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Adam S. Levine, M.D. recently finished his fellowship in reproductive endocrinology and infertility within the department of gynecology and obstetrics at the Johns Hopkins University School of Medicine. His areas of expertise include reproductive endocrinology, infertility, assisted reproductive technology, reproductive surgery, pediatric and adolescent gynecology, and menopause.

 

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infections & urogynecology

Q:   After the birth of my twins (I had my tubes tied at birth), I experienced frequent episodes of vaginal and anal itching. The worse episodes of itching seem to occur right before I get my menstrual period. I have been tested for yeast infection, and the test was negative. Can you tell me what could be causing this itching, which is only external?	A:   There are a variety of different conditions that may cause pruritus (the technical term for itching). Probably the most common condition causing pruritus is vaginitis (vaginal infection). Since there are several different organisms that may cause vaginitis, and each of the organisms generally requires a different treatment, the diagnosis should be made during an office examination. Vaginitis may be diagnosed during a pelvic examination when a health care provider can examine a vaginal sample under a microscope, and if necessary, send a portion of it to the laboratory for culture. Another common cause of pruritus may be related to the normal hormonal fluctuations that a woman has during her menstrual cycle. These hormonal changes may be more pronounced for several months post-partum. Because pruritus may be difficult to diagnose, I recommend a gynecologic evaluation when the symptoms are present.
Q:   I am a 26-year-old female who suffers from frequent urinary tract infections. I can quickly and reliably control them with a short course of sulfa-drugs. However, a test recently indicated that I am getting low-grade infections without symptoms. I am concerned that frequent infections (both low-grade and symptomatic) will do some long-term, chronic damage. Is this the case?	A:   Many women will have one or two urinary tract infections. However, in some cases, frequent urinary tract infections may represent another problem that may need to be treated. Frequent, untreated infections could potentially result in kidney or bladder damage. Since there are a wide variety of different problems that may masquerade as urinary tract infections, it is important to accurately diagnose them. If no cause for chronic urinary tract infections can be found, long-term antibiotic treatment may be necessary. In this case I would recommend evaluation by either a urologist or a urogynecologist.
Q:    Five years ago, I contracted genital warts. After I was treated for the warts, I stopped a relationship with the partner from whom I contracted them. Two years after the treatment, another wart appeared, and my gynecologist removed it. Since then I have been in a monogamous relationship with my husband. I have shown no signs of genital warts and neither has he. My concern is that we are going to start trying to have a baby, and I'm very worried that the warts may reappear. How likely is this? Would it be dangerous to the baby if they did come back? Also, I know that genital warts have been linked to cervical cancer. What kind of odds do I have of getting cancer?	A:   Genital warts may also be referred to as condyloma and are usually caused by a family of viruses called the human papilloma viruses. They are almost always benign growths that may be easily treated. However, no matter which method is used to remove the wart (surgical removal, acid, heat, freezing, laser, etc.), genital warts frequently return.    Fortunately, in healthy women, genital warts result in few long term effects. However, they may cause more problems in women with compromised immune systems. There is an association between women with abnormal Pap tests or cervical cancer, and certain specific types of human papilloma viruses. Since there is no way to completely eradicate the virus once someone has it, knowing which specific type of virus you have will not change your management. All women should have routine, yearly Pap testing which will detect cervical abnormalities. It is also important for an obstetrician to know that a woman has had genital warts, but they usually have no effect on pregnancy or delivery.
Q:   Several women in my exercise class, all over the age of 30, seem to experience poor bladder control during aerobic/jumping exercises. Is there any way to control this? These women are concerned that if they modify the exercises too much to accommodate this problem, they'll lose the aerobic benefits.	A:   The involuntary loss of urine (urinary incontinence) during exercise becomes more common as women age and have children. Women with incontinence may wish to seek a gynecologic, uro-Gynecologic, or urologic evaluation. Here are two suggestions for what to do in the interim.    The first suggestion is to begin exercising only after making sure that the bladder is empty. If aerobic activity is going to be prolonged, it may be reasonable to take a brief break to empty the bladder periodically.    The second suggestion is to strengthen the pelvic musculature using Kegel exercises. A relatively easy way to learn how to do these exercises is to try to stop the flow of urine in mid-stream by contracting the muscles in your pelvis. When you can stop the urine in mid-stream, practice starting and stopping the stream. This will teach you which muscles are important. Once you have identified which muscles need to be contracted, try contracting and relaxing them for increasing periods of time. Doing these exercises several times per day, every day, may help decrease the incidence of urinary incontinence. The most important part of these exercises is to do them several times, regularly, each day. It takes approximately 30 days before something becomes a habit. Once the exercises become a habit, you should begin to notice some improvement.
