This document provides information on a presentation about empowering the vaginal atrophy dialogue. It includes:
- Disclosures from the faculty member presenting, noting relationships with commercial interests including Novo Nordisk, whose product Vagifem will be discussed.
- Learning objectives of describing prevalence and pathophysiology of vaginal atrophy, examining its effects, and managing it using treatment recommendations.
- Results of a pre-test questionnaire asking about symptoms and treatments for vaginal atrophy.
- Information on prevalence, pathophysiology, symptoms, and impacts of vaginal atrophy, drawing from studies. It discusses treatment options including local estrogen therapy and notes many women's lack of knowledge about effective options.
The document discusses peripartum hysterectomy, including its definition, history, incidence and trends, risk factors, types, indications, complications, and techniques. A key point is that a sequence of conservative measures should be attempted before hysterectomy to control uterine hemorrhage, as indecisiveness can lead to fatal excessive bleeding. The "Triple-P procedure" is also summarized as a three-step conservative approach involving obstetric, anesthesia and interventional radiology teams to prevent hemorrhage and need for hysterectomy in high-risk cases.
Laparoscopy still remains an important diagnostic and therapeutic tool in the management of subfertile women. Optimal and prudent use of this minimally invasive technique may avert costly treatment like IVF but overzealous and unindicated use may compromise future fertility. The evidence indicates that laparoscopic surgery improves fertility outcomes for conditions like mild to moderate endometriosis, myomectomy for submucosal fibroids, and tubal surgery. However, more high-quality randomized controlled trials are needed to provide stronger evidence and guidelines for clinical practice in reproductive surgery.
This document discusses various aspects of female sexual function and dysfunction, including physiology, models of sexual response, phases of sexual response, and instruments used to assess female sexual dysfunction. It provides details on several validated questionnaires used to evaluate female sexual function, including the Female Sexual Function Index, Changes in Sexual Functioning Questionnaire, Derogatis Interview for Sexual Functioning, and Sexual Quality of Life-Female Questionnaire. It also discusses components of clinical evaluation for female sexual dysfunction, such as history, physical exam, lab tests, and treatment options.
Optimal protocols for Ovulation induction (Assisted Reproductive technologies)Anu Test Tube Baby Centre
Presentation given in Tirupati, India in 2018 on Ovulation Induction for assisted reproductive technologies. Dealing with infertility using Intra uterine insemination (IUI) and In vitro fertilization (IVF)
FIRST LINE THERAPY - CLOMIPHENE CITRATE & LETROZOLE BY DR SHASHWAT JANIDR SHASHWAT JANI
Dr. Shashwat Jani discusses ovulation induction using clomiphene citrate and letrozole. He explains that clomiphene citrate works by blocking estrogen receptors in the pituitary and hypothalamus, increasing FSH levels and causing the development of multiple follicles. However, it has anti-estrogenic side effects and a lower pregnancy rate than letrozole. Letrozole inhibits the aromatase enzyme, reducing estrogen levels and stimulating the hypothalamic-pituitary axis to induce mono-follicular development with fewer side effects and a higher pregnancy success rate than clomiphene citrate.
Endometrial hyperplasia is an overgrowth of the endometrium that is most common in postmenopausal women exposed to unopposed estrogen, but can occur in women of any age. The most common symptoms are abnormal uterine bleeding, vaginal discharge, and lower abdominal pain. It is classified by the WHO into two categories: hyperplasia without atypia and atypical hyperplasia. Diagnosis involves endometrial biopsy or dilation and curettage to sample the endometrial tissue. Treatment depends on the classification and symptoms, and may involve hormone therapy, progestins, or hysterectomy in severe cases.
The document discusses peripartum hysterectomy, including its definition, history, incidence and trends, risk factors, types, indications, complications, and techniques. A key point is that a sequence of conservative measures should be attempted before hysterectomy to control uterine hemorrhage, as indecisiveness can lead to fatal excessive bleeding. The "Triple-P procedure" is also summarized as a three-step conservative approach involving obstetric, anesthesia and interventional radiology teams to prevent hemorrhage and need for hysterectomy in high-risk cases.
