Gynaecological Conditions — Frequently Asked Questions

Guidelines do not define this in millilitres. The criterion is this: is the bleeding adversely affecting your quality of life physically, emotionally, socially or materially? Not being able to go to work, hesitating to go out, having to change pads frequently and feeling constantly weak are meaningful indicators. There is no need to compare with someone else's bleeding.

Yes. Every episode of bleeding after menopause is a finding that needs to be investigated; its amount and duration do not change that. In 5 to 10 per cent of women with this bleeding the underlying cause is cancer of the womb, and early diagnosis changes the outcome markedly.

Cycles without ovulation are common in adolescence, so a degree of irregularity is to be expected. But assessment is needed if the bleeding is excessive, produces symptoms of anaemia, or disrupts school and daily life; in that situation combined hormonal methods are recommended as first-line drug treatment.

It is the option guidelines place first in heavy menstrual bleeding and in thickening of the lining of the womb in which the cell structure is not disturbed. Because it acts locally inside the womb, the amount of hormone that passes into the body is small, which reduces the side effects seen throughout the body. Even so, as with every method, its suitability is assessed for the individual.

If you are of childbearing age, pregnancy is ruled out first. What follows depends on your age and the type of bleeding: after menopause, vaginal ultrasound comes first; before menopause, ultrasound is used mostly to look for structural causes such as fibroids and polyps. Anaemia is also looked for in everyone with abnormal bleeding.

The types that cause genital warts are the low-risk HPV 6 and 11. The types that cause cancers are different — most often 16 and 18. So having warts does not mean you are infected with a cancer-causing type. Even so, the screening recommendations should be followed.

They take the form of rounded bumps or plaques (raised patches) that may be skin-coloured, light and shiny, or dark grey, brown or purple; they are described as "cauliflower-like". They do not cause pain, but they may itch or become irritated.

The diagnosis is mostly made by examination. 3–5% acetic acid may be applied as an aid — it makes mucosal cells (the thin tissue lining the inner surface) infected with HPV turn white and so visible. HPV DNA can also be looked for by PCR in the samples taken. Because there are other conditions that look like warts (skin tags, moles, seborrhoeic keratosis, molluscum, condylomata lata and some skin cancers), assessment is necessary.

Partly. Used correctly and consistently they are quite effective, but they do not give complete protection: HPV can also be transmitted by skin-to-skin contact and from areas outside the barrier. It has also been documented that HPV can be transmitted without sexual intercourse — through intermediate objects such as clothing, medical equipment and surfaces, and through non-sexual skin contact.

There are two families. Tissue-destroying procedures: freezing (cryotherapy), cautery, surgical removal and laser vaporisation. Topical treatments: podofilox and imiquimod (which you apply yourself) and sinecatechin ointment (applied by the doctor). The choice is made according to the site, size and extent of the warts. Surgical removal, for example, provides tissue for pathological examination, while laser is useful for widespread lesions (tissue changes) that are difficult to reach.

Yes, recurrence is common and most people need more than one treatment session. This does not mean the treatment has not worked — it is the nature of the condition. Using tissue-destroying and topical methods together can increase clearance and reduce recurrence, particularly in widespread disease.

These heat-based methods can release virus particles into the air, and this carries a possible risk of warts forming in the throat. For this reason an appropriate respirator mask and a surgical smoke extractor need to be used during the procedure. That is why it matters that the procedure be carried out in a properly equipped setting.

HPV infection is mostly cleared by the immune system. But in people whose immune system is suppressed — those with systemic lupus (affecting the whole body), HIV infection or a history of organ transplant — the risk of the infection persisting is higher. Tobacco use is also among the factors that increase the risk.

No. It is direct visualisation of the inside of the womb with a fine telescope, but treatment can also be carried out in the same session — this is called the "see and treat" approach. Removing polyps and fibroids, dividing adhesions, cutting a septum, removing a lost coil and removing pregnancy tissue remaining in the womb can all be done this way.

The guideline prefers mechanical tissue-removal systems to small electrical tips, and recommends this at the highest level of evidence. In a comparative study the mechanical system was found to be less painful, faster and to have a higher success rate.

This is a real risk, because surgery on the womb is itself a cause of adhesions. For this reason treatment does not end with dividing the existing adhesion; protective measures such as barrier gels containing hyaluronic acid, absorbable medical membranes or an intrauterine device must be used to prevent a new one from forming.

