Vaginal Cancer

Vaginal cancer is a disease in which malignant (cancer) cells form in the vagina.

The vagina is the canal leading from the cervix (the opening of uterus) to the outside of the body. At birth, a baby passes out of the body through the vagina (also called the birth canal).

Vaginal cancer is not common. When found in early stages, it can often be cured. There are two main types of vaginal cancer:

• Squamous cell carcinoma: Cancer that forms in squamous cells, the thin, flat cells lining the vagina. Squamous cell vaginal cancer spreads slowly and usually stays near the vagina, but may spread to the lungs and liver. This is the most common type of vaginal cancer. It is found most often in women aged 60 or older.
• Adenocarcinoma: Cancer that begins in glandular (secretory) cells. Glandular cells in the lining of the vagina make and release fluids such as mucus. Adenocarcinoma is more likely than squamous cell cancer to spread to the lungs and lymph nodes. It is found most often in women aged 30 or younger.

What are causes and risk factors for vaginal cancer?

Age and exposure to the drug DES (diethylstilbestrol) before birth affect a woman's risk of developing vaginal cancer.

Anything that increases your risk of getting a disease is called a risk factor. Risk factors for vaginal cancer include the following:

• Being aged 60 or older.
• Being exposed to DES while in the mother's womb. In the 1950s, the drug DES was given to some pregnant women to prevent miscarriage (premature birth of a fetus that cannot survive). Women who were exposed to DES before birth have an increased risk of developing vaginal cancer. Some of these women develop a rare form of cancer called clear cell adenocarcinoma.
• Having human papilloma virus (HPV) infection.
• Having a history of abnormal cells in the cervix or cervical cancer.

Can A Vagina Be Too Big?

Faithful readers of this blog may remember that Masters and Johnson examined the vaginal sizes of 100 women who had never been pregnant. These women showed an un-stimulated vaginal length of 2 ¾-3 ¼ inches , with a ¾ inch width at the back of the vagina. During the sexual excitement phase the vaginal lengths increased to 3 ¾- 5 ¾ inches, with the width at the back of the vagina being 2 ¼-2 ½ inches. This correlates with our most common diaphragm sizes which are between 2 ½ -3 ½ inches in length.

"But I'm not worried about vaginal length," you might be thinking. "My problem is that I think my vagina is too loose - or too wide. Is that possible? If so what can I do?" Let's examine some of the medical data available to answer these questions.

Is my vagina too loose?
The vagina is like a collapsed, expandable tube lined with skin; the tissue below the skin is loose and contains large veins. Next are smaller circular muscles surrounded by stronger bands of muscle which run the length of the vagina. In addition, the lower third of the vagina is surrounded by a ring of muscles. This is covered by more connective tissue and blood vessels. Damage to these muscles, or if they become thin and weak, can allow the bladder ("cytocele") or rectum ("rectocele") to pouch into the vagina. Thus you can understand the importance of strong vaginal muscles. The ring of muscles around the vaginal opening contract during orgasm and may contribute to the intensity of an orgasm.

So what is too loose? This can be a matter of opinion based upon the input of a sexual partner, or one's observations of vaginal tone. Researchers have devised some ways to measure vaginal tone such as a pressure sensitive intravaginal balloon device, and ultrasound measurements of vaginal area ("pelvic floor") muscle thickness. A study of 30 women aged 20-42 found that better developed vaginal muscles were linked to having orgasms, and getting physical exercise. Conversely, increased age and having been pregnant were linked to decreased strength of vaginal muscles (McKey and Dougherty 1986).

A more recent study using ultrasound measurements (Bernstein,1997) found similar connections. Muscle thickness decreases with age, especially in women older than 60. Women with urinary incontinence had thinner pelvic floor muscles than women who were not incontinent.

Will exercising the vaginal muscles make my vagina tighter?
Two ultrasound studies of women who exercised their vaginal muscles did find that their muscles were thicker and stronger after pelvic floor muscle training. Among women with urine leakage, their thinner muscles became the thickness of healthy women's pelvic floor muscles. Additionally, they had less urine leakage - whether the problem was from stress or urge types of incontinence. The use of vaginal cones and/or Kegel exercises to increase muscle strength were both found to improve tone and decrease urine loss. While some of these studies did not measure vaginal tightness per se, when muscle bulk is increased, a woman can voluntarily contract those muscles to make the vaginal opening tighter.

