Common symptoms leading to gynecological consultations include vaginal bleeding, abnormal vaginal discharge, vulvar itching, lower abdominal pain, and lower abdominal masses. While women of different age groups may present with similar symptoms, the underlying causes can vary significantly. Understanding the key points for differentiating these symptoms is crucial for the diagnosis and treatment of gynecological conditions.
Vaginal Bleeding
Vaginal bleeding is one of the most common complaints. Apart from normal menstruation, bleeding can originate from any part of the female reproductive tract, including the vagina, cervix, uterus, and fallopian tubes. While the majority of bleeding originates in the uterus, it is referred to as "vaginal bleeding" until the exact source is identified.
Causes
The following common causes of vaginal bleeding are identified:
- Uterine bleeding related to pregnancy: This includes conditions such as miscarriage, ectopic pregnancy, molar pregnancy, retained placental fragments postpartum, and subinvolution of the uterus.
- Inflammatory conditions of the reproductive organs: Examples include vaginitis, acute cervicitis, cervical polyps, and endometritis.
- Benign lesions of the reproductive organs: These include endometrial polyps, adenomyosis, and endometriosis.
- Tumors of the reproductive organs: Uterine fibroids, a common benign tumor, can cause vaginal bleeding. Estrogen-secreting ovarian tumors may also result in bleeding. Most other tumors causing vaginal bleeding are malignant, such as vaginal cancer, cervical cancer, endometrial cancer, uterine sarcoma, gestational trophoblastic tumors, and fallopian tube cancer.
- Trauma, foreign bodies, and exogenous hormones: Trauma to the reproductive tract, such as vaginal injury from straddling, hymenal or vaginal tears due to intercourse, or the placement of an intrauterine contraceptive device (IUD), as well as foreign objects in the vagina of young girls, can cause bleeding. Improper use of estrogen or progestogen (including hormone-containing health products) can lead to "breakthrough bleeding" or "withdrawal bleeding."
- Vaginal bleeding secondary to systemic diseases: Conditions such as thrombocytopenic purpura, aplastic anemia, leukemia, and liver dysfunction can result in uterine bleeding.
- Ovarian hormonal dysfunction: Abnormal uterine bleeding caused by ovarian hormonal dysfunction includes both anovulatory and ovulatory types. Pregnancy and organic diseases must first be excluded. Additionally, bleeding may occur from local abnormalities in the endometrium or a transient decline in estrogen levels during midcycle follicular rupture.
Clinical Presentation
The clinical manifestations of vaginal bleeding include the following forms:
- Menorrhagia: Characterized by a normal menstrual cycle but with increased menstrual volume (>80 ml) or prolonged menstrual duration. It is often associated with uterine fibroids, adenomyosis, ovulatory abnormal uterine bleeding, IUD placement, or coagulation disorders.
- Irregular vaginal bleeding: Commonly seen in anovulatory abnormal uterine bleeding. In perimenopausal women, endometrial cancer should be ruled out. Hormonal or contraceptive-induced breakthrough bleeding also presents as irregular bleeding.
- Chronic continuous vaginal bleeding without a discernible cycle: This is often caused by malignant tumors of the reproductive organs, with cervical cancer and endometrial cancer being the primary considerations.
- Postmenstrual vaginal bleeding: In reproductive-age women, pregnancy-related conditions such as miscarriage, ectopic pregnancy, and molar pregnancy should be considered first. In adolescent females without a history of sexual activity, or in perimenopausal women, anovulatory abnormal uterine bleeding is more common, but malignant tumors of the reproductive organs should also be excluded.
- Vaginal bleeding with increased discharge: This is generally indicative of advanced cervical cancer, endometrial cancer, or submucosal uterine fibroids with infection.
- Post-coital bleeding: This presents as immediate bleeding after intercourse or a vaginal examination, which can range from light to heavy. Conditions such as acute cervicitis, cervical cancer, cervical polyps, or submucosal uterine fibroids should be considered.
- Intermenstrual bleeding: Bleeding that occurs 14–15 days before the next menstrual period, lasting 3–4 days with a small amount of blood, sometimes accompanied by lower abdominal pain or discomfort, is typically ovulatory bleeding. This occurs due to a temporary decline in estrogen levels following follicular rupture during the mid-menstrual cycle, causing endometrial shedding.
- Spotting before or after menstruation: Brownish-red vaginal discharge a few days before or after menstruation, characterized by a small amount and persistence, may be associated with ovulatory abnormal uterine bleeding, side effects of IUD placement, or endometriosis. Post-cesarean uterine scar diverticula can also result in slight prolonged bleeding after menstruation.