In people who have experienced recurrent pregnancy loss, correction of the septum with hysteroscopy is reported to reduce the rates of pregnancy loss markedly. Mechanical mini-scissors that use no electricity are preferred in the procedure; they are significantly less painful than electrical tips.

No, routine preventive antibiotics are not recommended. In a large randomised study no significant difference was found in the infection rate between those given antibiotics and those not given them (1.0% versus 1.3%). The exception: if an active infection is suspected before the procedure it is postponed and treated; if pus is found in the womb during the procedure, intravenous antibiotics are started immediately.

It is rare but serious; the reported rate is between 0.002% and 1.7%. In a diagnostic procedure it is less than one in a thousand, and a little more frequent when a polyp or fibroid is removed. Factors that increase the risk: the need to dilate the cervix by more than 6 mm, narrowing of the cervix, a tortuous canal and an excessively angled womb.

Fainting, nausea and dizziness can occur: reported at 1.1% in a diagnostic procedure and at 5.8–12% in treatment procedures such as polyp and fibroid removal. Using salt water instead of carbon dioxide to distend the inside of the womb reduces this reaction significantly.

It generally takes 10–15 minutes; it may take longer if an additional procedure is carried out. Taking a painkiller 1–2 hours before the appointment is recommended. Afterwards use a pad, not a tampon. Bleeding for a few days that is lighter than a period is normal.

If you have abdominal pain that does not settle with a simple painkiller, bleeding heavier than a period, or signs of infection such as fever, shivering and foul-smelling discharge, seek help without delay. You should be given telephone numbers you can reach, including an out-of-hours number.

Yes. The procedure can be stopped at any moment. If pain or discomfort becomes unbearable, telling the team is enough; the procedure is stopped immediately. The team is also obliged to take into account that you may not be in a position to say so.

HPV itself is not cancer. In about 90% of people the virus clears on its own within 1–2 years. Only when a high-risk type becomes persistent can changes begin in the cells of the cervix; these usually take 15–20 years to turn into cancer. Regular screening catches these changes before they turn into cancer.

Mostly, yes. According to the World Health Organization, in about 90% of people the immune system controls the infection on its own and the virus is usually cleared within 1–2 years. Stopping smoking reduces the chance that the virus becomes persistent.

A positive HPV test does not mean you have cancer. The next step is decided by the type found and by the cell examination: if HPV 16 or 18 was found, or if the cells show a change, a colposcopy (examination of the cervix under magnification) is done; with other types, if the cell examination is normal, the test is usually repeated after a certain time (most often 1 year). Please consult your doctor about what your own result means.

HPV is passed on through sexual contact and skin-to-skin contact; transmission outside sexual intercourse has also been documented. Condoms reduce the risk but do not give full protection, because they do not cover all of the skin in the genital area. The most effective way of protection is vaccination.

There is no medicine that removes the HPV infection itself; most of the time the body clears the virus. What is treated are the problems HPV causes: genital warts (freezing, cautery, surgery, laser, medicines applied to the skin) and precancerous changes in the cervix (destroying them, or removing them with small surgical procedures such as LEEP).

It is most effective at ages 9–14, before sexual life begins. It is recommended up to the age of 26 for people who have not been adequately vaccinated; between 27 and 45 it may be considered through a decision made together with the doctor. The vaccine is not recommended in pregnancy; it is postponed until after the pregnancy.

Yes. The vaccine protects against the types that most often cause cancer, but it does not replace screening. People who have been vaccinated should also follow the screening recommendations for their age.

The Turkish Ministry of Health national cervical cancer screening programme offers an HPV-DNA test every 5 years to women aged 30–65. Follow-up for people with a previous abnormal result or whose immune system is suppressed is planned separately.

No. Guidelines recommend treatments without medicines as the first step: in the stress and mixed types, supervised pelvic floor muscle training for at least 3 months; in the urge and mixed types, bladder training for at least 6 weeks. Surgery comes up after these and, where appropriate, drug treatment have been tried.

The programme should last at least 3 months, be supervised and include at least 8 contractions three times a day. Before starting, an examination is done to confirm that you can contract the muscles correctly — this step matters, because exercising the wrong muscle produces no result. Devices that show muscle activity on a screen are not routinely recommended.