Do tighter vaginal muscles really improve sexual response?
Despite the fact that most every discussion of Kegel exercises includes improved sex, there are not many scientific studies to back up this claim. One recent publication (Dean, 2008) reported on sexual function and pelvic muscle factors for some 2,800 women. Women who delivered only by Caesarean section (and their partners) perceived they had better vaginal tone leading to improved sexual satisfaction. Women who were currently doing pelvic muscle exercises scored much better on sexual satisfaction questions than women who did not. Women with incontinence (probably thinner muscles) scored the worst on the sex questions.

I've tried Kegel exercises but they don't work for me.
Assuming that the Kegel exercises have been done correctly, it may be time to move to other options. One low tech choice is weighted vaginal cones. This is a set of weights, shaped more like a tampon than a cone, where one inserts the lightest version then uses the vaginal muscles to hold it up inside. This is done twice daily. When this is easy the next heaviest cone is used - and so on. This is to be done while going about normal activities so that gravity provides an additional challenge to keeping the weight up inside.

More technology is involved in the electrical stimulator. A tampon shaped probe is inserted in the vagina and small electric shocks cause the muscles to contract then relax. This is done about 20 minutes up to several times a week. One patient of mine who used this device found it sexually pleasurable.

Less commonly used may be the "magnetic chair" ("Neocontrol"). This chair uses magnetic action to stimulate the muscles. I know this sounds very "woo, woo", but there is good data showing its effectiveness. This device is not for home use; treatments are given twice weekly by specially trained health care personnel.

Will plastic surgery make my vagina smaller?
Many genital plastic surgery techniques are based upon GYN surgical procedures used for medical problems such as reconstruction after cancer treatment, gender change, repair of cystocele/rectocele, etc. Unfortunately there are few good studies showing benefit where there is no overt medical problem.

One study of 53 women in Santiago, Chile (Pardo, 2006) was done specifically for complaints of wide vagina and decreased sexual satisfaction. The surgeons did two procedures. The first was inside the vagina where tissue along the roof was stitched tighter. This is similar to the type of repair done for a cystocele. Secondly, tissue around the vaginal opening and between the vagina and anus was stitched tighter. This is similar to the type of repair done for episiotomies after childbirth. Six months after surgery 94% claimed they experienced a tighter vagina, and had regained or improved orgasms. Yet some 4% of the women said they regretted the surgery.

The problem with this type of study is that sexual response can be very subjective. There is no easy way to measure sexual satisfaction in a group of diverse women. Every woman knew she got the surgical treatment so six months may not be a long enough time for any placebo response to wear off.

The American College of Obstetricians and Gynecologists (ACOG, 2007) has noted the lack of both safety and effectiveness data for genital plastic surgery. The possible complications for such surgery might include: infection, changes in sensation, pain with intercourse, and scar tissue. One GYN who has been performing genital plastic surgery for a number of years (Goodman, 2009) concluded that agreed upon terminology and training standards are still lacking.

What are you going to do, Jane?
As a big advocate of resistance/weight training to build muscles, I personally think exercise is a better place to start than surgery. As always, if a woman has concerns about sexual function, vaginal/genital structures, etc she should bring these up to her GYN. A GYN sees the wide range of "normal" in vaginal appearances. Yet, if one is having sexual problems due to genital changes, your GYN needs to know that is an issue.

Vaginal Weights for Stress Incontinence

Q: I leak urine when I laugh, sneeze or jump. A friend told me that vaginal weights can help with this, but it seems sort of weird. Are they really effective?

A: About one in three women leak urine after giving birth. This is called "stress incontinence" and it's due to weakened pelvic floor muscles, allowing for the neck of the bladder to "sag down" so that urine can escape with laughing, coughing, or sneezing.

Most doctors tell women to do Kegel exercises to strengthen their pelvic floor muscles. In some cases, surgery is required. But studies have also shown that vaginal weights can strengthen the muscles enough to reduce incontinence as well.

