize the Rh proteins on the surface of the baby’s blood cells as foreign. Her antibodies will pass into the baby’s bloodstream and attack those cells.

This can make the baby’s red blood cells swell and rupture. This is known as hemolytic or Rh disease of the newborn. It can make a baby’s blood count get very low.

How Is Rh Incompatibility Treated?

If a pregnant woman has the potential to develop Rh incompatibility, doctors give her a series of two Rh immune-globulin shots during her first pregnancy. She’ll get:

• the first shot around the 28th week of pregnancy
• the second shot within 72 hours of giving birth

Rh immune-globulin acts like a vaccine. It prevents the mother’s body from making any Rh antibodies that could cause serious health problems in the newborn or affect a future pregnancy.

A woman also might get a dose of Rh immune-globulin if she has a miscarriage, an amniocentesis, or any bleeding during pregnancy.

If a doctor finds that a woman has already developed Rh antibodies, her pregnancy will be closely watched to make sure that those levels are not too high.

In rare cases, if the incompatibility is severe and a baby is in danger, the baby can get special blood transfusions called exchange transfusions either before birth (intrauterine fetal transfusions) or after delivery. Exchange transfusions replace the baby’s blood with blood with Rh-negative blood cells. This stabilizes the level of red blood cells and minimizes damage from Rh antibodies already in the baby’s bloodstream.

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Menopause is the time that marks the end of your menstrual cycles. It’s diagnosed after you’ve gone 12 months without a menstrual period. Menopause can happen in your 40s or 50s, but the average age is 51 in the United States.

Menopause is a natural biological process. But the physical symptoms, such as hot flashes, and emotional symptoms of menopause may disrupt your sleep, lower your energy or affect emotional health. There are many effective treatments available, from lifestyle adjustments to hormone therapy.

Menopause occurs when a woman hasn’t menstruated in 12 consecutive months and can no longer become pregnant naturally. It usually begins between the ages of 45 and 55, but can develop before or after this age range.

Menopause can cause uncomfortable symptoms, such as hot flashes and weight gain. For most women, medical treatment isn’t needed for menopause.

Read on to learn what you need to know about menopause.

When does menopause begin and how long does it last?

Most women first begin developing menopause symptoms about four years before their last period. Symptoms often continue until about four years after a woman’s last period.

A small number of women experience menopause symptoms for up to a decade before menopause actually occurs, and 1 in 10 women experience menopausal symptoms for 12 years following their last period.

The median age for menopause is 51, though it may occur on average up to two years earlier for Black and Latina women. More studies are needed to understand the onset of menopause for women of color.

There are many factors that help determine when you’ll begin menopause, including genetics and ovary health. Perimenopause occurs before menopause. Perimenopause is a time when your hormones begin to change in preparation for menopause.

It can last anywhere from a few months to several years. Many women begin perimenopause some point after their mid-40s. Other women skip perimenopause and enter menopause suddenly.

About 1 percent of women begin menopause before the age of 40, which is called premature menopause or primary ovarian insufficiency. About 5 percent of women undergo menopause between the ages of 40 and 45. This is referred to as early menopause.

Perimenopause vs. menopause vs. postmenopause

During perimenopause, menstrual periods become irregular. Your periods may be late, or you may completely skip one or more periods. Menstrual flow may also become heavier or lighter.

Menopause is defined as a lack of menstruation for one full year.

Postmenopause refers to the years after menopause has occurred.

What are the symptoms of menopause?

Every woman’s menopause experience is unique. Symptoms are usually more severe when menopause occurs suddenly or over a shorter period of time.

Conditions that impact the health of the ovary, like cancer or hysterectomy, or certain lifestyle choices, like smoking, tend to increase the severity and duration of symptoms.

Aside from menstruation changes, the symptoms of perimenopause, menopause, and postmenopause are generally the same. The most common early signs of perimenopause are:

• less frequent menstruation
• heavier or lighter periods than you normally experience
• vasomotor symptoms, including hot flashes, night sweats, and flushing

An estimated 75 percent of women experience hot flashes with menopause.