At the first assessment, the Q-tip, Bonney and Marshall tests, and routine cystoscopy (examination of the bladder with a camera) and imaging methods (MRI, CT, X-ray) should not be used. What is needed: a detailed history, a urine dipstick test, an examination, a bladder diary for at least 3 days and, if necessary, measurement of the amount left after passing urine by ultrasound.

No. In people in whom the history and examination clearly identify the stress type or a stress-predominant mixed type, routine urodynamic testing before a first operation is not recommended. The situations in which it is needed: urge-predominant mixed type or uncertainty about the type, suspicion of difficulty emptying the bladder, accompanying pelvic organ prolapse, and a previous unsuccessful operation for stress incontinence (urinary leaking).

No, patience is needed. With medicines that relax the bladder (anticholinergics), at least 4 weeks are needed for the full benefit. Side effects such as dry mouth and constipation may indicate that the medicine is working. It should also be explained to you that the long-term effects on cognitive function are uncertain.

Hormone treatment that affects the whole body (systemic) has no place in the treatment of urinary incontinence. But if you have complaints such as dryness, painful intercourse and irritation due to menopause and also have an overactive bladder, local (vaginal) oestrogen should be offered. These two are different things.

Desmopressin may be considered for getting up at night where this affects your quality of life. But care is needed in patients with cystic fibrosis, and it should be avoided in those over 65 and those with cardiovascular disease.

The guideline recommends weight loss for women with a body mass index above 30. It also recommends reducing caffeine in overactive bladder, and fluid intake is adjusted if it is very high or very low.

No. Colposcopy is done not because a diagnosis of cancer has been made but to measure risk. Guidelines define colposcopy as a risk assessment tool: it guides whether treatment, biopsy or only follow-up is needed afterwards. Being able to show safely that there is no disease is also one of the benefits colposcopy provides.

Colposcopy usually takes 15–20 minutes. There may be mild discomfort while the speculum is put in, mild tingling or stinging while the liquid is applied and, if a biopsy is taken, a slight pinching feeling. Some people may find it painful; you can ask for the procedure to be stopped at any moment.

In the 24 hours before the procedure, do not have vaginal intercourse; do not use tampons, vaginal creams or medicines. If you use a coil, avoid intercourse or use a condom in the 7 days before. If you are pregnant or think you may be, say so beforehand.

Yes, it can also be done during your period. If you prefer, you can change your appointment to after your period has ended.

For as long as the bleeding and discharge continue, it is recommended that you do not have intercourse or use tampons. If only a biopsy was taken, this is usually a few days; if LEEP was done, you may be asked to avoid intercourse for 4 weeks.

CIN is a precancerous cell change in the surface layer of the cervix; it is not cancer. CIN 1 is low grade and is usually followed up; CIN 2 may be followed up or treated; CIN 3 is high grade and removal of the changed tissue is recommended.

Yes, colposcopy can also be done safely in pregnancy. Be sure to mention that you are pregnant before the procedure.

First acetic acid at a concentration of 3–5% is applied; this is a dilute vinegar solution and makes suspicious areas turn white temporarily. Where necessary, Lugol's iodine solution is also used to see whether the tissue takes up the stain. These two applications guide the taking of the biopsy from the right point.

Not always. In low-risk people whose colposcopic appearance is normal, not taking a biopsy is an acceptable approach. When a suspicious area is seen, targeted biopsies are generally taken from 2 to 4 points so that the most advanced change is not missed.

No. The colposcopic impression is a visual assessment and is not accepted as definitive on its own; for this reason it is recommended that suspicious areas be sampled by biopsy. The definitive diagnosis is made by the pathology (tissue) examination of the biopsy.

In selected situations, yes. In high-risk people with strong evidence in favour of high-grade disease, removal of the transformation zone with a loop may be done immediately after the colposcopy, so that diagnosis and treatment take place in the same session. This is not a practice that applies to everyone; your own findings determine the decision.

Colposcopy has other uses as well, such as assessment of the vagina and the vulva. But what is described on this page is colposcopic assessment within the scope of preventing cervical cancer.

There is less pain and less need for painkillers after the operation, the hospital stay is shorter and the return to work is faster. Wound infection is less frequent, there is less blood loss and the scar is very small. One of the most important: fewer adhesions form — which is particularly valuable for those thinking of a pregnancy later.

