Health challenges

1. Topic
Dr Neelam Ohri

6. “Women’s health” – what are we talking about?
• Who’s heard of the phrase “women’s troubles?”
 Menstrual Problems
 PCOS
 Ovarian Cyst
 Endometriosis
 Vaginal Discharge
 Urinary tract infections
Osteoporosis
 Autoimmune Diseases
(including Diabetes, thyroid
issues etc)
 Cardiovascular diseases
 Gallstones

7. Menstruation – how can this effect women’s health?
Premenstrual syndrome(PMS )
Symptoms include:
• Swollen or tender breasts
• Spotty skin or greasy hair
• Constipation or diarrhoea
• Bloating or a gassy feeling
• Cramping
• Headache or backache
• Clumsiness
• Lower tolerance for noise or light
• Irritability or hostile behaviour
• Feeling tired
• Sleep problems (sleeping too much or too
little)
• Appetite changes or food cravings
• Trouble with concentration or memory
• Tension or anxiety
• Depression, feelings of sadness, or crying
spells
• Mood swings
• Less interest in sex
Symptoms include:
• Lasting irritability or anger that may affect
other people
• Feelings of sadness or despair, or even
thoughts of suicide
• Feelings of tension or anxiety
• Panic attacks
• Mood swings or crying often
• Lack of interest in daily activities and
relationships
• Trouble thinking or focusing
• Tiredness or low energy
• Food cravings or binge eating
• Trouble sleeping
• Feeling out of control
• Physical symptoms, such as cramps,
bloating, breast tenderness, headaches,
and joint or muscle pain
Premenstrual dysphoric disorder (PMDD )

8. Menstruation – how can this effect women’s health?
What helps?
• Getting regular aerobic physical activity throughout the month. Exercise can help with
symptoms such as depression, difficulty concentrating, and fatigue.
• Choose healthy foods most of the time. Avoiding foods and drinks with caffeine, salt, and
sugar in the two weeks before your period may lessen many PMS symptoms.
• Get enough sleep. Try to get about eight hours of sleep each night. Lack of sleep is linked
to depression and anxiety and can make PMS symptoms such as moodiness worse.
• Find healthy ways to cope with stress. Talk to your friends or write in a journal. Some
women also find yoga, massage, or meditation helpful.
• Consult your GP – if the above aren't working keep a diary of your symptoms and speak
with your GP who may prescribe antidepressants
• Don’t smoke.
• Don’t drink too much alcohol

9. Menstruation - how can this effect women’s health?
Endometriosis
Symptoms:
• pain in your lower tummy or back
(pelvic pain) – usually worse during
your period
• period pain that stops you doing your
normal activities
• pain during or after sex
• pain when peeing or pooing during
your period
• feeling sick, constipation, diarrhoea, or
blood in your pee during your period
• difficulty getting pregnant
• You may also have heavy periods – you
might use lots of pads or tampons, or
you may bleed through your clothes
What to do:
• Keep a diary / log of your symptoms
• Arrange to see your GP to get a
diagnosis
• See support from Endometriosis UK
(details on final slide)
Treatments can include:
• Painkillers such as ibuprofen or
paracetamol
• Hormone medicine or contraceptives
• surgery
 On average it takes up to 7 years to diagnose from the onset of symptoms
 Women with endometriosis can suffer a 38% greater loss of work productivity than those
without endometriosis – this difference was mainly explained by a greater severity of pain
symptoms among women with endometriosis

10. Menstruation – what can be done to support and why it matters
Why it matters…
 58% had found it difficult to work because of the pain,
What can we do?
• Talk about it! We should all encourage a culture of greater openness about our
health, regardless of our gender.
• Encourage people to take exercise during the working day – even a walk around
campus can reduce pain and discomfort
• Relaxation techniques – providing space and time for individuals to practice
mindfulness during the day can be helpful or time to attend a yoga or Pilates class
• Encouraging staff to consult their GP if the pain is greater than mere discomfort
• Discuss opportunities to work more flexibly or working from home
• Be sensitive to those around you