Laparoscopy still remains an important diagnostic and therapeutic tool in the management of subfertile women. Optimal and prudent use of this minimally invasive technique may avert costly treatment like IVF but overzealous and unindicated use may compromise future fertility. The evidence indicates that laparoscopic surgery improves fertility outcomes for conditions like mild to moderate endometriosis, myomectomy for submucosal fibroids, and tubal surgery. However, more high-quality randomized controlled trials are needed to provide stronger evidence and guidelines for clinical practice in reproductive surgery.
This document discusses various aspects of female sexual function and dysfunction, including physiology, models of sexual response, phases of sexual response, and instruments used to assess female sexual dysfunction. It provides details on several validated questionnaires used to evaluate female sexual function, including the Female Sexual Function Index, Changes in Sexual Functioning Questionnaire, Derogatis Interview for Sexual Functioning, and Sexual Quality of Life-Female Questionnaire. It also discusses components of clinical evaluation for female sexual dysfunction, such as history, physical exam, lab tests, and treatment options.
Optimal protocols for Ovulation induction (Assisted Reproductive technologies)Anu Test Tube Baby Centre
Presentation given in Tirupati, India in 2018 on Ovulation Induction for assisted reproductive technologies. Dealing with infertility using Intra uterine insemination (IUI) and In vitro fertilization (IVF)
FIRST LINE THERAPY - CLOMIPHENE CITRATE & LETROZOLE BY DR SHASHWAT JANIDR SHASHWAT JANI
Dr. Shashwat Jani discusses ovulation induction using clomiphene citrate and letrozole. He explains that clomiphene citrate works by blocking estrogen receptors in the pituitary and hypothalamus, increasing FSH levels and causing the development of multiple follicles. However, it has anti-estrogenic side effects and a lower pregnancy rate than letrozole. Letrozole inhibits the aromatase enzyme, reducing estrogen levels and stimulating the hypothalamic-pituitary axis to induce mono-follicular development with fewer side effects and a higher pregnancy success rate than clomiphene citrate.
Endometrial hyperplasia is an overgrowth of the endometrium that is most common in postmenopausal women exposed to unopposed estrogen, but can occur in women of any age. The most common symptoms are abnormal uterine bleeding, vaginal discharge, and lower abdominal pain. It is classified by the WHO into two categories: hyperplasia without atypia and atypical hyperplasia. Diagnosis involves endometrial biopsy or dilation and curettage to sample the endometrial tissue. Treatment depends on the classification and symptoms, and may involve hormone therapy, progestins, or hysterectomy in severe cases.
This document contains a series of questions and answers related to obstetrics and gynecology. It includes questions about various medical instruments, procedures, conditions, and partographs. For example, it asks about the use of a uterine sound, characteristics of a hysterosalpingogram, and features that would be noted on a partograph depicting a prolonged active phase of labor.
DNB Obstetrics & gynaecology previous Year Question Papersapollobgslibrary
The document discusses the benefits of exercise for mental health. Regular physical activity can help reduce anxiety and depression and improve mood and cognitive functioning. Exercise causes chemical changes in the brain that may help protect against mental illness and improve symptoms.
Obstetric fistula is an abnormal connection between the vagina and bladder or rectum caused by prolonged obstructed labor without timely medical intervention. Nigeria accounts for 40% of global fistula cases with around 20,000 new cases annually. Risk factors include poverty, early marriage, and lack of access to emergency obstetric care. Clinical presentation includes urinary or fecal incontinence. Treatment involves surgical repair once inflammation subsides, while prevention focuses on girl child education, empowerment, antenatal care, and emergency obstetric services.
Cervical Mucus presented by Dr. Jyoti Agarwal / Dr. Sharda Jain Lifecare Centre
This document discusses vaginal and cervical dryness as an often overlooked cause of infertility. It provides facts about the high rates of vaginal dryness in couples trying to conceive and the negative effects dryness can have on sperm motility and fertility. The document examines the roles of cervical mucus in fertility and the optimal conditions for sperm, including pH between 7.0-8.5 and osmolality of 320 mosm/kg. It recommends a fertility-friendly vaginal gel that mimics natural secretions to maintain moisture, pH, and isotonic conditions in the vagina and cervix, thereby providing the best biochemical support for sperm motility and fertilization.