The great majority pass without problems. In diagnostic laparoscopy the risk of a serious complication is about two in a thousand. Bowel injury is 0.4–1.1 in a thousand; major vessel injury 0.1–0.2 in a thousand; injury to the bladder or urinary tract 0.3 in a thousand. Death is very rare (3–8 in a hundred thousand). The risks increase if an additional treatment procedure is carried out.

This is very important: about 15% of bowel injuries cannot be noticed during the operation and show themselves days later, often after you have been discharged. Increasing abdominal pain — particularly if accompanied by fever, loss of appetite and vomiting — means you should seek help without delay.

Shortness of breath, chest pain or coughing up blood — this may indicate that a clot has travelled to the lung; call for emergency help. Pain, redness, swelling or warmth in the leg, or difficulty putting weight on it, may also be a sign of a clot in a vein. Redness and pain around the scars suggest a wound infection.

This is expected and temporary: part of the gas used to inflate the abdomen during the operation remains behind and irritates the diaphragm, causing pain at the tip of the shoulder. Similarly, trapped wind can occur because the bowels slow down temporarily; walking relieves it.

Move as early as possible. Even while resting, move your ankle and pump each foot briskly up and down for 30 seconds. Also take your painkiller regularly — if the pain is under control you will get up earlier, which both speeds up healing and prevents clots.

This is assessed beforehand. The rate of adhesions around the navel can be as high as 50% after a midline incision and 23% after a low transverse incision. For this reason the surgeon may prefer to make the entry at a different point. Excess weight and being very thin also affect the entry plan.

Because when the abdominal wall is thin, the deep structures come very close to the skin. In young, very thin women with well-developed abdominal muscles who have never given birth in particular, the main artery may be only 2.5 cm below the skin. Because this is known, the entry method is chosen accordingly in this group.

Yes, this is a known possibility and it should be explained to you before the operation. It is also part of the information given that laparoscopy (viewing the abdomen with a camera) may not find the cause of your complaint.

A biopsy takes a small piece in order to make a diagnosis. LEEP removes the whole transformation zone; that is, it both treats and provides pathology with a complete tissue sample. That sample makes it possible to see whether there is a more advanced change than expected and whether the surgical margins are clear.

As a rule treatment is recommended for CIN 2; but follow-up can also come up — if your concerns about the effect of treatment on future pregnancies outweigh your concern about cancer. This is a matter for shared decision making. There are also situations in which follow-up is not accepted: if the upper border of the transformation zone cannot be seen, or if the sample taken from the canal shows CIN 2 or above. With CIN 3, follow-up is not accepted in those who are not pregnant.

Guidelines prefer removal methods for high-grade changes — but the reason is not a definite superiority in success. A Cochrane review comparing the surgical techniques concluded that no technique is clearly superior in terms of treatment failure or side effects. What LEEP actually provides is a tissue sample to send to pathology and information about the surgical margins; with burning methods this information cannot be obtained.

No. For high-grade cell changes, topical medicines, therapeutic vaccines and similar non-surgical methods are not acceptable outside the setting of a clinical trial. This is what the guidelines state plainly.

In some situations, yes; this is called expedited treatment. The decision depends on the current risk of CIN 3 or worse: if the risk is 60% or more, direct treatment is preferred; in the 25–59% range both direct treatment and colposcopy with biopsy first are acceptable. This decision should be taken together with your doctor, particularly if you are planning a pregnancy.

In glandular cell change in the cervical canal (AIS), removing the piece in one piece is preferred so that the margins can be interpreted correctly. A length of at least 10 mm is preferred; in those who have no concerns about the effect on future pregnancies it can be increased to 18–20 mm. Deliberately dividing the piece is not acceptable.

Generally no. CIN 1 is the appearance of HPV infection in the tissue and the rate of it regressing on its own is high, particularly at younger ages. Even in those aged 25 and over in whom CIN 1 has been found for at least two years in succession, follow-up is preferred; treatment is an acceptable option only as a personal preference after shared decision making.

Fibroids are almost always non-cancerous, and an existing fibroid is not expected to turn into cancer. The very rare muscle cancer of the womb (leiomyosarcoma) usually develops as a separate tumour, independent of fibroids. In operations done for presumed fibroids, this cancer has been found unexpectedly in about 1 in 400 to 1 in 1000 operations. A fibroid that grows after the menopause should be assessed in detail.