11. Menstrual Disorders

12. Definition
• Normal menstrual cycle involves
hypothalamus-pituitary-ovary and uterus and
is 28 days
• Vaginal bleeding is abnormal (Abnormal
Uterine Bleeding--AUB) when:
– Volume is excessive or
– Occurs at times other than expected, including
during pregnancy or menopause
• Known as dysfunctional uterine bleeding
(DUB) when organic causes are excluded

13. AUB
• Duration >7 days or
• Flow >80ml/cycle or
• Occurs more frequently than 21 days or
• Occurs more than 90 days apart or
• Intermenstrual or postcoital bleeding

14. Terminology
• Menorrhagia: excessive flow
• Menometrorrhagia: excessive volume
• Oligomenorrhea: scanty flow
• Dysmenorrhea: painful menstrual cycles

15. Causes of Menstrual Disorders
• Structural
• Pregnancy associated
• Hormonal and endocrine
• Hematologic and coagulation disorders
• Other

16. Causes--structural
• Endometrial polyps
• Endometrial hyperplasia
• Endometritis
• Fibroids
• Intrauterine devices
• Uterine arterio-venous malformation (AVM)
• Uterine sarcoma

17. Pregnancy related
• Implantational bleeding
• Ectopic pregnancy
• Spontaneous abortion [incomplete, missed,
septic, threatened]
• Therapeutic abortion
• Gestational trophoblastic disease

18. Hormonal and Endocrine causes
• Anovulatory (including polycystic ovary
syndrome)
• Ovarian cyst
• Estrogen-producing ovarian tumor
• Perimenopause
• Hormonal contraceptives
• Hormone Replacement Therapy
• Hypothyroidism

19. Hematologic
• Von Willebrand’s disease (most common
inherited bleeding disorder with frequency
1/800-1000)
• Hemophilia
• Thrombocytopenia
• Hematologic malignancies (leukemia)
• Liver disease

20. Other
• DUB (dysfunctional uterine bleeding): non-organic
causes, either ovulatory or anovulatory
• Fallopian tube cancer
• Trauma
• Foreign body
• Cervical bleeding--mets, cervicitis, cervical cancer
• Vaginitis--atrophic, cancer of vagina
• Endometrial cancer (10% of post-menopausal
bleeding)

21. Evaluation of Abnormal Uterine Bleeding
(AUB)
Acute
History suggestive of:
• Pregnancy and related
complications
• Recent and Heavy
bleeding
• Pelvic pain
• Medications
contributing to above
Chronic
History:
• Long standing abnormal
menstrual history
• Symptoms of anemia,
hypothyroidism,
perimenopause
• Personal or family history
of excessive bleeding

22. AUB Examination
• Assess vitals/hemodynamic stability
• Look for features of anemia (pallor,
tachycardia, syncope)
• Look for features of hypothyroidism
• Look for metabolic syndrome (obesity,
hirsutism, acne)
• Pelvic exam for structural abnormalities:
fibroids, pregnancy, active bleeding—uterine
vs. cervical bleeding

23. AUB Lab Studies
• Serum HCG to rule out pregnancy
• CBC and iron studies to assess severity of anemia
• TSH for thyroid disorders
• Coagulation studies (PT, PTT, platelet count, VWF) (primarily
for adolescents)
• Transvaginal ultrasound to look for fibroids and other
masses/lesions
• Endometrial biopsy to rule out endometrial cancer in
perimenopausal and chronic anovulatory cycles (primarily for
women >35 years with AUB and postmenopausal women)
• Sonohysterography is useful in diagnosis of anatomical lesions
which might even be missed with transvaginal ultrasound

24. Treatment of Chronic Menorrhagia for
Most Causes (including DUB)
 Combined hormonal contraceptives (cyclical
or continuous)
 DMPA (depot medroxyprogesterone)
 IUD (Intrauterine devices)

25. Treatment options continued
After excluding coagulopathy, pregnancy, or
malignancy:
• Progestins
• Estrogens including oral contraceptives
• Cyclic NSAIDS
• Dilatation and curettage (surgical)
• Endometrial ablation (surgical)
• Hysteroscopic endometrial resection (surgical)

26. Treatment for Fibroids
• Surgical: Hysterectomy/myomectomy, uterine
artery ablation
• Medical: Suppression of gonadotropins
(danazol and leuprolide)