Other common symptoms of menopause include:

• insomnia
• vaginal dryness
• weight gain
• depression
• anxiety
• difficulty concentrating
• memory problems
• reduced libido, or sex drive
• dry skin, mouth, and eyes
• increased urination
• sore or tender breasts
• headaches
• racing heart
• urinary tract infections (UTIs)
• reduced muscle mass
• painful or stiff joints
• reduced bone mass
• less full breasts
• hair thinning or loss
• increased hair growth on other areas of the body, such as the face, neck, chest, and upper back

In the months or years leading up to menopause (perimenopause), you might experience these signs and symptoms:

• Irregular periods
• Vaginal dryness
• Hot flashes
• Chills
• Night sweats
• Sleep problems
• Mood changes
• Weight gain and slowed metabolism
• Thinning hair and dry skin
• Loss of breast fullness

Signs and symptoms, including changes in menstruation can vary among women. Most likely, you’ll experience some irregularity in your periods before they end.

Skipping periods during perimenopause is common and expected. Often, menstrual periods will skip a month and return, or skip several months and then start monthly cycles again for a few months. Periods also tend to happen on shorter cycles, so they are closer together. Despite irregular periods, pregnancy is possible. If you’ve skipped a period but aren’t sure you’ve started the menopausal transition, consider a pregnancy test.

When to see a doctor

Keep up with regular visits with your doctor for preventive health care and any medical concerns. Continue getting these appointments during and after menopause.

Preventive health care as you age may include recommended health screening tests, such as colonoscopy, mammography and triglyceride screening. Your doctor might recommend other tests and exams, too, including thyroid testing if suggested by your history, and breast and pelvic exams.

Always seek medical advice if you have bleeding from your vagina after menopause.

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Why does menopause occur?

Menopause is a natural process that occurs as the ovaries age and produce less reproductive hormones.

The body begins to undergo several changes in response to lower levels of:

• estrogen
• progesterone
• testosterone
• follicle-stimulating hormone (FSH)
• luteinizing hormone (LH)

One of the most notable changes is the loss of active ovarian follicles. Ovarian follicles are the structures that produce and release eggs from the ovary wall, allowing menstruation and fertility.

Most women first notice the frequency of their period becoming less consistent, as the flow becomes heavier and longer. This usually occurs at some point in the mid-to-late 40s. By the age of 52, most U.S. women have undergone menopause.

In some cases, menopause is induced, or caused by injury or surgical removal of the ovaries and related pelvic structures.

Common causes of induced menopause include:

• bilateral oophorectomy, or surgical removal of the ovaries
• ovarian ablation, or the shutdown of ovary function, which may be done by hormone therapy, surgery, or radiotherapy techniques in women with estrogen receptor-positive tumors
• pelvic radiation
• pelvic injuries that severely damage or destroy the ovaries

Menopause can result from:

• Naturally declining reproductive hormones. As you approach your late 30s, your ovaries start making less estrogen and progesterone — the hormones that regulate menstruation — and your fertility declines. In your 40s, your menstrual periods may become longer or shorter, heavier or lighter, and more or less frequent, until eventually — on average, by age 51 — your ovaries stop releasing eggs, and you have no more periods.
• Surgery that removes the ovaries (oophorectomy). Your ovaries produce hormones, including estrogen and progesterone, that regulate the menstrual cycle. Surgery to remove your ovaries causes immediate menopause. Your periods stop, and you’re likely to have hot flashes and experience other menopausal signs and symptoms. Signs and symptoms can be severe, as hormonal changes occur abruptly rather than gradually over several years. Surgery that removes your uterus but not your ovaries (hysterectomy) usually doesn’t cause immediate menopause. Although you no longer have periods, your ovaries still release eggs and produce estrogen and progesterone.
• Chemotherapy and radiation therapy. These cancer therapies can induce menopause, causing symptoms such as hot flashes during or shortly after the course of treatment. The halt to menstruation (and fertility) is not always permanent following chemotherapy, so birth control measures may still be desired. Radiation therapy only affects ovarian function if radiation is directed at the ovaries. Radiation therapy to other parts of the body, such as breast tissue or the head and neck, won’t affect menopause.
• Primary ovarian insufficiency. About 1% of women experience menopause before age 40 (premature menopause). Premature menopause may result from the failure of your ovaries to produce normal levels of reproductive hormones (primary ovarian insufficiency), which can stem from genetic factors or autoimmune disease. But often no cause of premature menopause can be found. For these women, hormone therapy is typically recommended at least until the natural age of menopause in order to protect the brain, heart and bones