Here's how they work: You insert a cone-shaped weight into your vagina and then work on squeezing your muscles to keep the weights in place for about 15 minutes, once or twice a day. (You can actually go about your daily business while doing this!) Once you're able to hold this weight in easily, you try a slightly heavier weight (they are sold in sets).

Advocates of the weights believe that it's easier for a woman to learn to isolate and train her pelvic floor muscles properly using the weights than it is using just Kegels, which are easy to do incorrectly.

You can get vaginal weights over-the-counter, on-line, or as a prescription, via your health care provider.

The first published study on vaginal cones for urinary stress incontinence was published in 1988! While only 30 women completed the full month of using the cones, the results were amazing. Originally scheduled for surgery for stress incontinence, 63% of the women felt cured or improved enough to cancel their surgeries.

Now, after over 40 additional studies, the results are some what more measured. While some studies show the cones to be superior to pelvic floor muscle training using Kegel exercises (Arvonen, 2001), others have not (BØ, 1999). A critical evaluation of all trials done with cones was published in 2001 as a part of the famous Cochrane Database System Review. This excellent summary found the following:

• Cones were definitely better than no treatment.
• No significance was found between cones, Kegel exercises, and electro-stimulation of the pelvic floor muscles in their effectiveness.
• There is not enough evidence to show that combining cones plus Kegels gave any better results than any single treatment.

Generally most healthcare providers will adhere to a recommendation given by the Cochrane Review. But if you are a woman considering the use of weighted vaginal cones here are some additional things to think about.

• First, one really needs to be sure that they have stress incontinence. Cones may not be as successful with other types of urine leakage.
• Second, there may be better results among women who can advance to using the heaviest cones vs the lightest.
• Third, like different forms of birth control, one type of pelvic muscle strengthening may work better for you than your friend.

With some 5% of younger women, and almost 50% of elderly women, having symptoms of stress incontinence we should be able to access as many effective treatments as possible. Your best bet is to see your own MD or GYN to confirm that the urine loss is from stress incontinence. Then investigate your options as to cost, convenience, and preference. Weighted vaginal cones may be an excellent choice for you.

My Female Organs Are Falling Down

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VAGINA

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Have you ever looked "down there" with a mirror (or had a lover say to you) that there seemed to be a "bulge" or "ball of tissue" at the vaginal opening? The medical name for this condition is pelvic organ prolapse (POP). POP is purported to effect up to 50% of women who have had a vaginal delivery (Maher, 2008). In other studies of women in general, rates of POP with marked symptoms are reported to be 3.6 - 6%.

The first concern is that one's uterus, or other pelvic parts, might be falling out. In one of the more severe forms of POP the uterus can drop so far down into the vaginal canal that the cervix will scrape against the woman's underpants! Fortunately this is one of the least common forms of POP. So if you were to see a "bulge" of tissue what is that likely to mean to you? The goal of this blog is to share facts about the types of POP, the risk factors, and what treatment options you might have if POP seems to be linked to other, bothersome symptoms.

How do I know what type of prolapse I have?
When you go see your GYN or clinic you might expect questions about: urinary or bowel incontinence, difficulty emptying the rectum, or sexual problems. This can suggest areas which are involved with the "bulge". An exam should be done with you standing and/or bearing down when you are on the exam table. If loss of urine is a concurrent problem then a urinalysis may be done along with a Q-tip test and/or a measure of urine left in the bladder after you have go to the bathroom.

There are several types of prolapses. When the upper part of the vaginal canal loses its muscle tone or attachments holding the vagina up (especially common among women with hysterectomies) that is called vaginal prolapse. If muscle support is poor, or interrupted, the bladder can prolapse down through the "roof" of the vagina causing a cystocele. The urethra may drop down as well (urethrocele). If the weakness is in the "floor" of the vagina the rectum can bulge upward. As was mentioned above, the uterus and cervix can slump down through the vaginal canal.

What are the risk factors for pelvic prolapse?
The most consistently cited risk factors are: increasing age, being overweight, and increased number of vaginal deliveries. Number of deliveries by C-section does not increase prolapse risk (Luckacz, 2006). Other associated factors can include irritable bowel syndrome, constipation, and overall poor health (Rortveit, 2007). African American women are less likely to have symptomatic pelvic prolapse (Rortveit, 2007). One small study even found that having a history of stretch marks doubled one's risk for prolapse (Salter, 2006).