27. Treatment: progestins
• Inhibits endometrial growth by inhibiting
synthesis of estrogen receptors, promotes
conversion of estradiol to estrone, inhibits LH
• Organized slough to basalis layer
• Stimulates arachidonic acid production
• Progestins preferred for those women with
anovulatory AUB

28. Progestational Agents
• Cyclic medroxyprogesterone 2.5-10mg daily
for 10-14 days
• Continuous medroxyprogesterone 2.5-5mg
daily
• DMPA 150 mg IM every 3 months
• Levonorgestrel IUD (5 years)

29. Estrogens
• Conjugated estrogens given IV every 6 hours
effective in controlling heavy bleeding
followed by oral estrogen
• For less severe bleeding, oral conjugated
estrogens 1.25 mg, 2 tabs qid--until bleeding
stops

30. NSAIDS
• Cyclooxygenase pathway is blocked
• Arachidonic acid conversion from
prostaglandins to thromboxane and
prostacyclin (which promotes bleeding by
causing vasodilation and platelet aggregation)
is blocked

31. Clinical Highlights
• Most common cause of AUB in reproductive
age is pregnancy related--so initial evaluation
must include pregnancy test.
• Pregnancy must be ruled out before initiating
invasive testes or medical therapy

32. Clinical Highlights
• Endometrial biopsy is recommended for post
menopausal women
Or
• Younger women with history of chronic
anovulation >35 years of age

33. Clinical Highlights
• Uterine cancer and endometrial hyperplasia
must be ruled out before medical therapy is
initiated in postmenopausal/perimenopausal
bleeding
• NSAIDS may reduce menstrual flow by 20-60%
in women with chronic menorrhagia
• Coagulopathy workup must be initiated in
menorrhagia in adolescents

34. References
• ACOG Practice Bulletin #14, 2000
• American Journal Obstetrics and Gynecol
2005;193:1361
• Clinical Obstetrics & Gynecology 50(2):324-
353, June 2007
• Comprehensive Gynecology, 4th edition
• Harrison’s Principles of Internal Medicine, 14th
edition
• Karlsson, et al, 1995

35. Myths You’ll Not Heard About PCOS

36. • Women reproductive system is quite volatile and it often gets
infected with numerous infections and other health issues. PCOS
(Polycystic Ovary Syndrome) is one such problem that can prove to be
quite negative for a woman’s health.
• PCOS is a major hormonal and metabolic issue influencing females,
causing side effects, for example, infertility, weight increase, acne,
and abundance of hair in unwanted areas, hair loss, mind swings, skin
tags, and an increased danger of diabetes.
• There are numerous myths connected with PCOS, so it’s time to
debunk them!

37. Myth #1 – If a patient is overweight, then she has to endure it
because there’s no solution for the problem.
• Absolutely wrong! If you’ve Polycystic Ovary Syndrome and you’re
overweight, it can be more testing to shed pounds than the 'normal'
individual, yet it is absolutely not impossible to achieve this target. The
main way you’ll get fit and keep it off is by managing the basic factors
that cause your body to hold fat.
• Remember, fat cells won't get burned when insulin levels are high, so
you have to focus on insulin resistance by having a low GI diet,
following normal exercise for every 2 days, increasing your rest, and
taking health supplements.

38. Myth #2 – If you’ve Polycystic Ovary Syndrome you won't be able to
conceive children without the assistance of IVF.
• Absolutely wrong! Despite the fact that having PCOS can make it hard
to consider, and IVF has helped numerous females with PCOS to
conceive, it isn't the only option for females. There are additionally
numerous females who have become pregnant with less intrusive
medications, and some even just with common medicines. Remember,
you can have PCOS and become a mother!

39. Myth #3 – Polycystic Ovary Syndrome is just a matter of concern, if
you’re trying to get pregnant.
• Absolutely wrong! For some females, getting pregnant is one of the
biggest matters of concern if they’ve PCOS, yet Polycystic Ovary
Syndrome carries with it numerous different issues that can be
similarly as challenging as infertility. The impact that Polycystic Ovary
Syndrome has on a female's femininity and self-confidence can't be
ignored.
• Depression and mood swings can be occur because of this and must
be handled seriously. Consult renowned gynecologists to get the best
treatment for PCOS and issues connected with it.