How is menopause diagnosed?

It’s worth talking with your healthcare provider if you’re experiencing troublesome or disabling menopause symptoms, or you’re experiencing menopause symptoms and are 45 years of age or younger.

A new blood test known as the PicoAMH Elisa diagnostic test was recently approved by the Food and Drug AdministrationTrusted Source. This test is used to help determine whether a woman has entered menopause or is getting close to entering menopause.

This new test may be helpful to women who show symptoms of perimenopause, which can also have adverse health impacts. Early menopause is associated with a higher risk of osteoporosis and fracture, heart disease, cognitive changes, vaginal changes and loss of libido, and mood changes.

Your doctor can also order a blood test that will measure the level of certain hormones in the blood, usually FSH and a form of estrogen called estradiol.

Consistently elevated FSH blood levels of 30 mIU/mL or higher, combined with a lack of menstruation for one consecutive year, is usually confirmation of menopause. Saliva tests and over-the-counter (OTC) urine tests are also available, but they’re unreliable and expensive.

During perimenopause, FSH and estrogen levels fluctuate daily, so most healthcare providers will diagnose this condition based on symptoms, medical history, and menstrual information.

Depending on your symptoms and health history, your healthcare provider may also order additional blood tests to help rule out other underlying conditions that may be responsible for your symptoms.

Additional blood tests commonly used to help confirm menopause include:

• thyroid function tests
• blood lipid profile
• liver function tests
• kidney function tests
• testosterone, progesterone, prolactin, estradiol, and chorionic gonadotropin (hCG) tests

Complications

After menopause, your risk of certain medical conditions increases. Examples include:

• Heart and blood vessel (cardiovascular) disease. When your estrogen levels decline, your risk of cardiovascular disease increases. Heart disease is the leading cause of death in women as well as in men. So it’s important to get regular exercise, eat a healthy diet and maintain a normal weight. Ask your doctor for advice on how to protect your heart, such as how to reduce your cholesterol or blood pressure if it’s too high.
• Osteoporosis. This condition causes bones to become brittle and weak, leading to an increased risk of fractures. During the first few years after menopause, you may lose bone density at a rapid rate, increasing your risk of osteoporosis. Postmenopausal women with osteoporosis are especially susceptible to fractures of their spine, hips and wrists.
• Urinary incontinence. As the tissues of your vagina and urethra lose elasticity, you may experience frequent, sudden, strong urges to urinate, followed by an involuntary loss of urine (urge incontinence), or the loss of urine with coughing, laughing or lifting (stress incontinence). You may have urinary tract infections more often. Strengthening pelvic floor muscles with Kegel exercises and using a topical vaginal estrogen may help relieve symptoms of incontinence. Hormone therapy may also be an effective treatment option for menopausal urinary tract and vaginal changes that can result in urinary incontinence.
• Sexual function. Vaginal dryness from decreased moisture production and loss of elasticity can cause discomfort and slight bleeding during sexual intercourse. Also, decreased sensation may reduce your desire for sexual activity (libido). Water-based vaginal moisturizers and lubricants may help. If a vaginal lubricant isn’t enough, many women benefit from the use of local vaginal estrogen treatment, available as a vaginal cream, tablet or ring.
• Weight gain. Many women gain weight during the menopausal transition and after menopause because metabolism slows. You may need to eat less and exercise more, just to maintain your current weight.