No. For fibroids that cause no complaints and raise no suspicion of cancer, no surgery or medicine is needed. Keeping track of symptoms, regular gynaecological examinations and usually a yearly ultrasound check are enough.

Depending on the complaint, yes. Medicines that reduce bleeding (hormonal coil, medicines that stop clots from breaking down too early, contraceptive pills) and hormone-suppressing medicines that shrink the fibroid temporarily can be used; however, medicines do not remove fibroids. In women not planning a pregnancy, uterine artery embolisation, and focused ultrasound or heat-based shrinking, are counted among the womb-sparing options.

The decision on surgery is not made on the size in centimetres alone. What matters is the complaint the fibroid causes (heavy bleeding, anaemia, pressure, difficulty becoming pregnant), its position, the woman's age and her wish for children. A fibroid causing no symptoms can be monitored, while a small fibroid growing into the cavity of the womb may be removed because of bleeding or pregnancy problems.

Not every fibroid does. Fibroids that distort the cavity of the womb and large fibroids in the muscle wall can make it harder to become pregnant and have been linked with miscarriage and premature birth. Removing fibroids that grow into the cavity of the womb by hysteroscopy has been reported to increase pregnancy and live birth rates. A decision is made after assessing your situation with ultrasound.

After a myomectomy it is usually recommended to postpone pregnancy for 3 to 6 months so that the wall of the womb can heal. If the muscle of the womb was cut deeply or the cavity of the womb was entered, birth by caesarean section is recommended.

In a myomectomy only the fibroids are removed and the womb is kept, so new fibroids can develop in other parts of the womb. The only method that completely removes the risk of recurrence is removal of the womb (hysterectomy); pregnancy is not possible after this method.

Usually, yes. The growth of fibroids depends on the hormones oestrogen and progesterone; because these hormones fall at the menopause, fibroids usually shrink and complaints ease. A fibroid that grows after the menopause, or new bleeding, is unusual and should be assessed.

Most women with fibroids have no symptoms. When there are symptoms, the most common is heavy, long or clotty periods; anaemia and tiredness can develop as a result. Large fibroids can cause fullness in the abdomen, frequent urination or constipation.

The first step in diagnosis is ultrasound; this shows the number, size and position of the fibroids. When needed, a more detailed assessment is made with saline ultrasound, MRI or hysteroscopy (looking inside the womb with a camera).

The HPV test is more sensitive and, when negative, gives stronger reassurance that there is no cancer. For this reason screening with the HPV test alone (primary HPV screening) has become the preferred method in guidelines. A smear looks at cells, while an HPV test looks for the presence of the virus that can lead to cancer.

According to the American Cancer Society guideline, primary HPV screening is the preferred method, to be done every 5 years from the age of 25. If the sample was taken by a doctor and the result is negative, it is repeated every 5 years. National screening programmes differ between countries; ask your doctor about your own plan.

Yes, this is now an approved option and does not require an examination instrument (speculum). But a sample taken by a doctor is preferred; a self-collected sample is considered acceptable for people aged 25–65 at average risk. An important difference: if a test on a self-collected sample is negative, the repeat interval is not 5 years but 3 years. In some higher-risk people a doctor-taken sample continues to be recommended.

No. An HPV test is not a cancer test; it shows the presence of the virus that can lead to cancer. Most of those whose test is positive need further assessment steps — this usually means examination of the cells and, where necessary, Colposcopy. Your findings determine the next step.

For screening to be brought to an end in a person at average risk, the HPV tests done at ages 60 and 65 must be negative; it is a condition that the last HPV test not be at an age younger than 65. If these tests are not available, three consecutive negative examinations of the cells done at the recommended interval, the last of them at the age of 65, is acceptable.

It is recommended routinely at age 11 or 12 and can be started from the age of 9. The American Cancer Society encourages recommending it from the age of 9 or 10, because the vaccine is more effective at younger ages — being vaccinated at 12–13 is markedly more effective than at 14–15.

It is recommended up to the age of 26 for everyone who has not been adequately vaccinated. Between 27 and 45 it may be considered through a shared decision with the doctor; but it is stated that most adults in this age group will not benefit from the vaccine. The vaccine is not licensed for those over 45.