40. Myth #4 – Polycystic Ovary Syndrome disappearance after menopause or
a hysterectomy will end the issue.
• Absolutely wrong! It’s true that after menopause, many changes
happen. Some of your Polycystic Ovary Syndrome symptoms may die
down, for example, period issues, of course, yet the basic metabolic
reasons for PCOS will still be there. For more info, consult famous
gynaecologists.
• Remember, menopause won't cure your Polycystic Ovary Syndrome, in
spite of the fact that it will influence you in an unexpected way. You
may still witness acne and excessive hair in unwanted areas, weight
gain, and sugar cravings.

41. GYNECOLOGICAL INFECTIONS AND
ABNORMALITIES

42. Dysmenorrhea
• Most common cause of pelvic pain in
females.
• Definition - menstrual pain
• Etiology -
– Obstruction and anatomical cervical stenosis,
fibroids, anteflexion of uterus, PID
– Endocrine - excessive production of prostaglandins
which intensify uterine contractions.

43. Dysmenorrhea
• Management.
• NSAIDS (nonsteroidal anti inflammatory
drugs).
• Oral contraceptive.
• Adequate rest and sleep and regular exercise
may be beneficial.
• Heating--baths, soaks, showers and heating
pad.
• Muscle relaxants--PRN for cramping.

44. Premenstrual syndrome (PMS)
premenstrual tension
• Definition--is a distinct clinical entity
characterized by a cluster of physical and
psychological symptoms that are limited to a
week or 10 days, preceding menstruation and
are relieved by onset of the menses.

45. Premenstrual syndrome (PMS)
premenstrual tension
• Known precipitating factors include an
increase in antidiuretic hormone and
aldosterone secretion, as well as estrogen-
progesterone imbalance.

46. Premenstrual syndrome (PMS)
premenstrual tension
• PMS increases with age and body weight.
• Uncommon in women in their teens and
twenties.

47. Premenstrual syndrome (PMS)
premenstrual tension
• Symptoms.
• Physical.
Painful and swollen breast.
Bloating.
Abdominal pain.
Headache and back pain.

48. Premenstrual syndrome (PMS)
premenstrual tension
• Psychologically.
Depression.
Anxiety.
Irritability.
Behavioral changes.

49. Premenstrual syndrome (PMS)
premenstrual tension
• Treatment.
• Past treatment has been symptomatic.
• Diuretics to reduce fluid retention.
• Tranquilizer drugs for mood changes.
Diazepam 2 5 mg TID orally.
• Analgesics for pain, mild pain ASA 600 mg
orally Q 4 6 hrs PRN.
• Program of regular sleep and exercise.

50. Premenstrual syndrome (PMS)
premenstrual tension
• Treatment.
• Decrease salt intake to relieve bloating and
edema.
• Drug therapy should be avoided, when
possible.

51. Pelvic Inflammatory Disease
• Definition--Pelvic Inflammatory Disease (PID)
is any acute, subacute, recurrent, or chronic
infection of the oviducts, and ovaries, with
adjacent involvement.

52. Pelvic Inflammatory Disease
• Sites - it includes inflammation of the cervix
(cervicitis) uterus (endometritis) fallopian
tubes (salpingitis) and ovaries (oophoritis)
which can extend to the connective tissue
lying between the broad ligaments
(parametritis).

53. Pelvic Inflammatory Disease
• Cervicitis.
Definition--
inflammation
of the cervix.

54. Pelvic Inflammatory Disease
• Causative organisms - gonococcus,
streptococcus, staphylococcus, aerobic and
anaerobic organisms, herpes virus, and
chlamydia.

55. Pelvic Inflammatory Disease
• Forms of cervicitis--
• Acute and Chronic.

56. Pelvic Inflammatory Disease
• Acute cervicitis.
• Symptoms.
• Purulent, foul smelling vaginal discharge.
• Itching and/or burning sensation.
• Red, edematous cervix.
• Pelvic discomfort.
• Sexual dysfunction > infertility.

57. Pelvic Inflammatory Disease
• Acute cervicitis.
• Assessment.
• Physical examination.
• Cultures for N. gonorrhea are positive
greater than 90% of the time.
• Cytologic smears.
• Cervical palpation reveals tenderness.
• Management - based on culture results.