Treatment

Menopause requires no medical treatment. Instead, treatments focus on relieving your signs and symptoms and preventing or managing chronic conditions that may occur with aging. Treatments may include:

• Hormone therapy. Estrogen therapy is the most effective treatment option for relieving menopausal hot flashes. Depending on your personal and family medical history, your doctor may recommend estrogen in the lowest dose and the shortest time frame needed to provide symptom relief for you. If you still have your uterus, you’ll need progestin in addition to estrogen. Estrogen also helps prevent bone loss. Long-term use of hormone therapy may have some cardiovascular and breast cancer risks, but starting hormones around the time of menopause has shown benefits for some women. Talk to your doctor about the benefits and risks of hormone therapy and whether it’s a safe choice for you.
• Vaginal estrogen. To relieve vaginal dryness, estrogen can be administered directly to the vagina using a vaginal cream, tablet or ring. This treatment releases just a small amount of estrogen, which is absorbed by the vaginal tissues. It can help relieve vaginal dryness, discomfort with intercourse and some urinary symptoms.
• Low-dose antidepressants. Certain antidepressants related to the class of drugs called selective serotonin reuptake inhibitors (SSRIs) may decrease menopausal hot flashes. A low-dose antidepressant for management of hot flashes may be useful for women who can’t take estrogen for health reasons or for women who need an antidepressant for a mood disorder.
• Gabapentin (Gralise, Horizant, Neurontin). Gabapentin is approved to treat seizures, but it has also been shown to help reduce hot flashes. This drug is useful in women who can’t use estrogen therapy and in those who also have nighttime hot flashes.
• Clonidine (Catapres, Kapvay). Clonidine, a pill or patch typically used to treat high blood pressure, might provide some relief from hot flashes.
• Medications to prevent or treat osteoporosis. Depending on individual needs, doctors may recommend medication to prevent or treat osteoporosis. Several medications are available that help reduce bone loss and risk of fractures. Your doctor might prescribe vitamin D supplements to help strengthen bones.

Before deciding on any form of treatment, talk with your doctor about your options and the risks and benefits involved with each. Review your options yearly, as your needs and treatment options may change.

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Endometriosis is a disorder in which tissue similar to the tissue that forms the lining of your uterus grows outside of your uterine cavity. The lining of your uterus is called the endometrium.

Endometriosis occurs when endometrial tissue grows on your ovaries, bowel, and tissues lining your pelvis. It’s unusual for endometrial tissue to spread beyond your pelvic region, but it’s not impossible. Endometrial tissue growing outside of your uterus is known as an endometrial implant.

The hormonal changes of your menstrual cycle affect the misplaced endometrial tissue, causing the area to become inflamed and painful. This means the tissue will grow, thicken, and break down. Over time, the tissue that has broken down has nowhere to go and becomes trapped in your pelvis.

This tissue trapped in your pelvis can cause:

• irritation
• scar formation
• adhesions, in which tissue binds your pelvic organs together
• severe pain during your periods
• fertility problems

Endometriosis is a common gynecological condition, affecting up to 10 percent of women. You’re not alone if you have this disorder.

Endometriosis (en-doe-me-tree-O-sis) is an often painful disorder in which tissue similar to the tissue that normally lines the inside of your uterus — the endometrium — grows outside your uterus. Endometriosis most commonly involves your ovaries, fallopian tubes and the tissue lining your pelvis. Rarely, endometrial tissue may spread beyond pelvic organs.

With endometriosis, the endometrial-like tissue acts as endometrial tissue would — it thickens, breaks down and bleeds with each menstrual cycle. But because this tissue has no way to exit your body, it becomes trapped. When endometriosis involves the ovaries, cysts called endometriomas may form. Surrounding tissue can become irritated, eventually developing scar tissue and adhesions — abnormal bands of fibrous tissue that can cause pelvic tissues and organs to stick to each other.