Q:   I would like information on cervical inflammation. I have had only one sex partner in my life, and we are monogamous. I have a lot of problems year after year with inflammation and recurring bacterial infections, as well as with painful intercourse. How can we get information on this? It's not something I want to live with for 60 or 70 more years!	A:   Cervicitis (cervical inflammation) is a common problem. It may occur in response to an infective process (bacterial, viral or fungal) or as a type of allergic response following exposure to various substances (soaps, feminine hygiene products, etc.). Cervicitis may be diagnosed during a pelvic examination in the office. Frequently, cervical cultures will be obtained to determine its specific cause. Painful sexual intercourse is technically referred to as dyspareunia and may result from a variety of different conditions including cervicitis.    There are a variety of reasons why a woman may have recurrent cervicitis. Cervicitis is frequently treated as an infection when it is in fact an allergic reaction to a feminine hygiene product; this leads to many "treatment failures." Further, many women self-treat themselves with over-the-counter remedies which can confuse the final diagnosis. Women with cervicitis may benefit from careful attention to personal hygiene (avoiding the use of personal hygiene products, using hypoallergenic soap and laundry detergent, using plain, white, non-scented toilet tissue, wiping front to back, wearing cotton underwear and other non-occlusive clothing).    When a woman has recurrent cervicitis that does not respond to treatment, the first step is to re-examine the original diagnosis. When the diagnosis is absolutely certain and appropriate therapies have repeatedly failed, other reasons for recurrent infection should be sought. For example, recurrent cervicitis may be caused by the chronic use of certain medications, such as antibiotics for urinary tract infections or immunosuppressants for transplant patients. In other cases, an underlying disorder--such as diabetes or HIV--may predispose a woman to recurrent infection.    Cervicitis is not generally thought of as life threatening. However, it can be extremely disruptive and may have other adverse health consequences. In cases where recurrent cervicitis can not be resolved, it may be reasonable to seek guidance from an expert in Gynecologic Infectious Diseases.
Q:   Our 9-year-old daughter has had a vaginal discharge for over six months. It has been mildly responsive to topical antibiotic. Pediatrician has no answer. Exams prove negative so far.	A:   A physician should evaluate girls who develop either a vaginal discharge or bleeding before menarche (their first menstrual period). There are a wide variety of disorders that may result in a vaginal discharge or bleeding, including infections (bacteria, yeast, or viruses); allergic reactions to soaps, perfumes or dyes; skin conditions such as eczema; urologic problems (uretheral prolapse); trauma; and in some cases sexual assault or abuse.    Up to 90% of the time, a physician can find no single reason for the vaginal discharge after a physical examination and laboratory tests. In these cases, the discharge is called "nonspecific." Nonspecific vulvovaginal discharges may initially be treated by: 1) practicing good perineal hygiene (wiping front to back); 2) avoiding prolonged exposure to tight-fitting clothing, nylon underpants or tights, wet bathing suits, or dancing leotards; 3) using clean white cotton underpants, with careful attention to the detergent used in their cleaning; 4) using plain toilet paper without dyes or perfumes; 5) using mild soaps without dyes or perfumes; and finally 6) generally keeping the perineum clean, cool and dry.    In cases where the above steps have been followed, a brief trial of antibiotics may help. In some cases, a physician will recommend hormonal treatment (such as estrogen). If a child continues to have a vaginal discharge or bleeding despite treatment, it is reasonable to consult with a pediatric and adolescent gynecologist. These individuals specialize in evaluating and treating gynecologic disorders in children. A pediatric and adolescent gynecologist may generally be located through a teaching hospital or by calling the North American Society for Pediatric and Adolescent Gynecology.
Q:   I have had recurrent vaginal yeast infections since the age of 17. I am 43 years old. My doctor has been treating me with Diflucan 150 mg. One pill per week for over a year, and it has not eradicated the problem. My doctor is sending me to an infectious disease specialist. I have heard that there is no cure, and the best that can be hoped for is to put the yeast into remission for a few years. Do you know of any medications or other treatments that I should consider?	A:   Vaginitis (vaginal infection) is a common problem that affects many reproductive-age women. There are several different types of organisms that normally exist in the vagina. When the normal vaginal environment is disrupted (douching, antibiotic use, etc.), these organisms may be displaced by other bacteria or yeast, resulting in an infection. Vaginal infections may be suspected when a woman develops a vaginal discharge or experiences vaginal burning or itching. Because there are several different organisms that may cause vaginitis and each of the organisms generally requires different treatment, the diagnosis should be made during an office examination. Vaginitis is diagnosed during a pelvic examination when a health care provider can examine the vaginal sample under a microscope and send a portion of it to the laboratory for culture if necessary.    There are several reasons why women may have recurrent vaginal infections. However, women commonly refer to all vaginal discharges as yeast and may self-treat themselves with over-the-counter remedies. This leads to a large number of "treatment failures" and recurrent yeast infections. If the diagnosis of yeast is assured, there are a variety of anti-fungal vaginal preparations that may be used. These preparations are available in prescription and non-prescription strength. An important point is that not all of the different types of yeast will be eradicated with these preparations. Other therapies that may be used include the use of systemic medications such as Diflucan or vaginal boric acid suppositories.    When a woman has recurrent vaginal infections that do not respond to treatment, the first step is to re-examine the original diagnosis. When the diagnosis is absolutely certain, and appropriate therapies have repeatedly failed, other reasons for recurrent infection should be sought. For example, recurrent vaginitis may be caused by the chronic use of certain medications such as antibiotics for urinary tract infections or immunosuppressants for transplant patients. In other cases, an underlying disorder such as diabetes or HIV may predispose a woman to recurrent infection. Frequently, correction of an underlying disorder will end the recurrent vaginal infections.    While recurrent vaginal infections are not commonly life threatening, they can be extremely disruptive and may have other adverse health consequences. In cases where recurrent vaginal infections cannot be resolved, it is reasonable to seek guidance from an expert in gynecologic infectious diseases.