You notice a small amount of whitish discharge on your underwear, but don’t have any vaginal pain, itching, or burning. Between periods the vagina and cervix can produce normal discharge containing mucus and dead cells. The total shouldn’t exceed a teaspoon per day—enough to leave a mark on your underwear, but not much more. If you don’t have vaginal pain or itching, don’t worry about it.
You recently got an IUD and now have increased bleeding. Your odds of becoming pregnant just went way down, but your uterus may not like its new tenant and could register its displeasure during your period. The nonhormonal, copper IUD (ParaGard) frequently causes heavier periods. The hormonal IUD (Mirena, Skyla, or Liletta) increases menstrual bleeding at first, but eventually slows down your periods (and may stop them altogether).
It is physically possible that you are pregnant. If you’re under sixty and have had sex in the past nine months, then stop, do not pass go, and take a pregnancy test before considering any other explanation. Both normal and abnormal pregnancies can cause vaginal bleeding and discharge.
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Quick Consult
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Vaginal Dryness and Painful Intercourse
Vaginal dryness, also known as atrophic vaginitis, is a bothersome condition that typically results from low estrogen levels. Indeed, almost half of women experience vaginal dryness after menopause. Other common causes include breastfeeding, surgical removal of the ovaries, and certain medications (like leuprolide/Lupron for endometriosis, medroxyprogesterone/Provera for abnormal periods, some oral contraceptives, and antihistamines like diphenhydramine/Benadryl).
The major symptoms of vaginal dryness include pain during intercourse (dyspareunia), bleeding after intercourse (from excessive friction), and vaginal itching and burning. With the loss of protective mucus and secretions, the vagina also becomes less effective at clearing out bacteria, increasing their chances of invading the nearby urinary tract.
There are many available and effective treatments, so don’t accept vaginal dryness as an inevitable part of the normal aging process. The first-line, over-the-counter choices include lubricants (such as Astroglide liquid and K-Y Jelly), applied just before sex, and vaginal moisturizers (such as Vagisil ProHydrate gel and Replens), which provide more continuous relief. Your doctor may also prescribe an estrogen-containing vaginal treatment if estrogen deficiency is the likely underlying issue. The most common include creams (such as Estrace), vaginal suppositories (such as Vagifem), and a vaginal ring (Estring). Some women prefer to use estrogen pills or patches; however, these increase your whole body’s estrogen levels and aren’t recommended if you have a history of breast cancer or blood clots.
Of note, there are many other causes of painful intercourse besides vaginal dryness; the long list includes infection, anatomic abnormalities, endometriosis (see here), nerve disease, prior injury (for example, from surgery), anxiety, depression, and a history of sexual abuse. It’s always better to see a gynecologist for a thorough evaluation than just suffer with your symptoms or try to manage them on your own.
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Make an Appointment
Your vagina itches or burns, and there’s a thick, white discharge. You probably have a yeast infection, which causes vaginal pain, itching, and a thick discharge that is often compared to cottage cheese (which you assuredly won’t eat again). Antibiotics can cause yeast infections by killing the normal, good vaginal bacteria that keep yeast in check. Women with diabetes are also at increased risk. Your doctor can confirm the diagnosis by testing the discharge. A single antifungal pill is usually enough to clean house. If you’ve had previous yeast infections and feel confident you’re having another one, just hit the drugstore for an antifungal vaginal gel, which is available without a prescription.
You have a runny gray or green-colored vaginal discharge. You likely have either trichomoniasis or bacterial vaginosis.
Trichomoniasis, also known by its street name “trich,” produces bad-smelling discharge along with vaginal itching or burning. Sorry to break the news, but it’s a sexually transmitted infection. Your doctor will confirm the diagnosis by testing the discharge. Unfortunately, you’ll need antibiotics and so will your sexual partners (since otherwise the infection will just boomerang back to your vagina). Good luck crafting those text messages. Of note, infected men often have no symptoms, so they should be treated even if their bits feel normal.