- Postmenopausal vaginal bleeding: Minimal bleeding lasting 2–3 days is often due to endometrial atrophy or atrophic vaginitis. More substantial or persistent bleeding, especially if recurrent, suggests the possibility of endometrial cancer.
- Intermittent discharge of blood-tinged fluid: This raises suspicion for fallopian tube cancer.
- Vaginal bleeding following trauma: Frequently caused by straddle injuries, with bleeding volume varying from minimal to significant.
In addition to the various forms of vaginal bleeding mentioned above, age serves as a valuable reference in diagnosis:
- In newborn female infants, slight vaginal bleeding a few days after birth occurs due to the sudden drop in maternal estrogen levels, causing endometrial shedding.
- Vaginal bleeding in young girls raises concerns for precocious puberty or malignant reproductive tumors.
- Adolescent girls with vaginal bleeding are often diagnosed with anovulatory abnormal uterine bleeding.
- Reproductive-age women should be evaluated for pregnancy-related conditions if bleeding occurs.
- In perimenopausal women, anovulatory abnormal uterine bleeding is the most common cause of vaginal bleeding, but malignancies of the reproductive organs must first be excluded.
- In postmenopausal women experiencing bleeding years after menopause, endometrial cancer is the primary consideration.
Abnormal Vaginal Discharge
Vaginal discharge, also known as leucorrhea, is a mixture of exudates from the vaginal mucosa and secretions from the glands of the cervical canal, endometrium, and fallopian tubes. Its formation is influenced by estrogen. Normal vaginal discharge is characterized by a white, slightly viscous or egg-white-like appearance, with a small volume and no foul odor, and is referred to as physiological leucorrhea.
Under normal conditions, the volume and characteristics of vaginal discharge exhibit periodic changes in accordance with the menstrual cycle. Particularly during ovulation, the discharge becomes clear, stringy, and elastic, resembling egg whites. Before puberty and after menopause, the amount of vaginal discharge is reduced. When inflammation of the reproductive organs, such as vaginitis or acute cervicitis, occurs or if malignancy develops, the quantity of discharge increases significantly, and its characteristics change. This is referred to as pathological leucorrhea. The following types of pathological discharge are commonly seen in clinical practice:
Transparent and Sticky Discharge
The appearance resembles normal vaginal discharge, but the quantity increases significantly. This is often associated with cervical lesions, ovarian dysfunction, or occasionally conditions such as vaginal adenosis or cervical mucinous tumors.
Grayish-Yellow or Yellow-White Frothy Watery Discharge
This type is characteristic of trichomonas vaginalis infection. It is often accompanied by a foul odor, vulvar itching, and, in severe cases, vaginal mucosal congestion, ulceration, and vulvar swelling.
Curd-Like Clumpy Discharge
This is typical of vulvovaginal candidiasis and is often accompanied by severe vulvar itching or a burning sensation.
Gray-White Homogeneous Fishy-Scented Discharge
This is commonly seen in bacterial vaginosis and may be accompanied by mild vulvar itching.
Purulent Discharge
Yellow or yellow-green, thick discharge with a foul odor is often caused by pathogenic infections. Purulent discharge may be associated with gonococcal vaginitis, acute cervicitis, or endocervicitis. It may also result from conditions like vaginal or cervical cancers with secondary infections, uterine cavity pyometra, or retained foreign bodies in the vagina.
Bloody Discharge
This refers to vaginal discharge mixed with blood, which may vary in amount. Common causes include cervical cancer, endometrial cancer, cervical polyps, cervicitis, or submucosal uterine fibroids. The use of intrauterine contraceptive devices can also result in bloody vaginal discharge.
Watery Discharge
Persistent discharge resembling rice water and accompanied by a foul smell typically suggests advanced cervical cancer, vaginal cancer, or infected submucosal uterine fibroids. Intermittent discharge of clear, yellow-red, or red watery vaginal secretions raises the possibility of fallopian tube cancer.
Lower Abdominal Pain
Lower abdominal pain is a common symptom in women and is often attributed to gynecological conditions. Its characteristics and nature allow for the consideration of various gynecological causes, although other systemic diseases may also result in lower abdominal pain, making differential diagnosis essential.