Endometriosis can cause pain — sometimes severe — especially during menstrual periods. Fertility problems also may develop. Fortunately, effective treatments are available.

causes

During a regular menstrual cycle, your body sheds the lining of your uterus. This allows menstrual blood to flow from your uterus through the small opening in the cervix and out through your vagina.

The exact cause of endometriosis isn’t known, and there are several theories regarding the cause, although no one theory has been scientifically proven.

One of the oldest theories is that endometriosis occurs due to a process called retrograde menstruation. This happens when menstrual blood flows back through your fallopian tubes into your pelvic cavity instead of leaving your body through the vagina.

Another theory is that hormones transform the cells outside the uterus into cells similar to those lining the inside of the uterus, known as endometrial cells.

Others believe the condition may occur if small areas of your abdomen convert into endometrial tissue. This may happen because cells in your abdomen grow from embryonic cells, which can change shape and act like endometrial cells. It’s not known why this occurs.

These displaced endometrial cells may be on your pelvic walls and the surfaces of your pelvic organs, such as your bladder, ovaries, and rectum. They continue to grow, thicken, and bleed over the course of your menstrual cycle in response to the hormones of your cycle.

Another theory is that the endometrial cells are transported out of the uterus through the lymphatic system. Still another theory purports it may be due to a faulty immune system that isn’t destroying errant endometrial cells.

Some believe endometriosis might start in the fetal period with misplaced cell tissue that begins to respond to the hormones of puberty. This is often called Mullerian theory. The development of endometriosis might also be linked to genetics or even environmental toxins.

Although the exact cause of endometriosis is not certain, possible explanations include:

• Retrograde menstruation. In retrograde menstruation, menstrual blood containing endometrial cells flows back through the fallopian tubes and into the pelvic cavity instead of out of the body. These endometrial cells stick to the pelvic walls and surfaces of pelvic organs, where they grow and continue to thicken and bleed over the course of each menstrual cycle.
• Transformation of peritoneal cells. In what’s known as the “induction theory,” experts propose that hormones or immune factors promote transformation of peritoneal cells — cells that line the inner side of your abdomen — into endometrial-like cells.
• Embryonic cell transformation. Hormones such as estrogen may transform embryonic cells — cells in the earliest stages of development — into endometrial-like cell implants during puberty.
• Surgical scar implantation. After a surgery, such as a hysterectomy or C-section, endometrial cells may attach to a surgical incision.
• Endometrial cell transport. The blood vessels or tissue fluid (lymphatic) system may transport endometrial cells to other parts of the body.
• Immune system disorder. A problem with the immune system may make the body unable to recognize and destroy endometrial-like tissue that’s growing outside the uterus.

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symptoms

The symptoms of endometriosis vary. Some women experience mild symptoms, but others can have moderate to severe symptoms. The severity of your pain doesn’t indicate the degree or stage of the condition. You may have a mild form of the disease yet experience agonizing pain. It’s also possible to have a severe form and have very little discomfort.

Pelvic pain is the most common symptom of endometriosis. You may also have the following symptoms:

• painful periods
• pain in the lower abdomen before and during menstruation
• cramps one or two weeks around menstruation
• heavy menstrual bleeding or bleeding between periods
• infertility
• pain following sexual intercourse
• discomfort with bowel movements
• lower back pain that may occur at any time during your menstrual cycle

You may also have no symptoms. It’s important that you get regular gynecological exams, which will allow your gynecologist to monitor any changes. This is particularly important if you have two or more symptoms.

The primary symptom of endometriosis is pelvic pain, often associated with menstrual periods. Although many experience cramping during their menstrual periods, those with endometriosis typically describe menstrual pain that’s far worse than usual. Pain also may increase over time.

Common signs and symptoms of endometriosis include:

• Painful periods (dysmenorrhea). Pelvic pain and cramping may begin before and extend several days into a menstrual period. You may also have lower back and abdominal pain.
• Pain with intercourse. Pain during or after sex is common with endometriosis.
• Pain with bowel movements or urination. You’re most likely to experience these symptoms during a menstrual period.
• Excessive bleeding. You may experience occasional heavy menstrual periods or bleeding between periods (intermenstrual bleeding).
• Infertility. Sometimes, endometriosis is first diagnosed in those seeking treatment for infertility.
• Other signs and symptoms. You may experience fatigue, diarrhea, constipation, bloating or nausea, especially during menstrual periods.