"Stretch marks," you might be thinking "why would that be?" The bones of the female pelvis do a great job protecting lower abdominal contents, but they do not provide support. The pelvic organs are supported by the muscles in the pelvic floor and the ligaments which can attach from the organs to the bones. It has been theorized that pelvic muscle and ligament strength may be linked to strength of collagen. Collagen, along with fibrillin, is decreased in women with stretch marks (Mitts,2005).

What can be done if I have a mild form of prolapse, or do not want to have surgery?
According to the American College of Obstetrics and Gynecology (ACOG, 2007): "Pessaries can be fitted in most women with prolapse, regardless of prolapse stage or site of predominant prolapse." A pessary is a doughnut shaped device which can be made of various materials. There are also pessaries shaped like a cube, and similar to a shoe horn. If one has ever used a diaphragm for birth control, inserting and removing a pessary may seem familiar. Like a diaphragm, a pessary should be fit by a GYN as they come in different sizes.

Kegel exercises have been recommended for POP but, unlike urinary stress incontinence, there are few large studies demonstrating the effectiveness of Kegels. According to one recent study of 48 women, pelvic floor exercise/Kegels significantly improved symptoms of prolapse (Hagen, 2009). Kegels may not be as successful as they are with urinary incontinence for once the attachment ligaments are damaged, strengthening the pelvic muscles may not fix the prolapse.

What about surgery?
If one has a prolapse of the uterus, hysterectomy may be suggested. Care is taken to refasten the top of the vaginal canal to other structures so it does not droop down after the hysterectomy.

If the prolapse is coming from the top or "roof "of the vagina, pelvic fascia tissue can be used to bridge the weak area. If the prolapse is coming from the lower or "floor" of the vagina (causing a bulging of the rectum into the vaginal canal), the rectal muscles can be used to close the defect.

More recently synthetic mesh has been used to support the weakened areas. Mesh has been used extensively for repair of abdominal hernias. Overall, the use of mesh seems to decrease the reoccurrence of cystocele when an anterior ("top") of the vagina repair is done (Maher, 2008). The primary concern for mesh is that long term follow up in large numbers of POP women is lacking. Cases of the mesh eroding through vaginal tissues have been reported (Altman, 2007). By October of 2008 the FDA released a notification to GYN surgeons relating adverse events connected to mesh use as reported by manufacturers of different types of mesh. Some of these unwanted events included erosion, infection, and pain. Not surprisingly, the strength and health of the woman's own tissues will have an impact. Her own tissues will have to be incorporated into the mesh to form a strong bond.

In one study of 2,460 of women in their 50's, about 3% of women reported having surgery for POP (Fritel, 2009). Further, women who had such symptoms of POP as problems having a bowel movement or urinating, and abdominal pain reported a much lower quality of life than other women. In one very large study (Barber, 2009), 85% of women considered themselves "much better" when compared to before their surgery. Bottom line, surgery of some type can be very helpful if a woman has symptoms from her prolapse.

My mom and her sisters had prolapse; can I do anything to prevent it happening to me?
We cannot change our genetics, age, or number of vaginal births! Sadly there are not many scientific studies testing different forms of POP prevention. The strategies for prevention that are most often suggested include:

• Kegel exercises up to four times daily. The hope is that by strengthening muscles in the pelvic floor that those muscles can help delay, or reduce, the onset of prolapse. For information about how to do Kegels correctly check out this article: Kegel Exercises - Topic Overview


• Physical exercise. Regular exercise can help keep one's body weight down, and being overweight is linked to prolapse. Exercise is also reputed to keep muscles and ligaments more flexible.


• Decrease straining to have a bowel movement. Constipation, or having to bear down, increases pressure in the abdomen which "pushes down" on pelvic organs. Eating a healthy diet with whole grains, fruits, and vegetable not only helps constipation, but can improve body weight.