No. Doing a smear or HPV test before vaccination in order to decide whether the vaccine is appropriate is not recommended. The recommendations apply to everyone, regardless of behavioural or medical risk factors for HPV.

No. The vaccine does not take the place of screening. People who have been vaccinated also need to continue following the cervical cancer screening recommendations.

In pregnancy HPV vaccination is postponed until after the pregnancy; but there is no need for a pregnancy test before vaccination. People who are breastfeeding can be vaccinated.

No. In an adult woman with both irregular periods and excess male hormone, two of the three criteria are already met — there is no need for an ultrasound or an AMH test. An ultrasound is needed only if just one of these two findings is present, in order to assess the third criterion.

In young girls within the first 8 years after their first period, the use of ultrasound and AMH is not recommended. The reason is this: having many small follicles in the ovaries can be normal at this stage, and looking at an ultrasound leads to unnecessary diagnoses. In this age group, excess male hormone and irregular periods must be present together for the diagnosis.

The guideline states plainly: there is no single diet or exercise programme specific to PCOS. The general principles of healthy eating apply, and the form you can keep up and prefer yourself should be chosen. Approaches claiming that "this diet solves PCOS" have no counterpart in the guideline.

The first step is contraceptive pills; they are also the first option for irregular periods and acne. If an adequate response is not obtained from these or from cosmetic methods for at least 6 months, anti-androgen medicines are considered. Laser and light-based treatments are also effective in reducing unwanted hair.

You must use a highly effective method of contraception. These medicines can cause a developmental problem in a male baby. For this reason contraception must not be neglected during treatment.

Everyone at diagnosis — regardless of age and weight — should have fasting blood lipids checked and their blood sugar situation assessed. Blood pressure is measured every year. Lipid and sugar screening is repeated every 1–3 years if there are risk factors. The most sensitive test for sugar is the glucose tolerance test.

In premenopausal women with PCOS the risk is increased 2- to 6-fold, but the actual risk is still low. Routine screening of thickness by ultrasound is not recommended. However, if you have not had periods for a long time, have abnormal bleeding or have risk factors such as excess weight, the threshold for investigation is kept low. The way to protect against it: weight management, establishing a regular menstrual cycle and regular progesterone treatment.

PCOS is regarded as high risk in pregnancy. When planning a pregnancy, blood pressure should be measured and a glucose tolerance test done. If this was not done beforehand it is done at the first antenatal visit and then repeated at weeks 24–28.

Yes, and this should not be overlooked. Anxiety, low mood, sleep disturbance and eating disorders are markedly more common in PCOS. Sleep apnoea is also more common; if there is snoring and excessive daytime sleepiness, it should be assessed.

Metabolic syndrome, type 2 diabetes and high blood pressure are more common in the fathers and brothers of women with PCOS. This means family members should not neglect their own check-ups either.

Most polyps are benign (not cancer). Before the menopause, the risk of finding cancer or a precancerous change inside a polyp is about 1–2%; after the menopause it is clearly higher, at 3–13% (on average 5.4%). In polyps that bleed the risk is about 4.5–5.1%, and in polyps that never bleed and are found by chance it is 0.2–1.5%. Being over 60, a polyp larger than 1.5 cm and use of tamoxifen increase the risk.

Small polyps without symptoms can disappear on their own. Follow-up studies have reported that about 27% of polyps without symptoms disappear within a year, and that this rate rises to 50% for those smaller than 1 cm. For this reason, in women before the menopause who have no complaints and a small polyp, an ultrasound check every 6–12 months may be an option.

The polyp is removed by hysteroscopy (viewing the inside of the womb with a camera); no cut is made in the abdomen. The cervix is gently widened, and the polyp is seen with the camera, cut together with its root and removed. The time depends on the size and number of polyps. Most women go home the same day and can return to daily life within 1–2 days.

Not always. Small, single polyps can be removed as an outpatient without general anaesthesia, with light local numbing or without any numbing. For large or multiple polyps, or when the cervix is narrow, the procedure is done in the operating theatre under light sedation or general anaesthesia.

It can. A polyp is found in about 15–32% of women being assessed for infertility. A polyp can disturb the surface where the embryo attaches, make it harder for sperm to move forward or block the openings of the tubes. In one study the pregnancy rate was higher in women whose polyp was removed before insemination (51% versus 28%). ESHRE and ASRM guidelines recommend removing the polyp before IVF. Results can vary from person to person.

