Showing posts with label Obs and Gynae. Show all posts
Showing posts with label Obs and Gynae. Show all posts

Sunday, July 19, 2015

Menopause - Definition, symptoms and hormone replacement therapy

 Menopause  refers to a point in time that follows 1 year after the permanent cessation of menstrual periods that occurs naturally or is induced by surgery, chemotherapy or radiation.

On average, natural menopause occurs between 50 and 51 years (range 45–59) and is part of the process of normal ageing. It has been noted that smoking advances the age of menopause by approximately 2 years.
The diagnosis can only be made retrospectively and it is usually preceded by months or years of irregular cycles, that is not associated with some other physiological or pathological causes.

If the cessation of menses occurs before the age of 40, then it is referred to as the "Premature ovarian failure".
The older terms perimenopause or climacteric generally refer to the time period in the late reproductive years, usually late 40s to early 50s. Characteristically, it begins with menstrual cycle irregularity and extends to 1 year after permanent cessation of menses. The more correct terminology for this time is menopausal transition. This transition typically develops over a span of 4 to 7 years, and the average age at its onset is 47 years

Up to 75% of women will experience adverse symptoms related to menopausal transition while the others may not have any symptoms at all. Although symptoms associated with menopause occur as a result of oestrogen deficiency, replacing it is not always the treatment of choice.
The use of HT should be made on an individual basis, after careful consideration of quality of life and personal risk factors. In addition to any pharmacological treatments considered, lifestyle modifications are essential.

Below a few of the symptoms are discussed and whether hormone replacement may be helpful:

Hot flushes are characterised by a feeling of intense warmth, often accompanied by profuse sweating, anxiety, skin reddening and palpitations. They are sometimes followed by chills.
In most cases, they will resolve in around 1 year or less without any treatment.
1/3 rd of the patients will have symptoms for up to 5 years after natural menopause and in 20% they may persist for up to 15 years or more.
Menopause induced by surgery is associated with about a 90% probability of hot flushes during the first year. In these cases, symptoms are often more abrupt and severe and can last longer than those associated with a non-surgical menopause.

Hormone therapy is the most effective (80% efficacy) treatment for vasomotor symptoms associated with menopause at any age, but benefits are more likely to outweigh risks for symptomatic women before the age of 60 years or within 10 years after menopause.
Extra care must be taken in women with a history of hormone-dependent cancer, e.g. breast cancer.

Genitourinary symptoms due to menopause can affect up to 50% of women, however it is under diagnosed and under treated. The pathology here is that there is a loss of estrogen which results in urogenital ageing. The tissues of the vaginal walls becomes thinner since the amount of collagen and elastin is reduced. The walls become pale, thin and lose their elasticity. A reduction in vaginal secretions and decreased tissue elasticity also increases the susceptibility to trauma and pain or irritation during or after intercourse.

In addition to vulvo-vaginal symptoms, the less acid pH of the estrogen-deficient vagina increases the likelihood of urinary tract infections.

Vaginal symptoms become apparent 4–5 years after the menopause. 25–50% of all postmenopausal women have some objective changes as well as subjective complaints.
Symptoms may include vaginal dryness (75%), dyspareunia (38%), vaginal itching, burning and pain (15%).
Locally administered vaginal estrogens (creams, pessaries, tablets and vaginal rings) are equally effective in the treatment of menopause-related vulval and vaginal symptoms. Local estrogen therapy will lower vaginal pH, thicken the epithelium, increase blood flow and improve vaginal lubrication.

There are no evidence to support the use of hormone replacement for the urinary symptoms.

The decline in estrogen results in a decrease in the bone mineral density and a subsequent significant increase in the prevalence of osteoporosis.

General management includes:
1) assessment of the risk of falls and their prevention,
2) maintenance of mobility and
3) correction of nutritional deficiencies, particularly of calcium, vitamin D and protein.