Threatened Miscarriage Verdict is out on Hormonal Treatment Dr Jyoti AgarwalLifecare Centre
- Threatened miscarriage occurs in around 15% of clinically recognized pregnancies and can cause significant emotional and psychological stress for couples.
- Multiple meta-analyses and randomized controlled trials have found that oral administration of dydrogesterone is more effective at reducing the risk of miscarriage in cases of threatened miscarriage compared to vaginal progesterone or no treatment.
- Dydrogesterone has higher bioavailability when taken orally compared to micronized progesterone, requires a lower dose, and may have immunomodulatory properties that further reduce the risk of miscarriage.
This document provides an overview of obstetrics exam questions, cases, and notes on topics like fetal monitoring, biophysical profile (BPP) scoring, Doppler ultrasound, fetal heart rate patterns, and fetal assessment tests. It includes 26 multiple choice questions on these topics, along with brief explanations of answers. The key points covered are the criteria for normal vs abnormal test results on non-stress tests (NST), BPP, oxytocin challenge test (OCT), and definitions of different types of fetal heart rate decelerations and their clinical significance.
The method of ovulation induction selected by the clinician should be based upon the underlying cause of anovulation and the efficacy, costs, risks, burden of treatment, and potential complications associated with each method as they apply to the individual woman. In this presentation I have mentioned every points in detail.
This document provides an overview of a slide presentation introducing the World Health Organization's (WHO) Labour Care Guide. The Labour Care Guide is a new partograph designed to improve labor monitoring and care based on WHO's 2018 intrapartum care recommendations. It aims to promote individualized, woman-centered care and prevent unnecessary interventions during labor by establishing thresholds to identify complications. The guide contains 7 sections to document a woman's care throughout labor and encourage shared decision-making between providers and women.
Chronic pelvic pain is defined as noncyclic pain lasting at least 6 months that localizes to the pelvis, lower abdomen, or lower back. It can be caused by visceral, parietal, or referred pain and may have nociceptive or neuropathic characteristics. Evaluation involves assessing onset, relationship to menstruation, character, location, severity, and associated symptoms. Causes include residual or remnant ovarian tissue remaining after hysterectomy, which can cause pain and dyspareunia. Neuropathic pain results from damage to the somatosensory nervous system and may involve abnormal sensations or pain from non-painful stimuli. Diagnosis involves laparoscopy and histopathology to identify potential causes.
Müllerian agenesis, or Mayer-Rokitansky-Küster-Hauser syndrome, is a condition where women are born without a uterus and have an underdeveloped or absent vagina. It occurs in 1 in 4,500-5,000 females. Evaluation should include testing for associated kidney, skeletal, or hearing abnormalities which occur in up to 53% of cases. Primary treatment is dilation of the vagina which succeeds for 90-96% of patients. Surgery to create a neovagina is only recommended if dilation fails or is refused by the patient. Lifelong follow up is important due to risks of sexual health issues and cancer.
This document contains 35 multiple choice questions related to a gynaecology exam. It provides the questions, possible answers and the key/correct answer for each question. The questions cover topics such as infertility, ectopic pregnancy, menopause, prolapse, ovarian tumors, contraception and more.
This document discusses trial of labor after cesarean section (TOLAC) versus elective repeat cesarean section for women with a prior cesarean delivery. It notes that 60-80% of women who attempt TOLAC will have a successful vaginal birth. The risks of TOLAC include uterine rupture, failed trial of labor requiring emergency cesarean, and slightly increased risk of complications for the baby. The risks of elective repeat cesarean include increased risks for placenta problems and complications in future pregnancies. The document provides an overview of the risks, benefits, and success rates to help women decide which option is safest for their individual situation.