58. Pelvic Inflammatory Disease
• Chronic cervicitis.
• Symptoms.
• Cervical dystocia--difficult labor.
• Lacerations or eversion of the cervix.
• Ulceration vesicular lesions (when cervicitis
results from Herpes simplex

59. Pelvic Inflammatory Disease
• Assessment.
• Physical examination.
• Chronic cervicitis, causative organisms are
usually staphylococcus or streptococcus.

60. Pelvic Inflammatory Disease
• Management - manage by cauterization,
cryotherapy, conization (excision of a cone of
tissue).

61. Pelvic Inflammatory Disease
• Endometritis.
• Definition - inflammation of the
endometrium.
• Etiology - produced by bacterial infection most
commonly staphylococci, colon bacilli, or
gonococci, trauma, septic abortion

62. Pelvic Inflammatory Disease
• Endometritis.
• Etiology - produced by bacterial infection most
commonly staphylococci, colon bacilli, or
gonococci, trauma, septic abortion.
• Sites - uterine ligaments, (uterosacral, broad,
round) and ovaries, (extra uterine locations).

63. NOTE
• Endometriosis - ectopic endometrium
located in various sites throughout the
pelvis or on the abdominal wall.

65. Pelvic Inflammatory Disease
• Endometriosis
• Symptoms.
• Low back and low abdominal pain.
• Dysmenorrhea.
• Menorrhagia.
• Pain on defecation, constipation.
• Sterility.

66. Pelvic Inflammatory Disease
• Endometriosis
• Assessment.
• Physical examination.
• Vaginal cultures.
• Management - based upon culture results.

67. Pelvic Inflammatory Disease
• Salpingitis and Oophoritis.
• Definition - infection of the fallopian tubes
and ovaries.
• History - usually recent sexual intercourse,
insertion of an IUD, or a recent childbirth or
abortion, gonococcus, chlamydia,
streptococcus, and anaerobes have been
implicated as causative organisms

68. Pelvic Inflammatory Disease
• Salpingitis and Oophoritis.
• Signs and symptoms.
• Lower abdominal pain sometimes with signs
and symptoms of acute abdomen can be
unilateral or bilateral.
• Fever.
• Severe pain with palpation of the cervix,
uterus, and adnexa (Chandelier sign).

69. Pelvic Inflammatory Disease
• Salpingitis and Oophoritis.
• Signs and symptoms (cont.)
• Purulent cervical discharge.
• Leukocytosis.

70. Pelvic Inflammatory Disease
• Salpingitis and Oophoritis.
• Assessment.
• Physical examination.
• Gonorrhea culture.
• Test for chlamydia.

71. Pelvic Inflammatory Disease
• Salpingitis and Oophoritis
• Complications.
• Tubal abscess.
• Infertility--common.

72. Pelvic Inflammatory Disease
• Salpingitis and Oophoritis
• Management.
• IV fluids to correct dehydration.
• NG suction in the presence of abdominal
distention or ileus.
• Manage the associated symptoms.
• Bedrest and restrict oral feedings.

73. OTHER GYN ASSOCIATED
ABNORMALITIES.

74. Ovarian Cyst

75. Ovarian Cyst
• Ovarian cysts are usually nonneoplastic sacs
on an ovary that contain fluid or semisolid
material.
• Ovarian cysts are frequently asymptomatic,
but the pressure of an abnormal mass may
cause discomfort, aching, or heaviness to the
pelvic region and on abdominal organs.

76. Ovarian Cyst
• Sudden or sharp pain may indicate rupture,
hemorrhage, or torsion of cyst.
• Fever, leukocytosis or s/s of shock may be
present.

77. OTHER GYN ASSOCIATED
ABNORMALITIES
Leukorrhea -
white/yellowish mucoid
discharge from cervical
canal or vagina.

78. Leukorrhea
• Probably most frequently encountered
gynecological symptom.
• Generally associated with simple infection of
the cervix and vagina.

