Women’s Health: Start Here!

Hormonal Changes

Puberty is the process of the body maturing physically and sexually, and it is a time of major hormonal change.^2(p1) Puberty in girls usually begins between the ages of 8 and 13 years,^2(p1) causing physical changes like breast development, pubic hair growth, the start of menstruation (monthly periods) and growth in the size of the ovaries, uterus and labia.^2(p2)

Puberty can also cause emotional turmoil as young teenagers struggle to come to terms with their changing bodies and worry about being different from their peers.^2(p1)

The main hormones associated with puberty are oestrogen and progesterone.^2(p2),3(p1)

• Hormonal Acne

Description: Acne is a prevalent skin condition during puberty, affecting about 80% of teenagers and also young adults up to 30 years.^4(p2) Hormonal acne is often triggered by changes in androgen, oestrogen and progesterone hormone levels, which results in the skin producing more sebum (oil). This oil can then clog the skin’s pores, causing acne.^4(p2,3)

Treatment:

• Common acne treatments that can be applied directly to the skin include benzoyl peroxide, retinoids (a type of vitamin A), salicylic acid and antibiotics.^5(p2)
• Oral treatments also include retinoids and antibiotics, as well as corticosteroids and the contraceptive pill.^4(p10),5(p2)
• In some cases, a dermatologist may prescribe medication to control the levels of androgen hormones.^{4(p2,10),5(p2)}
• A good skincare routine can also help to manage acne.^5(p4)

Description: Irregular periods are common during the first few years of menstruation as the body adjusts to new hormonal levels.^6(p2)

Treatment:

• Oral contraceptive pills can help to regulate the menstrual cycle and can also help with painful periods.^7(p2,8)
• Lifestyle habits like regular exercise and a balanced diet can promote more regular periods and help to relieve premenstrual syndrome (PMS) – see Emotional and Psychological Changes^8(p7)

Description: Lack of iron can cause anaemia, with common symptoms such as:^(p1)

• Shortness of breath.
• Heart palpitations.
• Pale skin.

Low iron levels can be caused by heavy periods or by not eating enough iron-rich foods.^9(p2) Pregnancy can also cause this condition.^9(p2)

Treatment:

• Iron levels can be increased with an oral iron supplement.^9(p2)
• Iron-rich foods like meat, leafy greens, pulses and iron-fortified cereals can also help to improve iron levels.^9(p2)

Description: Hormonal changes during puberty can affect mood and emotional well-being,^2(p1) and many young women experience conditions like PMS.^11(p1)

Typical PMS symptoms include:^11(p1)

• Mood swings.
• Irritability.
• Bloating.
• Fatigue.
• Headaches.

Treatment:

• Lifestyle habits like a healthy diet and regular exercise can help to manage PMS.^11(p1)
• Counselling and support from family and friends can make emotional changes easier to handle.^11(p2)
• In more serious cases, when the patient’s quality of life is being affected, a doctor might prescribe oral contraceptive pills or antidepressants.^11(p2)

There are many contraceptive options available for sexually active teenagers, including:

• Barrier methods, e.g. condoms, spermicide creams or gels, a diaphragm or a cervical cap.^12(p6)
• Hormonal methods, e.g. the oral contraceptive pill, an intrauterine device (IUD) or an implant.^12(p8)

It is also important that teens and young adults have access to comprehensive sex education, to encourage healthy sexual behaviour and responsible contraceptive use, and to reduce the risk of sexually transmitted diseases (STDs).^{13(p4,5),14(p1)}

Hormonal Changes

During the reproductive years, women experience regular menstrual cycles with associated hormonal fluctuations.^16(p1) The continuously rising and falling oestrogen and progesterone levels affect various aspects of health.^{17(p1),18(p1)}

• Urinary Tract Infections (UTIs)

Description: A UTI is an infection of the bladder (cystitis), urethra (urethritis) or kidneys (pyelonephritis).^19(p3) UTIs are very common, with 50% to 60% of adult women experiencing one in their lifetime.^19(p4) Sexual activity, spermicide use and lack of oestrogen after menopause are all risk factors for developing a UTI.^19(p4)

Symptoms include painful, frequent urination and cloudy urine.^19(p7,9)

Treatment:

• A UTI is typically treated with antibiotics.^19(p29,35)
• Low-dose preventative antibiotics or cranberry supplements can help to prevent or reduce the risk of developing a UTI.^19(p98,99)

Description: Thrush, also called candidiasis, is caused by an overgrowth of Candida albicans, a yeast which is naturally present in the vagina.^{21(p7),22(p1)} This overgrowth can be caused by: ^21(p8)

• Antibiotic use.
• Poorly controlled diabetes.
• High oestrogen levels.