The severity of your pain isn’t necessarily a reliable indicator of the extent of the condition. You could have mild endometriosis with severe pain, or you could have advanced endometriosis with little or no pain.

Endometriosis is sometimes mistaken for other conditions that can cause pelvic pain, such as pelvic inflammatory disease (PID) or ovarian cysts. It may be confused with irritable bowel syndrome (IBS), a condition that causes bouts of diarrhea, constipation and abdominal cramping. IBS can accompany endometriosis, which can complicate the diagnosis.

When to see a doctor

See your doctor if you have signs and symptoms that may indicate endometriosis.

Endometriosis can be a challenging condition to manage. An early diagnosis, a multidisciplinary medical team and an understanding of your diagnosis may result in better management of your symptoms.

Endometriosis stages

Endometriosis has four stages or types. It can be any of the following:

• minimal
• mild
• moderate
• severe

Different factors determine the stage of the disorder. These factors can include the location, number, size, and depth of endometrial implants.

Stage 1: Minimal

In minimal endometriosis, there are small lesions or wounds and shallow endometrial implants on your ovary. There may also be inflammation in or around your pelvic cavity.

Stage 2: Mild

Mild endometriosis involves light lesions and shallow implants on an ovary and the pelvic lining.

Stage 3: Moderate

Moderate endometriosis involves deep implants on your ovary and pelvic lining. There can also be more lesions.

Stage 4: Severe

The most severe stage of endometriosis involves deep implants on your pelvic lining and ovaries. There may also be lesions on your fallopian tubes and bowels.

Risk factors

Several factors place you at greater risk of developing endometriosis, such as:

• Never giving birth
• Starting your period at an early age
• Going through menopause at an older age
• Short menstrual cycles — for instance, less than 27 days
• Heavy menstrual periods that last longer than seven days
• Having higher levels of estrogen in your body or a greater lifetime exposure to estrogen your body produces
• Low body mass index
• One or more relatives (mother, aunt or sister) with endometriosis
• Any medical condition that prevents the normal passage of menstrual flow out of the body
• Reproductive tract abnormalities

Endometriosis usually develops several years after the onset of menstruation (menarche). Signs and symptoms of endometriosis may temporarily improve with pregnancy and may go away completely with menopause, unless you’re taking estrogen.

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Complications

Infertility

Fertilization and implantation

The main complication of endometriosis is impaired fertility. Approximately one-third to one-half of women with endometriosis have difficulty getting pregnant.

For pregnancy to occur, an egg must be released from an ovary, travel through the neighboring fallopian tube, become fertilized by a sperm cell and attach itself to the uterine wall to begin development. Endometriosis may obstruct the tube and keep the egg and sperm from uniting. But the condition also seems to affect fertility in less-direct ways, such as by damaging the sperm or egg.

Even so, many with mild to moderate endometriosis can still conceive and carry a pregnancy to term. Doctors sometimes advise those with endometriosis not to delay having children because the condition may worsen with time.

Cancer

Ovarian cancer does occur at higher than expected rates in those with endometriosis. But the overall lifetime risk of ovarian cancer is low to begin with. Some studies suggest that endometriosis increases that risk, but it’s still relatively low. Although rare, another type of cancer — endometriosis-associated adenocarcinoma — can develop later in life in those who have had endometriosis.

Diagnosis

The symptoms of endometriosis can be similar to the symptoms of other conditions, such as ovarian cysts and pelvic inflammatory disease. Treating your pain requires an accurate diagnosis.

Your doctor will perform one or more of the following tests:

Detailed history

Your doctor will note your symptoms and personal or family history of endometriosis. A general health assessment may also be performed to determine if there are any other signs of a long-term disorder.