79. OTHER GYN ASSOCIATED
ABNORMALITIES
• Candidiasis
• Trichomonas
• Gardnerella
• Bartholin’s abscess
VAGINITIS - Inflammation of the vagina

80. Monoliasis or Candidiasis

81. Monoliasis or Candidiasis
• Signs and symptoms.
• Marked leukorrhea, marked redness of vulva,
extreme pruritus.
• White, creamy, cheesy, sweet smelling
discharge, thrush patches.
• Commonly seen in pregnancy, diabetics,
women on BCP or antibiotics (ampicillin).

82. Monoliasis or Candidiasis
• Assessment - lab KOH wet mount NS KOH 10%
20% look for (branching Hyphae or Mycelium
fungus nails).
• Management - Nystatin--intravaginal adult
tabs 0.1 to 0.2 million units daily times 7 to 10
days.

83. Trichomonas Vaginitis

84. Trichomonas Vaginitis
• Signs and symptoms.
• Leukorrhea, vaginal soreness, burning,
pruritus, dyspareunia (pain during
intercourse).
• Bubbly, yellowish thick discharge, foul
smelling.
• Strawberry appearance of cervix.

85. Trichomonas Vaginitis
• Assessment - lab wet prep, microscopic
exam reveals pear shaped parasite with
long flagella and undulated (wavy outline in
appearance) cell membrane.
• Management.
• Metronidazole (Flagyl) anti protozoal 250
mg TID to 500 mg BID orally for 5 days.
• Patient education of feminine hygiene,
douching.
• Management based on culture results.

86. Bacterial Vaginitis
(Gardnerella vaginitis)
• Signs and symptoms.
• Leukorrhea, pruritus, dyspareunia.
• Turbid, chalky, white/gray or yellowish
discharge; malodorous ("fishy").

87. Bacterial Vaginitis
(Gardnerella vaginitis)
• Assessment.
• Gram-positive nonmotile coccobacillus that
normally inhabits the vagina.
• Wet smears of this nonspecific vaginitis yields
vaginal desquamated epithelial cells covered
with many bacteria.

88. Bacterial Vaginitis
(Gardnerella vaginitis)
• Management.
• Metronidazole (Flagyl) 250 mg TID to 500
mg BID orally for 7 10 days.
• Ampicillin 500 mg QID x 7 days.
• Douching with povidone iodine solution.
• About 25% of the patients have recurrence
and require treatment in 2 3 months.
• Management based on culture results.

89. Perineal pain -
Bartholin’s abscess
• Definition and etiology - acute or chronic
infection of the Bartholin's gland
(streptococci, staphylococci, E. coli,
anaerobes; may result in infection).
• History - recent intercourse, venereal disease,
trauma, spontaneous abortion, wiping from
rectum to vagina.

90. Perineal pain -
Bartholin’s abscess
• Signs and symptoms.
• Mass in perineum that is hot, tender, and
fluctuant.
• Pus draining from Bartholin's duct.

92. Perineal pain -
Bartholin’s abscess
• Management.
• I & D.
• Sitz bath.
• Broad-spectrum antibiotics which cover gram-
positive organisms and some common vaginal
gram-negative organisms.

93. BREAST ABNORMALITIES.

94. Acute Mastitis
• Definition - bacterial infection of breast.
• Time - confined generally to the first 2 months
of lactation.
• Organism - usually staphylococcus, sometimes
streptococcus.
• RULE - signs and symptoms of mastitis in
female; rule out cancer

95. Acute Mastitis
• Signs and symptoms.
• Pain in the breast.
• Withdraw from palpation.
• Erythema.
• Induration.
• Hot.

96. Acute Mastitis
• Management.
• Prevention by good hygiene.
• Preabscess--antibiotics.
• Abscess I & D.

97. Chronic Cystic Mastitis
• Benign pathology - fibrocystic syndrome.
• Age - begins in twenties and increases with
age.
• Signs and symptoms.
• Single or multiple cysts.
• Pain/tenderness.
• Nodular, well defined cysts.
• Smooth, firm, mobile cysts.

98. Chronic Cystic Mastitis
• Significance - increased incidence of breast
cancer 3-5 times.
• Management.
• Rule out cancer.
• Avoid caffeine and tobacco products, may
need referral to rule out cancer; follow-up
patient education.
• NOTE: In a field environment have
patient return for follow up.

99. QUESTIONS???