Because the risk of cancer or a precancerous change is higher in polyps found after the menopause, removal of all polyps found in this period is recommended. Polyps are responsible for about 25–38% of bleeding after the menopause.

Between 12% and 50% of polyps cause no symptoms at all. When there are symptoms, the most common are spotting or bleeding between periods, heavier or longer periods, bleeding after sex and bleeding after the menopause. Less often, cramps, period pain or discharge may occur.

Yes. Ultrasound done through the vagina is the first-step examination. Ultrasound done after saline is placed inside the womb shows the size and stalk of the polyp with a sensitivity of 88–95%. A definite diagnosis, and the chance of removal in the same session, are provided by hysteroscopy.

For polyps removed completely under direct vision together with their root, the risk of coming back is under 5%. The root not being fully cleared, or hormonal factors such as oestrogen dominance or tamoxifen use continuing, increase the likelihood of recurrence.

Yes, there is discharge in the vagina normally too. Normal discharge is small in amount, clear or white and has no smell; it is not accompanied by itching, burning or irritation. It is also normal for it to increase temporarily and become more watery in the middle of the menstrual cycle (at ovulation).

The smell is an important clue. A fishy smell — particularly if it becomes more noticeable after intercourse and during the period — suggests bacterial vaginosis. In thrush there is no smell. In trichomoniasis an unpleasant smell is seen together with frothy, yellow-green discharge.

Severe itching is the most typical feature of thrush; it is seen together with burning, irritation, swelling and redness of the external area, and the discharge is in clumps like cottage cheese. In bacterial vaginosis, by contrast, because there is no true inflammation, marked itching is generally not seen. Even so, the definite distinction is made by examination.

That is a risky route: according to the sources, more than half of the diagnoses people make themselves are wrong. The three conditions produce similar complaints but their treatments are completely different. Also, no response within 3 days to a medicine bought without prescription, or immediate recurrence, may point to a resistant species.

Simple and quick steps: the appearance of the discharge is assessed, the acidity (pH) is measured, a smell test is done and a sample is examined under the microscope. These few steps are enough to tell the three conditions apart. Because the detection power of the microscope is limited in trichomoniasis (51–70%), molecular testing may be preferred.

No. Bacterial culture has no place in this diagnosis — because the bacterium held responsible can be found in the normal flora of 50–60% of healthy women as well. The diagnosis is made by assessing certain criteria together.

That depends on the organism. In bacterial vaginosis treating the partner is not recommended — it has been shown not to reduce recurrence. In thrush it is not routinely recommended either. But in trichomoniasis it is essential: because it is transmitted sexually, partners need to be treated at the same time whether or not they have symptoms, and sexual contact should be avoided until the treatment is finished.

No, seek help without delay. Bacterial vaginosis and trichomoniasis during pregnancy can lead to the waters breaking early, premature birth and low birth weight.

No. Although it may look like cleaning, it removes the protective Lactobacillus bacteria, disturbs the natural acid balance of the vagina and prepares the ground for infection. Antibiotic use and hormonal changes are also among the factors that can disturb this balance.

Yes. Any vaginal discharge that starts after menopause must be investigated. It may be due to thinning of the tissues, but other causes need to be ruled out as well.

In thrush the discharge is thick, white and looks like cottage cheese, usually has no smell, and severe itching is to the fore. In bacterial vaginosis the discharge is thin and grey-white, there is a fishy smell, and itching is usually absent. Even so, the definite distinction is made at the examination by measuring the pH (level of acidity) and looking under the microscope.

It is not considered a classic sexually transmitted infection; it can also occur in women who have never had sex. Even so, a new partner or more than one partner and unprotected sex increase the risk. Treating the male partner is not recommended.

Vaginal thrush is not a sexually transmitted infection, and partner treatment is not routinely recommended. Only if the male partner has symptoms of balanitis (redness and itching of the head of the penis) is a local antifungal cream recommended for him too.

Trichomoniasis is a sexually transmitted infection. If the partner is not treated, the infection is passed on again. This is why partners are treated at the same time, even if they have no symptoms, and sex is avoided until the treatment has been completed and the symptoms have gone.

No. According to the guidelines, vaginal metronidazole gel is not adequate for treating trichomoniasis. Treatment is with medicines from the nitroimidazole group (antibiotics that work against parasites) taken by mouth.