The document discusses the lymphatic drainage patterns of the vulva and vagina and describes vulval cancer. It notes that the vulva has dense lymphatic plexuses that drain to the superficial and deep inguinal lymph nodes and external iliac nodes. Vulval cancer is rare and usually occurs in postmenopausal women. Risk factors include conditions like lichen sclerosus. Diagnosis is by biopsy and treatment involves radical vulvectomy with bilateral lymph node dissection or radiotherapy depending on the stage of cancer. Prognosis depends on lymph node involvement, with 5-year survival rates ranging from 90-100% without node involvement to below 20% with positive pelvic nodes.
This document discusses vulvodynia, specifically vulvar vestibulitis syndrome (VVS). It defines VVS as a chronic condition characterized by severe pain on vestibular touch or attempted vaginal entry. The causes are unclear but may be multifactorial, and treatments include reassurance, medical options like topical creams or antidepressants, behavioral therapies, and surgery like vestibulectomy in some cases. Diagnosis involves assessing for tenderness localized within the vestibule using a cotton swab test.
hydrosalphinx in accumulation fluid in fallopian tube that make problems for sperm to pass through the tube to meet te oocyte. People who want to get pregnant should meet the doctor to solve this problem. pregnancy can achieve after operation by laparoscopic for diagnostic and treatment
This document discusses endometriosis, including its definition, prevalence, age at diagnosis, sites, types, pathogenesis, risk factors, classification systems, clinical presentation, diagnosis, and laparoscopic findings. Some key points include:
- Endometriosis is defined as endometrial glands and stroma outside the uterus, and is prevalent in 5% of women of reproductive age.
- It is most commonly diagnosed between ages 26-35 and presents with symptoms like infertility, pelvic pain, dysmenorrhea, and dyspareunia.
- Diagnosis is usually confirmed via laparoscopy, though atypical lesions can be difficult to identify visually and may require biopsy. Laparoscopy allows visualization
BOTs are rare ovarian tumors that exhibit some malignant characteristics but are not fully invasive. They have an overall excellent prognosis, though risk of recurrence increases with higher stage, certain histologies, and younger age. Surgical staging is important for prognosis and often involves comprehensive staging surgery. Most patients require only observation after surgery, though some higher risk cases may benefit from repeat surgery or chemotherapy. Long term follow up is important due to risk of recurrence or progression.
Atrophic vaginitis is a condition that affects postmenopausal women, characterized by a pale, thin vaginal epithelium due to declining estrogen levels. Diagnosis involves examining symptoms, signs of vaginal dryness and atrophy, and ruling out other infections. Treatment begins with lubricants and moisturizers, while local estrogen therapies applied topically to the vagina are most effective at treating symptoms and reversing atrophy by improving blood flow and tissue health. Proper treatment typically provides relief, but may require long-term maintenance.
Atrophic vaginitis under treated under diagnosed(f)Shambhu N
Atrophic vaginitis is underdiagnosed and undertreated in postmenopausal women. It affects around 80% of postmenopausal women, with around 20% experiencing symptoms. Local estrogen therapy is effective at treating atrophic vaginitis symptoms by improving vaginal health and reducing pH levels. Treatment options include low dose vaginal creams, rings, or tablets containing estradiol or other estrogens.
This document contains a series of questions and answers related to obstetrics and gynecology. It includes questions about various medical instruments, procedures, conditions, and partographs. For example, it asks about the use of a uterine sound, characteristics of a hysterosalpingogram, and features that would be noted on a partograph depicting a prolonged active phase of labor.
DNB Obstetrics & gynaecology previous Year Question Papersapollobgslibrary
The document discusses the benefits of exercise for mental health. Regular physical activity can help reduce anxiety and depression and improve mood and cognitive functioning. Exercise causes chemical changes in the brain that may help protect against mental illness and improve symptoms.
Obstetric fistula is an abnormal connection between the vagina and bladder or rectum caused by prolonged obstructed labor without timely medical intervention. Nigeria accounts for 40% of global fistula cases with around 20,000 new cases annually. Risk factors include poverty, early marriage, and lack of access to emergency obstetric care. Clinical presentation includes urinary or fecal incontinence. Treatment involves surgical repair once inflammation subsides, while prevention focuses on girl child education, empowerment, antenatal care, and emergency obstetric services.