Onset and Progression
Conditions such as inflammation of the internal reproductive organs or malignant tumors typically present with a gradual onset and progressive worsening of pain. In contrast, sudden onset of pain is more commonly observed in ovarian cyst torsion or rupture or with the torsion of subserosal uterine fibroids. A history of recurrent mild pain followed by the sudden appearance of severe, tearing pain suggests the possibility of ruptured or aborted tubal pregnancy.
Location of Pain
Midline lower abdominal pain is often associated with uterine lesions, although this is relatively uncommon.
Unilateral lower abdominal pain suggests ipsilateral adnexal conditions, such as torsion of an ovarian cyst, acute salpingitis and oophoritis, or ectopic pregnancy. Right-sided lower abdominal pain may also indicate acute appendicitis.
Bilateral lower abdominal pain commonly occurs in pelvic inflammatory disease.
Widespread lower abdominal pain or even generalized abdominal pain is often observed in cases of ovarian cyst rupture, ruptured tubal pregnancy, or pelvic peritonitis.
Nature of Pain
Persistent dull pain is often due to inflammation or intra-abdominal fluid accumulation.
Severe, intolerable pain is frequently associated with advanced malignant tumors of the reproductive organs.
Intermittent colicky pain is indicative of spasm or contraction of hollow organs such as the uterus or fallopian tubes.
Sharp, tearing pain is characteristic of ruptured ovarian tumors or a ruptured ectopic pregnancy.
A heavy feeling of pressure in the lower abdomen may occur when blood or pus accumulates in the uterine cavity but cannot be expelled.
Timing of Pain
Pain occurring mid-cycle, located on one side of the lower abdomen, may be due to ovulation (mittelschmerz).
Menstrual-related pain (dysmenorrhea) during menstruation is typically associated with primary dysmenorrhea or secondary dysmenorrhea, such as that caused by endometriosis.
Cyclic lower abdominal pain without menstrual bleeding is usually caused by obstruction of menstrual flow, as seen in congenital anomalies of the reproductive tract or uterine and cervical adhesions following surgery.
Chronic lower abdominal pain unrelated to the menstrual cycle is often caused by postoperative adhesions, sequelae of pelvic inflammatory disease, pelvic venous congestion syndrome, or gynecologic tumors.
Radiation of Pain
Abdominal pain radiating to the shoulder suggests intra-abdominal bleeding.
Pain radiating to the lumbosacral region is frequently caused by cervical or uterine lesions.
Pain radiating to the inguinal region or inner thigh is typically due to ipsilateral adnexal conditions.
Accompanying Symptoms
Lower abdominal pain accompanied by a history of amenorrhea often indicates pregnancy complications.
Pain with nausea and vomiting raises suspicion for torsion of an ovarian cyst.
Chills and fever alongside pain are commonly associated with pelvic inflammatory disease.
Abdominal pain with symptoms of shock suggests intra-abdominal hemorrhage.
Pain accompanied by rectal pressure is often due to the accumulation of fluid in the rectouterine pouch.
Cachexia alongside abdominal pain frequently indicates advanced-stage malignancies of the reproductive organs.
Vulvar Pruritus
Vulvar pruritus (pruritus vulvae) is a common symptom in gynecological patients and is often caused by various conditions affecting the vulva and vagina. However, it can also occur in individuals with normal vulvovaginal anatomy. Severe itching may lead to restlessness, significantly affecting a patient’s daily life and work.
Causes
Local Causes
The most common causes of vulvar itching are vulvovaginal candidiasis and trichomoniasis. Other potential causes include bacterial vaginosis, atrophic vaginitis, pubic lice, scabies, pinworm infestation, verruca vulgaris (common warts), herpes, eczema, hypopigmentation disorders of the vulva, allergic reactions to medications or skincare products, and poor hygiene practices.
Systemic Causes
Conditions such as diabetes, jaundice, vitamin A or B deficiency, severe anemia, leukemia, and intrahepatic cholestasis of pregnancy can also lead to vulvar itching.
In addition to local and systemic causes, some cases of vulvar itching are idiopathic in nature.
Clinical Presentation
Location of Itching
Vulvar itching typically affects areas such as the clitoris, labia minora, labia majora, perineum, and sometimes the perianal region. Prolonged scratching may result in local skin damage or secondary folliculitis.