Pharmacological interventions include bisphosphonates, denosumab, parathyroid hormone peptides, raloxifene and strontium ranelate. All have been shown to reduce the risk of vertebral fracture and some have been shown to reduce the risk of non-vertebral fractures. However, all are associated
with side effects and many women will fail to comply.
Hormone therapy reduces the risk of spine and hip, as well as other osteoporotic fractures even in women at low risk. It would appear that half of the traditional bone conserving doses are effective in conserving bone mass and are successful means of fracture prevention. However, hormone replacement is not the first line therapy in treating post menopausal osteoporosis.

The incidence of CVD increases with age and menopause may have an adverse effect. Hormone therapy was thought to confer CVD risk reduction but some studies demonstrated an increased number of coronary heart disease events and strokes and concluded that the risks outweighed the benefits. These studies were carried out on elderly women though and probably there was already an element of atherosclerosis that influenced the outcomes. Recent studies suggest that if hormone replacement is started soon after menopause, it may actually be beneficial.

Since the sex hormones are known to be thrombogenic there is an expected increase in the risk of deep vein thrombosis and stroke when using oral replacement therapy. The risk is further increase if the patient is a smoker.

Friday, January 9, 2015

Hyperemesis gravidarum - definition, epidemiology, pathophysiology, complications, management

Mild to moderate nausea and vomiting are seen commonly until approximately 16 weeks in most pregnant ladies. Although nausea and vomiting tend to be worse in the morning, thus erroneously termed morning sickness, they frequently continue throughout the day. In some cases, however, it is severe and unresponsive to simple dietary modification and antiemetics.
Hyperemesis gravidarum is defined as vomiting sufficiently severe to produce weight loss, dehydration, alkalosis from loss of hydrochloric acid and hypokalemia. Rarely, acidosis from partial starvation and transient hepatic dysfunction develop.
Modified PUQE scoring index (Pregnancy-Unique Quantification of Emesis and Nausea) can be used to quantify the severity of nausea and vomiting. 

There appears to be an ethnic or familial predilection. The hospitalization rate for hyperemesis is around 0.5 to 0.8%. Hospitalization is less common in obese women. In women hospitalized in a previous pregnancy for hyperemesis, up to 20 percent require hospitalization in a subsequent pregnancy.

Hyperemesis appears to be related to high or rapidly rising serum levels of pregnancy-related hormones. The presumed culprits include human chorionic gonadotropin (hCG), estrogens, progesterone, leptin, placental growth hormone, prolactin, thyroxine and adreno-cortical hormones. Some studies have implicated the vestibular system while others have showed some involvement of psychological components.
Other factors that increase the risk for admission include
1) hyperthyroidism, 
2) previous molar pregnancy, 
3) diabetes, 
4) gastrointestinal illnesses and 
5) asthma. 
For unknown reasons, a female fetus increases the risk by 1.5-fold.

Vomiting may be prolonged, frequent and severe.
1) Various degrees of acute renal failure from dehydration are encountered.
2) Life-threatening complications of continuous retching include Mallory-Weiss tears shown in the figure below. Others are esophageal rupture, pneumothorax and pneumomediastinum.
3) At least two serious vitamin deficiencies have been reported with hyperemesis in pregnancy. Wernicke encephalopathy from thiamine (vitamin B1) deficiency is not uncommon. Vitamin K deficiency has been reported causing maternal coagulopathy and fetal intracranial hemorrhage.

The photo shows a Mallory Weiss tear with the endoscope in retroflexion.