Cervical Mucus presented by Dr. Jyoti Agarwal / Dr. Sharda Jain Lifecare Centre
This document discusses vaginal and cervical dryness as an often overlooked cause of infertility. It provides facts about the high rates of vaginal dryness in couples trying to conceive and the negative effects dryness can have on sperm motility and fertility. The document examines the roles of cervical mucus in fertility and the optimal conditions for sperm, including pH between 7.0-8.5 and osmolality of 320 mosm/kg. It recommends a fertility-friendly vaginal gel that mimics natural secretions to maintain moisture, pH, and isotonic conditions in the vagina and cervix, thereby providing the best biochemical support for sperm motility and fertilization.
Threatened Miscarriage Verdict is out on Hormonal Treatment Dr Jyoti AgarwalLifecare Centre
- Threatened miscarriage occurs in around 15% of clinically recognized pregnancies and can cause significant emotional and psychological stress for couples.
- Multiple meta-analyses and randomized controlled trials have found that oral administration of dydrogesterone is more effective at reducing the risk of miscarriage in cases of threatened miscarriage compared to vaginal progesterone or no treatment.
- Dydrogesterone has higher bioavailability when taken orally compared to micronized progesterone, requires a lower dose, and may have immunomodulatory properties that further reduce the risk of miscarriage.
This document provides an overview of obstetrics exam questions, cases, and notes on topics like fetal monitoring, biophysical profile (BPP) scoring, Doppler ultrasound, fetal heart rate patterns, and fetal assessment tests. It includes 26 multiple choice questions on these topics, along with brief explanations of answers. The key points covered are the criteria for normal vs abnormal test results on non-stress tests (NST), BPP, oxytocin challenge test (OCT), and definitions of different types of fetal heart rate decelerations and their clinical significance.
The method of ovulation induction selected by the clinician should be based upon the underlying cause of anovulation and the efficacy, costs, risks, burden of treatment, and potential complications associated with each method as they apply to the individual woman. In this presentation I have mentioned every points in detail.
This document provides an overview of a slide presentation introducing the World Health Organization's (WHO) Labour Care Guide. The Labour Care Guide is a new partograph designed to improve labor monitoring and care based on WHO's 2018 intrapartum care recommendations. It aims to promote individualized, woman-centered care and prevent unnecessary interventions during labor by establishing thresholds to identify complications. The guide contains 7 sections to document a woman's care throughout labor and encourage shared decision-making between providers and women.
Chronic pelvic pain is defined as noncyclic pain lasting at least 6 months that localizes to the pelvis, lower abdomen, or lower back. It can be caused by visceral, parietal, or referred pain and may have nociceptive or neuropathic characteristics. Evaluation involves assessing onset, relationship to menstruation, character, location, severity, and associated symptoms. Causes include residual or remnant ovarian tissue remaining after hysterectomy, which can cause pain and dyspareunia. Neuropathic pain results from damage to the somatosensory nervous system and may involve abnormal sensations or pain from non-painful stimuli. Diagnosis involves laparoscopy and histopathology to identify potential causes.
Müllerian agenesis, or Mayer-Rokitansky-Küster-Hauser syndrome, is a condition where women are born without a uterus and have an underdeveloped or absent vagina. It occurs in 1 in 4,500-5,000 females. Evaluation should include testing for associated kidney, skeletal, or hearing abnormalities which occur in up to 53% of cases. Primary treatment is dilation of the vagina which succeeds for 90-96% of patients. Surgery to create a neovagina is only recommended if dilation fails or is refused by the patient. Lifelong follow up is important due to risks of sexual health issues and cancer.
This document contains 35 multiple choice questions related to a gynaecology exam. It provides the questions, possible answers and the key/correct answer for each question. The questions cover topics such as infertility, ectopic pregnancy, menopause, prolapse, ovarian tumors, contraception and more.