Symptoms and Characteristics
Vulvar itching may be intermittent or persistent and often worsens at night. The severity of itching varies widely depending on the underlying disease and the individual. Vulvovaginal candidiasis and trichomoniasis are primarily characterized by vulvar itching and increased vaginal discharge. Hypopigmentation disorders of the vulva present with severe itching and skin discoloration. Pinworm infections often cause itching that intensifies at night. In diabetic patients, glucose in the urine can irritate vulvar tissues, leading to severe itching, especially when candidiasis is also present. Idiopathic vulvar itching typically occurs in reproductive-age or postmenopausal women, involving severe, sometimes unbearable itching, despite normal-appearing skin and mucosa or only scratch marks and scabs. Chronic conditions such as jaundice, vitamin A or B deficiency, severe anemia, and leukemia may cause vulvar itching as part of generalized pruritus. In intrahepatic cholestasis of pregnancy, vulvar itching is part of a systemic itching pattern. Persistent itching with local skin lesions, particularly in older patients, may suggest vulvar cancer.
Lower Abdominal Mass
A lower abdominal mass is a common complaint among gynecological patients. It may arise from an enlarged uterus, adnexal masses, intestinal or mesenteric lesions, urinary system tumors, intra-abdominal tumors, or masses in the abdominal wall or retroperitoneum. The mass itself is often asymptomatic and may be discovered incidentally by the patient, their family, or during evaluations prompted by other symptoms such as lower abdominal pain or vaginal bleeding. Gynecological examination or ultrasound often confirms its presence. Depending on the nature of the mass, it may be classified as cystic or solid.
Cystic masses are often benign and may include ovarian cysts, tubo-ovarian cysts, hydrosalpinx, or even a full urinary bladder. However, a cystic mass that grows rapidly within a short period may indicate malignancy.
Solid masses, aside from physiological pregnancy-related uterine enlargement, are often benign when associated with uterine fibroids, ovarian fibroma, or pelvic inflammatory disease. However, all other solid masses should raise suspicion for malignancy.
Uterine Enlargement
A midline lower abdominal mass connected to the cervix may have the following causes:
- Pregnant uterus: In reproductive-age women with a history of amenorrhea, a midline abdominal mass is most likely a pregnant uterus. If irregular vaginal bleeding occurs and the uterine size exceeds what is expected for the duration of amenorrhea, gestational trophoblastic diseases should be considered. In early pregnancy, softening of the uterine isthmus may give the impression that the uterine body is separated from the cervix, which could lead to the misdiagnosis of a pregnant uterus as an ovarian tumor.
- Uterine fibroids: The uterus may be uniformly enlarged or exhibit singular or multiple spherical protrusions. The typical symptom of uterine fibroids is heavy menstruation. Subserosal fibroids with pedicles, connected only by a stalk to the uterine body, are often asymptomatic and can be mistaken for an ovarian solid tumor during gynecological examination.
- Adenomyosis: The uterus is diffusely enlarged, usually not exceeding the size of a 3-month pregnancy, and feels firm on palpation. Patients often present with progressively worsening dysmenorrhea, heavy menstrual bleeding, and prolonged menstruation.
- Malignant uterine tumors: In elderly patients, uterine enlargement accompanied by irregular vaginal bleeding suggests endometrial cancer. Rapid uterine enlargement accompanied by abdominal pain and irregular vaginal bleeding may indicate uterine sarcoma. Patients with a history of pregnancy or miscarriage, especially those with a history of molar pregnancy, presenting with abnormal uterine enlargement and irregular bleeding should be evaluated for gestational trophoblastic neoplasia.
- Uterine malformations: Conditions such as a double uterus or a rudimentary uterine horn may present as a mass on one side of the uterus. These masses may be symmetrical or asymmetrical to the main uterus, with a similar level of firmness.
- Hematometra or pyometra: In adolescents presenting with primary amenorrhea and cyclical lower abdominal pain, a midline abdominal mass may indicate imperforate hymen or transverse vaginal septum. Uterine enlargement may also be found in cases of endometrial cancer complicated by pyometra.
Adnexal Masses
The adnexa (adnexa uteri) includes the fallopian tubes and ovaries, which are typically not palpable. The presence of a palpable adnexal mass is usually pathological. The following types of adnexal masses are commonly seen in clinical practice:
Tubal Pregnancy
Patients often have a short history of amenorrhea. The mass is located beside the uterus, with variable size and shape, and is associated with significant tenderness. There may be persistent vaginal spotting and abdominal pain.
Inflammatory Adnexal Masses
These masses are often bilateral, located on both sides of the uterus, and show adhesion to the uterus with marked tenderness. Acute adnexitis may present with fever and abdominal pain. In cases of significant adnexal tenderness, tubo-ovarian abscess or pyosalpinx should be considered. Hydrosalpinx is often associated with a history of infertility and chronic lower abdominal pain, with occasional recurrent episodes of acute pelvic inflammatory disease.