Bacterial vaginosis (BV) is generally not as unpleasant as trichomoniasis and occurs when the vagina’s normal bacteria get out of balance. BV is extremely common, though most women don’t have symptoms. In a select few, however, it causes a thin gray discharge bearing the delightful aroma of dead fish. The odor often worsens after sex, so consider lighting a scented candle as your partner grabs a towel. Unlike trichomonoiasis, BV does not cause vaginal pain or itching. If your underwear smells like a fishing dock in the late afternoon sun, ask your doctor to test your discharge. The treatment is antibiotics. (Male sexual partners don’t need treatment.) Unfortunately, treatment failure is common, and the disease can come back, so you may need more than one course of antibiotics.
You have heavy, painful periods. You may have abnormal growths of the uterine wall, known as fibroids. Fibroids are extremely common, particularly in black women. They’re not cancerous, meaning they don’t spread outside of the uterus, and usually don’t cause any problems. In some women, however, they result in heavy periods and dull pelvic pain. Sometimes the fibroids become large enough to push on adjacent organs, like the bladder (causing frequent urination) or guts (causing constipation). Fibroids on the inside of the uterus can cause infertility and miscarriages.
Your doctor can diagnose fibroids with an ultrasound. If bleeding is the main problem, birth control pills and other drugs can help. If the fibroids are really bothersome and don’t improve with medications, you may need a procedure to shrink or remove them. Sometimes a doctor can simply inject chemicals into the blood supply of the uterus to make the fibroids shrink. In other cases, the uterus has to be partially or completely removed. The overall plan will depend on the size of your fibroids and whether you plan to become pregnant.
You’ve had longer periods since having a Cesarean section. During a Cesarean section, the uterus is opened and your little bundle of joy is finally evicted. Sometimes, however, the incision leaves behind a persistent slit-like area on the inside of the uterus. During your period, blood can collect in this area and then seep out over the course of a few extra days. The condition is annoying but not dangerous, and it can be confirmed with an ultrasound. If you’re planning to have more kids, your doctor may recommend closing the gap.
You have spotting after vaginal intercourse. If your partner treats your lady parts with the same finesse as a SWAT team ramming down a door, you may sometimes experience mild bleeding and soreness. If you regularly bleed after sex, however, you could have an infection or even a tumor. The abnormal cells are fragile and prone to bleeding after any kind of repeated contact (even the gentlest and most lubricated kind). If you’re postmenopausal and struggle with vaginal dryness, you could also have postintercourse bleeding because of excessive friction (see the Quick Consult). See your gynecologist for a thorough physical examination.
You regularly bleed between periods. If you’ve bled between your last few periods, there could be a perfectly innocent explanation. In some women, the uterus doesn’t completely purge itself in one fell swoop. On the other hand, you could have an abnormal growth that is bleeding independently of your cycle. Your gynecologist should perform a complete examination to rule out anything dangerous.
You’re bleeding but thought you already went through menopause. The transition from regular periods to menopause is rarely instantaneous. Periods typically slow down to every few months or become irregular before stopping altogether. If you’re several years into menopause, however, vaginal bleeding is more concerning. If you also experience vaginal dryness and pain, the bleeding may simply be from
inadequate natural lubrication and excessive friction. This condition, known as vulvovaginal atrophy, is common among older women and highly treatable (see the Quick Consult). If you don’t have vaginal dryness or pain, the bleeding could be from a tumor or other abnormal growth. You should see your gynecologist for a complete examination.
You have always had heavy periods, and there doesn’t seem to be anything wrong with your uterus. If you regularly go through boxes of super tampons, but your gynecologist can’t find any problems with your plumbing, you could have a blood clotting disorder. This diagnosis is especially likely if you also have a history of excess bleeding after tooth extractions or surgeries. Your doctor can screen for most clotting disorders with simple blood tests.