This document discusses trial of labor after cesarean section (TOLAC) versus elective repeat cesarean section for women with a prior cesarean delivery. It notes that 60-80% of women who attempt TOLAC will have a successful vaginal birth. The risks of TOLAC include uterine rupture, failed trial of labor requiring emergency cesarean, and slightly increased risk of complications for the baby. The risks of elective repeat cesarean include increased risks for placenta problems and complications in future pregnancies. The document provides an overview of the risks, benefits, and success rates to help women decide which option is safest for their individual situation.
The document discusses the lymphatic drainage patterns of the vulva and vagina and describes vulval cancer. It notes that the vulva has dense lymphatic plexuses that drain to the superficial and deep inguinal lymph nodes and external iliac nodes. Vulval cancer is rare and usually occurs in postmenopausal women. Risk factors include conditions like lichen sclerosus. Diagnosis is by biopsy and treatment involves radical vulvectomy with bilateral lymph node dissection or radiotherapy depending on the stage of cancer. Prognosis depends on lymph node involvement, with 5-year survival rates ranging from 90-100% without node involvement to below 20% with positive pelvic nodes.
This document discusses vulvodynia, specifically vulvar vestibulitis syndrome (VVS). It defines VVS as a chronic condition characterized by severe pain on vestibular touch or attempted vaginal entry. The causes are unclear but may be multifactorial, and treatments include reassurance, medical options like topical creams or antidepressants, behavioral therapies, and surgery like vestibulectomy in some cases. Diagnosis involves assessing for tenderness localized within the vestibule using a cotton swab test.
hydrosalphinx in accumulation fluid in fallopian tube that make problems for sperm to pass through the tube to meet te oocyte. People who want to get pregnant should meet the doctor to solve this problem. pregnancy can achieve after operation by laparoscopic for diagnostic and treatment
This document discusses endometriosis, including its definition, prevalence, age at diagnosis, sites, types, pathogenesis, risk factors, classification systems, clinical presentation, diagnosis, and laparoscopic findings. Some key points include:
- Endometriosis is defined as endometrial glands and stroma outside the uterus, and is prevalent in 5% of women of reproductive age.
- It is most commonly diagnosed between ages 26-35 and presents with symptoms like infertility, pelvic pain, dysmenorrhea, and dyspareunia.
- Diagnosis is usually confirmed via laparoscopy, though atypical lesions can be difficult to identify visually and may require biopsy. Laparoscopy allows visualization
BOTs are rare ovarian tumors that exhibit some malignant characteristics but are not fully invasive. They have an overall excellent prognosis, though risk of recurrence increases with higher stage, certain histologies, and younger age. Surgical staging is important for prognosis and often involves comprehensive staging surgery. Most patients require only observation after surgery, though some higher risk cases may benefit from repeat surgery or chemotherapy. Long term follow up is important due to risk of recurrence or progression.
Atrophic vaginitis is a condition that affects postmenopausal women, characterized by a pale, thin vaginal epithelium due to declining estrogen levels. Diagnosis involves examining symptoms, signs of vaginal dryness and atrophy, and ruling out other infections. Treatment begins with lubricants and moisturizers, while local estrogen therapies applied topically to the vagina are most effective at treating symptoms and reversing atrophy by improving blood flow and tissue health. Proper treatment typically provides relief, but may require long-term maintenance.
Atrophic vaginitis under treated under diagnosed(f)Shambhu N
Atrophic vaginitis is underdiagnosed and undertreated in postmenopausal women. It affects around 80% of postmenopausal women, with around 20% experiencing symptoms. Local estrogen therapy is effective at treating atrophic vaginitis symptoms by improving vaginal health and reducing pH levels. Treatment options include low dose vaginal creams, rings, or tablets containing estradiol or other estrogens.
1. The document discusses sublingual immunotherapy (SLIT) tablets for treating grass pollen induced allergic rhinitis. It summarizes the product monograph for Grastek, a 2800 BAU SLIT tablet containing standardized Timothy grass extract.