Ovarian Endometriotic Cyst
This cystic mass is often adherent to the uterus, has limited mobility, and is tender. The condition is usually associated with a history of secondary dysmenorrhea, dyspareunia, and infertility.
Non-Neoplastic Ovarian Cysts
These are generally unilateral, mobile, cystic masses, with a typical diameter not exceeding 8 cm. Common types include corpus luteum cysts and tubo-ovarian cysts. Corpus luteum cysts can occur in early pregnancy. Molar pregnancies are often complicated by one or both luteinized ovarian cysts. Tubo-ovarian cysts may have a history of infertility or pelvic infection, presenting as a cystic adnexal mass with or without tenderness, clear or unclear borders, and restricted mobility.
Neoplastic Ovarian Masses
Masses with a smooth, cystic, and mobile surface, regardless of size, are often benign ovarian tumors. Masses that are fixed to one side of the uterus, solid, irregular in surface appearance, and immobile, particularly if associated with multiple nodules in the pelvic cavity, ascites, or gastrointestinal symptoms, are highly suggestive of malignant ovarian tumors. Bilateral masses may point to metastatic ovarian tumors.
Intestinal and Mesenteric Masses
Fecal Impaction
The mass is situated in the lower left abdomen, usually conical in shape with a diameter of 4–6 cm, firm in texture, and slightly movable. The mass disappears after a bowel movement.
Appendiceal Abscess
Initial symptoms include periumbilical pain that gradually shifts and localizes to the lower right abdomen. The mass is located in the right lower abdomen, has unclear borders, is fixed and distant from the uterus, and exhibits significant tenderness. It is often accompanied by fever, elevated white blood cell counts, and an increased erythrocyte sedimentation rate.
Postoperative or Post-Infectious Adhesions of Intestinal Loops and Omentum
Patients often have a history of abdominal surgery or pelvic infection. These masses have unclear borders, and some areas produce tympanic sounds upon percussion.
Mesenteric Masses
These are located higher in the abdomen, with a smooth surface and marked lateral mobility but restricted vertical movement. Mesenteric masses are sometimes misdiagnosed as ovarian tumors.
Colorectal Cancer
The mass is located on one side of the lower abdomen, particularly the left lower abdomen. It feels strip-like, is slightly movable, and may have mild tenderness. Patients often have a history of lower abdominal pain, constipation, diarrhea, or alternating constipation and diarrhea, as well as blood-stained stools.
Masses in the Urinary System
Distended Bladder
The mass is located in the midline of the lower abdomen, above the pubic symphysis. It has a cystic nature, smooth surface, and is immobile. The mass disappears after catheterization.
Ectopic Kidney
Congenital ectopic kidneys are commonly situated in the iliac fossa or pelvis and resemble normal kidneys, although slightly smaller. They are typically asymptomatic. Intravenous urography can confirm the diagnosis.
Abdominal and Pelvic Cavity Masses
Ascites
Large amounts of ascites can often be mistaken for a giant ovarian cyst. Percussion reveals dullness in both flanks and tympany around the umbilicus. In cases of ascites coexisting with ovarian tumors, palpation combined with percussion may reveal an underlying mass.
Encapsulated Fluid due to Pelvic Tuberculosis
Such masses are cystic in nature, with a smooth surface, indistinct borders, and are immobile. The size of the mass may increase with disease progression or decrease with improvement.
Rectouterine Abscess
The mass is cystic, protrudes into the posterior vaginal fornix, and is associated with marked tenderness. Symptoms include fever and signs of acute pelvic peritonitis. Diagnosis can be confirmed by puncture and aspiration of purulent fluid from the posterior vaginal fornix.
Abdominal Wall and Retroperitoneal Masses
Abdominal Wall Hematoma or Abscess
These masses are often seen in patients with a history of abdominal surgery or trauma. The mass is located within the abdominal wall and not connected to the uterus. When the patient tenses the abdominal muscles by lifting their head, the mass becomes more prominent, suggestive of an abdominal wall mass.
Retroperitoneal Tumors or Abscesses
These masses are located behind the rectum and vagina, fixed to the posterior abdominal wall, and are immobile. Most are solid in nature, with sarcomas being the most common. Cystic masses, such as teratomas or abscesses, may also occur. Intravenous urography may show displacement of the ureters.