Physical exam

During a pelvic exam, your doctor will manually feel your abdomen for cysts or scars behind the uterus.

Ultrasound

Your doctor may use a transvaginal ultrasound or an abdominal ultrasound. In a transvaginal ultrasound, a transducer is inserted into your vagina.

Both types of ultrasound provide images of your reproductive organs. They can help your doctor identify cysts associated with endometriosis, but they aren’t effective in ruling out the disease.

Laparoscopy

The only certain method for identifying endometriosis is by viewing it directly. This is done by a minor surgical procedure known as a laparoscopy. Once diagnosed, the tissue can be removed in the same procedure.

Endometriosis treatment

Understandably, you want quick relief from pain and other symptoms of endometriosis. This condition can disrupt your life if it’s left untreated. Endometriosis has no cure, but its symptoms can be managed.

Medical and surgical options are available to help reduce your symptoms and manage any potential complications. Your doctor may first try conservative treatments. They may then recommend surgery if your condition doesn’t improve.

Everyone reacts differently to these treatment options. Your doctor will help you find the one that works best for you.

It may be frustrating to get diagnosis and treatment options early in the disease. Because of the fertility issues, pain, and fear that there is no relief, this disease can be difficult to handle mentally. Consider finding a support group or educating yourself more on the condition. Treatment options include:

Pain medications

You can try over-the-counter pain medications such as ibuprofen, but these aren’t effective in all cases.

Hormone therapy

Taking supplemental hormones can sometimes relieve pain and stop the progression of endometriosis. Hormone therapy helps your body regulate the monthly hormonal changes that promote the tissue growth that occurs when you have endometriosis.

Hormonal contraceptives

Hormonal contraceptives decrease fertility by preventing the monthly growth and buildup of endometrial tissue. Birth control pills, patches, and vaginal rings can reduce or even eliminate the pain in less severe endometriosis.

The medroxyprogesterone (Depo-Provera) injection is also effective in stopping menstruation. It stops the growth of endometrial implants. It relieves pain and other symptoms. This may not be your first choice, however, because of the risk of decreased bone production, weight gain, and an increased incidence of depression in some cases.

Gonadotropin-releasing hormone (GnRH) agonists and antagonists

Women take what are called gonadotropin-releasing hormone (GnRH) agonists and antagonists to block the production of estrogen which stimulate the ovaries. Estrogen is the hormone that’s mainly responsible for the development of female sexual characteristics. Blocking the production of estrogen prevents menstruation and creates an artificial menopause.

GnRH therapy has side effects like vaginal dryness and hot flashes. Taking small doses of estrogen and progesterone at the same time can help to limit or prevent these symptoms.

Danazol

Danazol is another medication used to stop menstruation and reduce symptoms. While taking danazol, the disease may continue to progress. Danazol can have side effects, including acne and hirsutism. Hirsutism is abnormal hair growth on your face and body.

Other drugs are being studied that may improve symptoms and slow disease progress.

Conservative surgery

Conservative surgery is for women who want to get pregnant or experience severe pain and for whom hormonal treatments aren’t working. The goal of conservative surgery is to remove or destroy endometrial growths without damaging the reproductive organs.

Laparoscopy, a minimally invasive surgery, is used to both visualize and diagnose, endometriosis. It is also used to remove the endometrial tissue. A surgeon makes small incisions in the abdomen to surgically remove the growths or to burn or vaporize them. Lasers are commonly used these days as a way to destroy this “out of place” tissue.

Last-resort surgery (hysterectomy)

Rarely, your doctor may recommend a total hysterectomy as a last resort if your condition doesn’t improve with other treatments.

During a total hysterectomy, a surgeon removes the uterus and cervix. They also remove the ovaries because these organs make estrogen, and estrogen causes the growth of endometrial tissue. Additionally, the surgeon removes visible implant lesions.

A hysterectomy is not usually considered a treatment or cure for endometriosis. You’ll be unable to get pregnant after a hysterectomy. Get a second opinion before agreeing to surgery if you’re thinking about starting a family.

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