2. The monograph outlines the tablet formulation, indications for reducing moderate-severe grass pollen rhinitis symptoms, and contraindications for patients with severe asthma or oral conditions.
3. Safety information notes local reactions are common with SLIT but systemic anaphylaxis was not reported in clinical studies. Physicians must be trained to treat any potential severe allergic reactions.
This clinical practice guideline from the Canadian Thoracic Society provides recommendations for targeted testing and augmentation therapy for alpha-1 antitrypsin deficiency in patients with chronic obstructive pulmonary disease (COPD). The guideline was developed using a systematic review of the literature and consensus process. The evidence supports targeted testing for alpha-1 antitrypsin deficiency in individuals diagnosed with COPD before age 65 or with a smoking history of less than 20 pack-years. The evidence also supports consideration of alpha-1 antitrypsin augmentation therapy in nonsmoking or former smoking patients with emphysema and documented severe deficiency, as it may provide benefits in lung density and mortality when used with optimal COPD treatment.
Sat 1540-clinical-approach-to-red-eye- -parkIhsaan Peer
This document provides an overview of red eye (conjunctivitis) for clinical practice. It begins with learning objectives and then covers topics such as ocular anatomy, causes of red eye, evaluation of red eye, differential diagnosis, treatment recommendations, and when to refer to an ophthalmologist. Key points include differentiating conditions that cause red eye based on symptoms and signs, describing ideal treatments for various conjunctivitis types, and discussing recommendations for returning to activities with infectious conjunctivitis. The document provides guidance on evaluating and diagnosing different red eye conditions.
This document provides an overview and summary of the "A GP for Me" initiative and related GPSC incentives for June 2013. It discusses the background and goals of the initiative to increase access to primary care physicians in BC. It then summarizes the various fee incentives available, including attachment fees for participating in the initiative, complex care management fees, telephone management fees, and patient conferencing fees. The presentation was developed by the Society of General Practitioners of BC to provide information on the initiative and billing incentives to physicians.
Sat 0810-smith-case-for-legalizing-medically-assisted-dying-in-canada- -parkIhsaan Peer
This document summarizes a presentation by Dr. Derryck H. Smith arguing for the legalization of medically-assisted dying in Canada. Dr. Smith outlines the common arguments for and against assisted dying, noting evidence does not support claims it would undermine palliative care or lead to abuse. Data from jurisdictions where assisted dying is legal show it is infrequently used and mostly by well-educated, terminally ill patients wishing to control their death. Dr. Smith argues individual autonomy should drive policy over religious beliefs alone, and that legalization need not compromise palliative care access or oversight.
This document provides information on lower back physical exams. It reviews the approach to lower back conditions and the components of the lower back physical exam. It then presents three case studies of patients with different lower back issues and demonstrates how to conduct the physical exam and determine appropriate investigations and management for each case. The cases include a grad student with back strain, a construction worker with an acute disk prolapse, and a gymnast with spondylolysis.
The document appears to be a multi-page summary of 2012 guidelines for the management of stable and unstable angina. It likely provides recommendations on diagnosing and treating patients with these conditions through lifestyle modifications and medical therapies. The guidelines aim to help healthcare providers optimize outcomes for individuals suffering from angina through evidence-based clinical care.
The document summarizes rural healthcare programs and initiatives in British Columbia. It describes the goals of the Rural Coordination Centre of BC (RCCbc) to support rural health education and partnerships. It outlines several programs that provide financial incentives and continuing education for rural physicians, including the Rural Retention Program, Rural GP Locum Program, and Rural Continuing Medical Education. It also describes the Rural Education Action Plan (REAP) which provides funding for skills training, specialty education, and first-year physicians practicing in rural communities. Contact details are provided for additional information.
The document provides an overview of the Royal College of Physicians and Surgeons of Canada's (RCPSC) Continuing Professional Development (CPD) program for physicians. It outlines the program requirements, which include completing a minimum of 40 credits annually and 400 credits over a five-year cycle. It also describes the seven categories through which physicians can earn credits by participating in various learning activities, such as group learning sessions, self-directed learning projects, teaching, and personal practice reviews. Physicians document their learning activities and credits earned using the online MAINPORT tool. The RCPSC's Educational Support Centre is available to assist physicians with navigating the CPD program.