You have vaginal discharge and intense pelvic pain. You may have an infection of your reproductive tract (cervix, uterus, Fallopian tubes) known as pelvic inflammatory disease, which can cause discharge or even bleeding. Another concerning possibility is an ectopic pregnancy, which occurs when a fertilized egg implants in the cervix or a Fallopian tube (instead of the uterus). The egg rapidly runs out of room to grow, causing pain and bleeding. If you can’t get a same-day appointment with your gynecologist, or the pain is truly unbearable, go to the E.R.
Get to the E.R.
You have heavy bleeding and feel really lightheaded, especially when standing. For the moment, the cause of your bleeding is irrelevant. The more important issue is that your blood loss has become critical, and that your blood pressure is dropping. If you’ve been quickly soaking through tampons or pads and now feel lightheaded, you must get to the emergency room. You may need a blood transfusion and/or a procedure to stop the bleeding.
Part 5
Gentleman Parts
Blood in Semen
Few situations provide the opportunity to gaze upon one’s own semen . . . but you found one, and you were disturbed by what you saw. Is that . . . blood?! Surely the end is near, right? Time to get your affairs in order, right? You’re going to lose at least one testicle at a minimum, right?
Don’t go nuts! You’re not going to bleed to death, and you’re (probably) not going to lose a testicle.
Semen consists of sperm mixed with fluids from the prostate and other glands located along the tubes connecting the testicles to the penis. Blood in the semen, known as hematospermia, may be terrifying to see but is often nothing to worry about. In many cases, it just reflects a tiny burst capillary in the prostate or penis, which will heal on its own. On occasion, however, hematospermia can be a sign of an underlying infection or even cancer.
So, should you ignore it? Definitely not. (Didn’t think you would.) But is it worth throwing on some pants and getting to a doctor?
Take a Chill Pill
It only happened once or twice, then stopped. You probably burst a small capillary somewhere in there and then it closed up. No harm, no foul. You’re cleared to return to play.
You’re like Old Faithful. If you, um, “erupt” several times per day, you can wear out your pipes and cause bleeding. It’s a sign you should slow down and find a different hobby. (We hear knitting is terrific, and it’ll keep your hands busy too!)
You recently had a vasectomy. You just went through the ordeal of a vasectomy, and now have to suffer the horror of seeing blood in your semen. You collapse into your armchair with a sigh, asking the universe, “How could it get worse?” Relax, Job. It’s common to see blood in your semen during the week after a vasectomy. Let your urologist know, but don’t panic. If you also have pain or burning on urination, you could have an infection that requires more urgent attention. If you also have a high fever and feel lightheaded, you could have a severe infection that mandates an E.R. visit.
You had a prostate biopsy not long ago. As it turns out, the prostate makes most of your semen. (Those darn testicles—always stealing all the credit!) You shouldn’t be too surprised, then, that stabbing a biopsy needle into your prostate and ripping out a piece of flesh may produce blood where it doesn’t belong. Just let your urologist know.
You have known prostate cancer. If you have active prostate cancer, especially if you recently underwent a procedure or treatment, don’t be surprised to see blood in your semen. Let your doctor know, to be safe.
Make an Appointment
It burns when you pee, you have discharge from your penis, or you have scrotal pain. You likely have an infection down there. Depending on the exact location, the infection is known as urethritis (if it’s in the urethra, the tube inside your penis), prostatitis (in the prostate gland), or epididymitis (in the epididymis, the area on top of your testicles that stores sperm). You may need a course of pain medications and/or antibiotics. If you don’t improve with these treatments, and a scan doesn’t reveal anything concerning, you could have a rare condition known as chronic nonbacterial prostatitis, also called chronic pelvic pain syndrome. Common symptoms include pain with urination, frequent urge to pee, pain with ejaculation, and problems with erections. Although the cause and ideal treatment are not yet known, your doctor may prescribe anti-inflammatory medications and a drug known as an alpha blocker.