Symptoms include itching and a thick, white vaginal discharge.^22(p1)

Treatment: Thrush can be treated using topical cream or oral tablets.^22(p2) Some treatments are available over the counter at pharmacies, while others require a prescription from a doctor.^22(p2)

Description: Bacterial vaginosis is a common vaginal infection that occurs when the balance of flora in the vagina is disrupted.^21(p4)

Symptoms include a grey or white vaginal discharge with a strong odour.^23(p1)

Treatment: Bacterial vaginosis is treated with antibiotics.^{21(p4),23(p2)}

Description: OAB is a condition characterised by an urgent and frequent need to urinate, often accompanied by incontinence (leaking of urine).^24(p1)

It can be caused by increased sensation from small volumes of urine in the bladder, which may cause unwanted muscle contractions.^24(p2) It can also be a symptom of an underlying problem like:^24(p2)

• Diabetes
• A UTI or other bladder disease.
• Pelvic organ prolapse.

Treatment:

• Medications are available to help treat an overactive bladder.^24(p3)
• Pelvic floor physiotherapy and bladder training may also be helpful.^24(p3)
• In more serious cases, surgery may be needed.^24(p4)

Description: Female infertility (struggling to conceive) is a widespread problem for women around the world.^25(p1,2) Research shows that one in six people experience infertility at some point in their lifetime.^{26(p1),26b(p13)}

Infertility in women can be caused by:

• Problems with ovulation.^25(p4)
• Tubal disease.^25(p4)
• Abnormalities in the cervix or uterus.^25(p4)
• Tubal factor infertility (TFI) caused by infection accounts for over 85% of female infertility cases in parts of sub-Saharan Africa, compared to only 33% of cases worldwide.²⁷

Treatment: Infertility treatments vary depending on the underlying cause and the patient’s age.^25(p3) Options include:^{25(p27-29,31)}

• Hormone therapy.
• Medications that stimulate ovulation (like clomiphene citrate).
• Assisted reproductive technologies (ART) such as in vitro fertilisation (IVF).

Lifestyle habits, like maintaining a healthy weight and managing stress, can also improve fertility.^25(p28,52)

Description: Endometriosis is a chronic inflammatory condition that occurs when endometrial tissue grows outside the uterus.^33(p3,23) Symptoms include:^33(p10,11)

• Painful, irregular periods.
• Pelvic pain.
• Painful intercourse.
• Infertility.

Women with endometriosis are also likely to have depression and anxiety.^33(p11)

Treatment:

• Non-steroidal anti-inflammatory drugs (NSAIDs) or oral contraceptive pills can be used to manage pelvic pain and regulate periods.^33(p23)
• Hormonal therapies, like progestogens and antiprogestins, or gonadotropin-releasing hormone (GnRH) analogues.^33(p24)
• Severe cases may require surgery.^33(p25)

Description: PCOS is a common endocrine disorder in women of reproductive age.^35(p3) Symptoms include: ^35(p8)

• Irregular, infrequent periods.
• Acne.
• Excess body hair growth.
• Scalp hair loss.
• High body mass index (BMI).
• High blood pressure.

These symptoms are a result of excess androgen (male sex hormone) production and lack of ovulation.^{35(p6,8),35b(p1)} PCOS is a leading cause of infertility and pregnancy complications.^35(p3)

Treatment: Treatment will depend on the patient’s goals, and may involve improving fertility or managing the symptoms:

• Medications like metformin and clomifene can restore ovulation and help with conception.^35(p27)
• Oral contraceptive pills can be used to manage acne and hair growth while regulating periods.^35(p29)
• Healthy lifestyle habits like a balanced diet and regular exercise are also recommended, to control weight and optimise overall health.^35(p26)

The contraceptive method used during the reproductive years will depend on if or when a woman plans to get pregnant. Long-acting reversible contraceptives (LARCs) such as an IUD, implant or injection may be suitable during this time.^12(p5) LARC methods are typically more cost-effective than oral contraceptive pills.^12(p5)

Hormonal Changes

Pregnancy brings about profound hormonal shifts, such as higher oestrogen and progesterone levels.^36(p1) Additional hormones are also produced to support the development of the foetus and prepare the body for childbirth.^36(p1) These hormones decline during the postpartum period,^36(p1) which can affect the mother’s mental and physical health.^37(p3)