The diagnoses people make themselves are wrong in more than half of cases. If the symptoms are actually due to bacterial vaginosis or trichomoniasis, a thrush cream will not work, delays the diagnosis and can upset the balance of the vagina even further. If the symptoms are happening for the first time, or do not go away with over-the-counter medicine, a doctor's assessment is needed.

With 4 or more episodes a year, it is considered recurrent thrush. A culture is done to identify the species responsible. In treatment the infection is first brought under control, then a maintenance (continuing) treatment lasting several months is given. For resistant species, other options are considered.

After treatment, bacterial vaginosis can come back within 3 months in about 30% of women. When it keeps recurring, a suppressive treatment lasting several months or a switch to a different group of antibiotics may be planned. Avoiding douching and perfumed products helps to protect the balance.

Yes, but the choice of medicine changes. In pregnancy, bacterial vaginosis and trichomoniasis are linked to a risk of premature birth. For thrush, antifungal medicines taken by mouth are avoided and vaginal creams and pessaries are preferred. Medicines should not be self-prescribed in pregnancy.

The use of probiotics containing Lactobacillus to support treatment or to prevent recurrence is being studied. However, current guidelines do not yet have enough evidence that they can replace antibiotic or antifungal treatment.

Most functional (temporary) cysts do. Before the menopause, cysts that look simple on ultrasound and are smaller than 5 cm usually disappear on their own within 1–3 menstrual cycles. Yellow body cysts in early pregnancy also usually shrink by the second three months. For other types, such as chocolate cysts, dermoid cysts and cystadenomas, a separate monitoring or treatment plan is made.

The decision is not based on size alone. Before the menopause, among cysts with a simple appearance, those under 5 cm usually disappear on their own, and those between 5 and 7 cm can be monitored with a yearly ultrasound; for persistent cysts larger than 7 cm, surgery is considered. Regardless of size, growing cysts, suspicious ultrasound findings, severe pain, and emergencies such as twisting of the ovary or a burst cyst are also reasons for surgery.

A chocolate cyst (endometrioma) can damage ovarian tissue and lower the ovarian reserve (the remaining store of eggs); removing the cyst surgically can also affect this reserve. According to the ESHRE 2022 guideline, routine surgery before IVF solely to increase the chance of pregnancy is not recommended. The decision is made individually, based on age, reserve, symptoms and pregnancy plans.

The vast majority of cysts found before the menopause are non-cancerous. The cancer risk of a cyst is assessed from its ultrasound appearance (IOTA rules, O-RADS). After the menopause, cysts are examined more carefully; ultrasound findings and CA-125 are combined to calculate a cancer risk score, and those at high risk are referred to a women's cancer team.

When the wall of the cyst tears and its contents empty into the abdomen, there can be sudden, severe pain and internal bleeding. If the bleeding continues or the general condition worsens, emergency surgery is needed. With sudden, severe pain in the lower abdomen or belly, go to the emergency department without waiting.

Sudden, severe, doubling-up pain on one side of the lower abdomen or belly, together with nausea and vomiting, is typical. Urgent surgery is needed so that the ovary does not lose its blood supply. In pregnancy, this risk is highest with cysts between 6 and 10 cm and in the first three months.

No. Studies and systematic reviews have shown that the contraceptive pill does not speed up the disappearance of existing functional cysts. Because the pill suppresses ovulation, it is effective in preventing new functional cysts from forming.

No, not on its own. Before the menopause, CA-125 can also rise in non-cancerous conditions such as endometriosis, fibroids, infections in the pelvic area and even during a period; for this reason, it is not recommended as a routine test at this stage. After the menopause, it is more useful when assessed together with the ultrasound findings.

For cysts that look non-cancerous, the first choice is laparoscopic cystectomy: during keyhole surgery only the cyst is removed by peeling away its wall, and healthy ovarian tissue is preserved. To protect the ovarian reserve, burning the tissue more than necessary is avoided. Simply draining the fluid from the cyst is not recommended, because the cyst comes back in a high proportion of cases.

No. In polycystic ovary syndrome (PCOS), many small egg sacs are seen in the ovary on ultrasound; these are not cysts that need treatment. PCOS is a separate condition that affects hormones, the menstrual cycle and metabolism, and it is managed differently from an ovarian cyst.