You take a blood thinner. Blood thinners like warfarin/Coumadin, apixaban/Eliquis, rivaroxaban/Xarelto, dabigatran/Pradaxa, and aspirin can all cause bleeding into your semen. Sometimes the bleeding is simply from burst capillaries that didn’t close up as quickly as they normally would. In some cases, however, the blood thinner actually causes bleeding from a tumor that was previously hidden. (Perhaps the medication saved your life by unmasking the diagnosis early!)
None of the previous explanations apply, and you’re older than forty. You made it this far and we didn’t ring any bells. Sorry about that. You should get checked out, though. The long list of remaining possibilities include infection, stones in the prostate, cancers, abnormalities in blood vessels, and so on. Your doctor will slide a finger into your rectum to check your prostate for tumors (not so bad if you just relax), evaluate your urine for infection, and measure the levels of a chemical called prostate-specific antigen, or PSA. If no cause is found, you may need imaging tests of your prostate and testicles.
Get to the E.R.
You have intense pain in your pelvis or scrotum, along with fever, chills, and/or lightheadedness. You may have a serious prostate or testicular infection. If you can’t see your doctor within the next few hours, get to the E.R. instead. You need further testing and may require urgent antibiotics.
Lump on Your Testicle
The testicles produce sperm and essential male hormones like testosterone. Like so many things in life—for example, saying “bless you” to anyone who sneezes, and absolutely nothing to a person hacking up a lung—we blindly accept the weirdness of the testicles without ever questioning it. Why are they outside of the body in a little pocket of their own? Isn’t that dangerous? Why don’t women have a bag of ovaries hanging between their legs? Why do people stop answering our texts whenever we ask these questions?
The best explanation is that the testicles prefer a slightly cooler temperature than the rest of the body. Indeed, the skin of the scrotum is very thin, and the blood vessels run right along the surface. Both factors promote heat loss into the surrounding air. But, hold on, the testicles didn’t ask to freeze! If you walk outside in snow boots and a bathrobe, your testicles will cling like magnets to the rest of your body, trying to get some of that heat back.
Because the testicles are just hanging out in the open, men often notice irregularities in their surface. Some doctors recommend men check their testicles at least once per month. Although that might be overkill—and besides, who even has that kind of free time?—you should check yourself at least four or five times per year. The exam is easiest right after a warm shower, when the boys are relaxed and ready to roll. Each testicle should have a smooth surface except at the stalk that connects back to the rest of the body.
If you do feel a bump in one testicle and can’t find a matching bump on the other side, does that auto
matically mean you have cancer? Are you going to need a fake testicle, like your neutered dog?
Make an Appointment
There are wormlike cords above your testicle. These lumpy tubes are actually enlarged veins draining the testicles. Way back when you were a fetus, your testicles were inside your abdomen, only later venturing down to your scrotum. Because of this quirky developmental adventure, the testicles’ veins have a long, winding course inside the body. As a result, it’s easy for the veins to get compressed somewhere in the pelvis, resulting in engorgement and fullness down in the scrotum. In some cases, the enlarged veins are painful, or they make the testicle too warm and unable to produce sperm. If the enlarged veins are causing problems, they can be surgically repaired.
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Quick Consult
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Testicular Pain
Most boys learn in elementary school gym class that the testicles are exquisitely tender. A swift blow between the legs can leave a person incapacitated for several minutes—and why shouldn’t it? Nature wants you to know that those little hangers-on are pretty important, and that you should treat them right.
But what happens if a testicle starts aching on its own? Should you curl into a ball and wait for the pain to subside? Pray that the agony will soon render you unconscious?
In fact, sudden-onset testicular pain can signal a real emergency. Sometimes, a testicle gets twisted around the blood vessels in the scrotum. If those blood vessels don’t get rapidly untwisted, they can’t deliver blood to the testicle—which screams in agony and then eventually dies. Once the pain begins, the clock is ticking. If the testicle isn’t fixed quickly, it will need to be surgically removed. As someone important once said, time is testicle.
Am I Dying Page 13