1) Eating small meals at more frequent intervals but stopping short of satiation is valuable. The herbal remedy, ginger, was effective as showed by this meta-analysis published in 2014. Ginger capsules 250 mg 4 times daily.
2) A number of antiemetics given orally or by rectal suppository as first-line agents. When simple measures fail, intravenous crystalloid solutions are given to correct dehydration, ketonemia, electrolyte deficits, and acid-base imbalances. Thiamine, 100 mg, is given to prevent Wernicke encephalopathy. Diclegis (Doxylamine and Pyridoxine (Vitamin B6) ) is the only FDA approved medication for nausea and vomiting in pregnancy. 
3) If vomiting persists after rehydration and failed outpatient management, hospitalization is recommended. Antiemetics such as 
- Promethazine 12.5-25 mg 4 hourly, 
- Prochlorperazine 5-10 mg 6 hourly, 
- Metoclopramide 5-10 mg 8 hourly are given parenterally.
With persistent vomiting after hospitalization, appropriate steps should be taken to exclude possible underlying diseases as a cause of hyperemesis (gastroenteritis, cholecystitis, pancreatitis, hepatitis, peptic ulcer and pyelonephritis).

Further readings:

Sunday, August 7, 2011

Mittelschmerz's syndrome

It refers to pain at the time of ovulation. It is not that frequently encountered.

Clinical features:
Patient will complain of pain in either the suprapubic region or right/left iliac fossa. It usually starts around the mid cycle. The pain does not shift and is not associated with nausea or vomiting. It is there for less than 12 hours. Patient may have slight vaginal bleeding or leucorrhea. Relief of pain occurs spontaneously. Severity varies from patients and usually range from 3 to 5 on a scale of 10.

The most probable causes are:
1) increased tension of the growing Graafian follicle just prior to rupture,
2) irritation of the peritoneum by the released follicular fluid following ovulation.

Non opiod analgesics and assurance do good in this condition. In difficult cases, we may look into a possibility to render the cycle anovular with contraceptive pills.


It is strictly defined as an excessive normal vaginal discharge and it should fulfill the following criteria:
1) the excess secretion is evident from persistent moistness of the vulva or staining of the undergarments,
2) it is non-purulent,
3) since it is non-irritant, it never causes pruritus.

Normal vaginal secretion depends on the estrogen level. So a rise in the level of estrogen eventually causes increased secretion. This rise is seen during puberty, around ovulation and pregnancy.
Some cervical causes of leucorrhea include erosions, chronic cervicitis, polyp and ectropion.

1) Local hygiene is very important.
2) Use of cotton undergarments is recommended.
3) Anxiety of the patient must be relieved through counselling.
4) Treat the possible cause of the leucorrhea.

Monday, June 13, 2011

Abnormal Uterine Bleeding (AUB) - PALM-COEIN classification

This is a new classification for abnormal bleeding in a non pregnant woman of reproductive age group. It stands for :
P - Polyp
A- Adenomyosis
L- Leiomyoma
M- Malignancy/ Hyperplasia

C- Coagulopathy
O- Ovulatory dysfunction
E- Endometrial causes
I- Iatrogenic
N- Not classified causes.

The classification is as such since the first 4 ones i.e. PALM can be diagnosed and measured directly by inspection or imaging techniques. The other ones need investigations other than imaging in most cases to reach a diagnosis.

Friday, February 4, 2011

HPV vaccination

Two vaccines (Cervarix and Gardasil) are available to protect females against the types of HPV that cause most cervical cancers. One of these vaccines (Gardasil) also protects against most genital warts. 
Both vaccines are recommended for 11 and 12 year-old girls, and for females 13 through 26 years old, who did not get any or all of the three recommended doses when they were younger. These vaccines can also be given to girls beginning at age 9. It is recommended that females get the same vaccine brand for all three doses, whenever possible.
One available vaccine (Gardasil) protects males against most genital warts. This vaccine is available for boys and men, 9 through 26 years of age.
The best way a person can be sure to get the most benefit from HPV vaccination is to complete all three doses before beginning sexual activity.
Quadrivalent human papillomavirus (HPV) vaccine may prevent infection with HPV types 6, 11, 16, and 18.
The cost for this vaccination is around 90 euros for 1 dose. 3 doses are required at 6 months interval if possible.