• Treat chronic coughs. If one is a smoker - quit. If there is another reason for a chronic cough - have it treated. A cough increases the pressure inside the abdomen which can "push down" on pelvic organs. There are studies linking smoking with poorer tissue integrity after POP repair (Araco, 2009).


• Use a correct technique for heavy lifting. Straining to lift increases pressure within the abdomen. Here is a good over view of safe lifting: Back Problems - Proper Lifting


• Hysterectomy surgery considerations. If one is having a hysterectomy there are studies which suggest that attaching the uterine ligaments to the top of the vagina may help to keep the vagina from dropping down (

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The vagina is the female internal sex organ that begins on the outside at the vaginal opening and extends about three to five inches inside, ending at the cervix, or neck of the uterus (womb).

Three Layers of Tissue
The vagina consists of three layers of tissue. The mucosa is the layer on the surface that can be touched. It consists of mucous membranes and is a surface similar to the lining of the mouth.

Unlike the smooth surface of the mouth lining, the vagina contains folds or wrinkles. The next layer of tissue is a layer of muscle, concentrated mostly around the outer third of the vagina. The third, innermost layer consists of fibrous tissue that connects to other anatomical structures.

In the sexually unstimulated state, the vagina is shaped like a flattened tube, the sides of which are collapsed on each other. It is not a continually open space, or "hole" as often thought by both women and men. It is a potential space.

Because of its muscular tissue, the vagina has the ability to expand and contract, like a balloon, allowing a baby to pass through during childbirth, or adjusting to fit snugly around a tampon, a finger or any size penis.

The internal walls of the vagina itself do not have a great supply of nerve endings, thus are not very sensitive to touch. The outer one-third of the vagina, especially near the opening, contains nearly 90 percent of the vaginal nerve endings and therefore is much more sensitive to touch than the inner two-thirds of the vaginal barrel.

Vaginal Fluid
During sexual excitement, droplets of fluid appear along the vaginal walls and eventually cover the sides of the vagina completely. The vaginal tissue does not contain any secretory glands itself, but is loaded with blood vessels, which when engorged with blood as a result of sexual arousal, press against the tissue, forcing natural tissue fluids through the walls of the vagina.

The fluid is not only a sign of sexual arousal, but serves as a lubricant for intercourse if that is what is to follow. Without this natural lubricant, or an artificial one, a woman would most likely find penetration painful.

Sometimes the process of vaginal expansion and lubrication does not occur exactly as described or exactly when a woman would like. The causes of too little vaginal lubrication can be physical, emotional, or some combination of the two.

Physically, for example, it may be the result of a hormonal deficiency, or an infection or cyst in the vagina. Sometimes a woman who is using a birth control pill that is high in progesterone can experience lessened vaginal lubrication.

In other cases, emotional problems in a relationship with a partner may be the reason behind too little vaginal lubrication.

In these situations, feelings may block natural physical responses. This kind of experience is not unusual. Partners may be able to deal with the situation on their own, or it may be helpful to discuss the problem with a qualified therapist.

Vaginal lubrication typically decreases as women age, but this is a natural physical change that does not normally mean there is any physical or psychological problem.

After menopause, the body produces less estrogen, which, unless compensated for with estrogen replacement therapy, causes the vaginal walls to thin out significantly. The vagina also tends to become slightly shorter and narrower, and it takes longer to produce even a reduced amount of lubrication.

The vagina also loses its ability to expand as easily during sexual excitation. A woman not using estrogen replacement may use artificial lubricants, and engaging in longer periods of foreplay may help post-menopausal women avoid pain with intercourse.

Sometimes after childbirth a woman's vagina may lose some of its muscle tone, loosen a bit, and feel larger. For some women this means that they may not feel the pleasure they once did from their partner's penis making contact with the vaginal walls. The partner may also notice that he is not held as tightly by the vagina.

Post-Childbirth Exercises
There are specific exercises that women can do after childbirth to strengthen and tighten the muscles around the vagina and improve the tone and feeling.

These exercises, called Kegel exercises after the physician who developed them, require the woman to contract the muscles used to stop the flow of urine. The contraction is held for 3-5 seconds, repeated ten times in a series, and the series is usually repeated several times a day. These voluntary contractions can also be done during intercourse, and some women and men find it sexually enhancing.