• Gestational Diabetes

Description: Gestational diabetes is the development of hyperglycaemia (high blood sugar levels) during pregnancy.^38(p3) This can cause health issues for the mother and baby.^38(p3,4)

Treatment:

• Diet and exercise are crucial for managing gestational diabetes.^38(p17)
• Patients must monitor their blood sugar. ^38(p16-19)
• They may also need to take medication or insulin.^38(p16-19)

Description: Pre-eclampsia is a condition characterised by hypertension (high blood pressure) and protein in the urine.^40(p1) It may also cause:^40(p1)

• Headaches.
• Vision problems.
• Swelling of the hands, face or feet.

While many cases are mild, pre-eclampsia can cause serious complications if it is not monitored and managed.^40(p1) Early diagnosis ensures better outcomes for the mother and baby.^40(p1)

Pre-eclampsia usually improves soon after delivery, but complications can still occur a few days afterwards.^42(p2)

Treatment: Treatment involves close monitoring of the mother and baby, which includes:^42(p1)

• Regular blood pressure checks.
• Blood and urine tests.
• Ultrasound scans.
• Medication to lower blood pressure.

Induced labour or a caesarean section may be needed to ensure safe delivery.^42(p2)

Description: Hormonal changes after childbirth can contribute to postpartum depression, affecting the mother’s emotional well-being and her ability to care for her newborn.^37(p3,4) About 10% of mothers experience depressive symptoms during the first six months following childbirth.^37(p7)

Symptoms of postpartum depression include:^37(p3) 

• Low mood.
• Weight changes.
• Sleep disturbance.
• Low energy.
• Feelings of excessive guilt.
• Low confidence.
• Poor concentration.
• Psychomotor problems.

Treatment: Treatment options include:^37(p28)

• Counselling.
• Cognitive behavioural therapy (CBT).
• Support groups.
• Antidepressant medication.

Early intervention and support are essential to managing the symptoms of postpartum depression effectively.^37(p9)

Description: The postpartum period (the first six to eight weeks after childbirth) involves significant physical and emotional recovery as the body returns to its pre-pregnancy state.^43(p1)

Common physical postpartum symptoms include:^43b(p2-4)

• Vaginal bleeding and discharge.
• Swollen, painful breasts.
• Sore nipples.
• Constipation.
• Painful urination.
• Urinary incontinence.

Treatment:

• Adequate rest, good nutrition, hydration and gradual reintroduction of physical activity are all important for healthy postpartum recovery.^43(p11,12)
• Any birth-related injuries or complications should be discussed with a healthcare professional.^43(p13)

Sex can resume at any time after childbirth, depending on the mother’s recovery and comfort levels.^44(p1) Ovulation (and the ability to conceive) can resume three weeks to six months after pregnancy.^{44(p1),45(p1)}

Condoms, spermicide, IUDs, the implant and the injection can be used at any time after childbirth.^{44(p1),45(p7)} The cervical cap, diaphragm and sponge can be used from six weeks after childbirth, once the uterus and cervix have returned to their normal size.^{44(p1),45(p7)} The use of oral contraceptive pills will depend on whether the mother is breastfeeding and her risk of developing blood clots.^44(p2)

Hormonal Changes

Menopause marks the end of a woman’s reproductive years, when her menstrual cycle stops, typically occurring between ages 45 and 55.^{46(p3),47(p1)} Oestrogen and progesterone levels decline significantly, leading to various physical and emotional changes.^{46(p4),47(p3)}

Hot Flushes and Night Sweats

Description: These are common vasomotor symptoms of menopause, causing sudden feelings of heat, sweating and heart palpitations.^47(p3) These symptoms may begin years before menopause starts.^46(p8)

Treatment:

• Hot flushes and night sweats can be treated with hormone therapy or medication, like oestrogen, gabapentin and selective serotonin reuptake inhibitors (SSRIs).^{46(p13,14,19)}
• Self-care habits such as avoiding caffeine and alcohol, wearing layered clothing, drinking cold water and doing gentle exercises like Pilates are also helpful.^46(p24)

Description: Decreased oestrogen levels during menopause can cause symptoms like vaginal dryness, itching and painful intercourse.^{46(p8),47(p3)} Urinary urgency and frequency may also be symptoms of urogenital atrophy.^46(p20)

Treatment: Vaginal creams, rings or tablets containing oestrogen can help with vaginal and urinary symptoms.^46(p20)

Description: Hormonal fluctuations during menopause can lead to mood swings, irritability, anxiety and depression.^46(p8) Sleep disturbance caused by menopause can also affect mood and memory.^46(p8)

Treatment:

• Hormone therapy, antidepressants, CBT and counselling can all help with mood changes and depressive symptoms during menopause.^46(p21)
• Hormone therapy can also improve sleep quality.^46(p21)
• Lifestyle habits like good nutrition and regular exercise can also help.^46(p36)

While menopause means a decrease in fertility, menopausal women are still vulnerable to STDs and should use contraception where appropriate.^47(p3) Contraception is recommended to prevent unintended pregnancy until menstruation has stopped for 12 consecutive months.^47(p3) Menopausal women can also experience low libido, which can be treated with androgen supplementation.^47(p21)

Hormonal Changes

After menopause, women may continue to experience some health challenges related to the changes their bodies have been through.^48(p1)

Osteoporosis

Description: Women start gradually losing bone density from around the age of 35, but bone density typically declines rapidly after menopause due to low oestrogen levels.^{48(p9),49(p1)} This increases the risk of fractures.^{48(p9),49(p1)}

Treatment:

• Hormone therapy is an effective treatment for the prevention of osteoporosis in women under the age of 60 years and women within 10 years of menopause starting.^46(p36)
• Medications like bisphosphonates or selective oestrogen receptor modulators (SERMs) can help to maintain bone density.^{46(p14,37),50(p1,2)}
• Exercise, a healthy diet and calcium and vitamin D supplementation also promote bone health.^{46(p36),50(p3)}

Description:

The risk of heart disease increases after menopause due to changes in lipid profiles and blood pressure, resistance to insulin and the redistribution of fatty tissue.^{46(p5),48(p7)} While arteries are also more vulnerable to disease at this age, becoming thicker and stiffer,^51(p2) menopause symptoms like hot flushes, night sweats and depression have been linked to a greater risk for high blood pressure and other heart disease risk factors.^51(p2)

Treatment: 

• Lifestyle habits such as a healthy diet and regular exercise help to maintain heart health and reduce the risk of cardiovascular disease.^52(p1)
• Medications to manage high blood pressure, high blood lipids and diabetes also reduce the risk.^52(p2)

Description:  Weakened pelvic floor muscles can lead to urinary incontinence, affecting quality of life.^53(p2) Urinary incontinence affects women twice as often as men, and affects more than half of postmenopausal women.^53(p1)

Treatment:

• Pelvic floor physiotherapy, bladder training and anticholinergic medications can help to manage urinary incontinence.^53(p3)
• In more serious cases, surgical intervention may be needed.^53(p3)

Postmenopausal women are still susceptible to STDs and should use contraception as protection against these diseases as appropriate.^{47(p3),54(p4)} Reduced oestrogen levels can reduce the libido and cause issues like vaginal dryness and irritation.^{46(p20,21),54(p2)} Vaginal oestrogen creams, rings and tablets can help with dryness, as can water-based lubricants.^54(p3)

Addressing psychological struggles with a counsellor or therapist can also improve sexual health.^54(p4)

Sexual safety is an important aspect of women’s health at all stages of life. Key points include:

• Contraception: Various contraceptive methods are available to prevent unwanted pregnancy, and some provide protection from STDs as well.^56(p1,3) Discussing options with a healthcare provider can help women choose the best method for their needs.^12(p5)
• STD protection: Women of all ages are susceptible to STDs and should use protective contraception when having intercourse with a new partner or multiple partners.^{47(p3),54(p4)}
• Regular screenings: Routine screenings for STDs are important for maintaining sexual health.^57(p1)
• Vaccinations: The human papillomavirus (HPV) vaccine is recommended for women up to the age of 26, to protect against HPV.^57(p28)
• Communication: It is essential to encourage open and honest communication with sexual partners about STD status and safe sex practices.

A woman’s health is dynamic and complex, influenced by hormonal changes throughout the different stages of her life.^1(p1) Understanding these changes and the challenges that come with them can empower women to take proactive steps in managing their health from puberty to postmenopause.

By staying informed and working closely with their healthcare providers, women can navigate these challenges and maintain a high quality of life. Regular screenings, a healthy lifestyle and awareness of treatment options are key components of optimal health for women at every stage of life.

By increasing their understanding of women’s health issues, South African healthcare professionals can take informed, proactive steps to enhance their patients’ overall well-being and quality of life.