This document provides a summary of a webinar about the UBC International Medical Graduate Program held on September 13, 2011. It discusses the Physician Information Technology Office (PITO) program, which aims to support physician adoption of electronic medical records (EMRs) in British Columbia. Some key points include:
1. PITO was created in 2007 to help physicians implement EMRs and achieve benefits like improved patient care and physician satisfaction.
2. EMR adoption rates vary significantly depending on practice size, location, and specialty. Large family practices have over 90% adoption while solo practitioners and specialists have lower rates.
3. PITO offers services like funding, implementation support, peer ment
This document summarizes a presentation on hepatitis C given by Dr. Alnoor Ramji. It discusses the epidemiology and natural history of HCV, including its worldwide prevalence and genotype distribution. Screening and treatment options are also reviewed, noting the increasing efficacy of newer antiviral regimens. SVR rates with various treatment combinations are presented according to genotype and fibrosis stage. The importance of viral eradication is highlighted, with SVR associated with reduced mortality.
The document summarizes key points from the Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines for COPD. It describes GOLD's structure, objectives to increase awareness and improve management of COPD. It provides an overview of COPD definitions, risk factors, burden, and mechanisms. It also summarizes GOLD's approach to diagnosing and assessing COPD through evaluating symptoms, spirometry measurements, exacerbation risk, and comorbidities. Assessment results are combined to classify patients into groups A through D to guide treatment decisions.
Nutrition che slide handout 6 per page eIhsaan Peer
1) The document discusses the importance of counselling parents on optimal infant nutrition. Growth and development are rapid in early life and certain nutrients are associated with development and health.
2) It provides an overview of the macronutrient composition of breast milk, which is considered the gold standard. Breast milk contains proteins, carbohydrates primarily in the form of lactose, and lipids where over half the calories come from.
3) Optimizing infant nutrition requires considering factors beyond just calories and macronutrients. Components of breast milk like fats, prebiotics, vitamins and minerals can impact health, development, cognition and specific organ health.
This document summarizes an educational presentation on approaches to food allergies. It discusses diagnosing food allergies through history, skin prick tests, and IgE blood tests. It also covers managing non-acute food allergies through allergen avoidance, medical treatment, and immunotherapy. Finally, it reviews updates on preventing food allergies through early introduction of foods for high-risk infants and maintaining regular ingestion once introduced. Clinical teaching points emphasize the importance of history, avoiding IgG tests, baked goods aiding egg tolerance, flu vaccine safety, epinephrine dosing, and early solid food introduction.
Sat 1025-hair-management-too-much-too-little- -parkIhsaan Peer
Dr. Shehla Ebrahim presented a talk on hair loss. The presentation covered the different types of non-scarring alopecia including male/female pattern hair loss, telogen effluvium, alopecia areata, and androgen excess. Clinical scenarios were provided to demonstrate distinguishing features. Treatment options were discussed for each condition. The presentation emphasized taking a thorough history and examining the scalp, eyebrows, and body hair to determine the cause and guide management of hair loss.
This document provides information on various billing codes related to chronic disease management, prevention, mental health, and hospital visits. It discusses codes for complex care fees, telephone consultations, attachment fees, chronic disease management bonuses, and hospital visit fees. Requirements and limitations are outlined for billing each fee code. High level prevention guidelines and screening recommendations are also summarized.
This document provides an overview of actinic keratosis and its treatment options presented by Dr. Marcie Ulmer. It begins with introductions of Dr. Ulmer and discloses her relationships with pharmaceutical companies. The document then discusses actinic keratosis, its link to non-melanoma skin cancer, risk factors, clinical signs and symptoms. It presents various treatment options for actinic keratosis, including topical medications appropriate for field-directed treatment. The document aims to educate primary care physicians on diagnosing and managing actinic keratosis lesions.
A gp for me overview presentation codes onlyIhsaan Peer
This document provides information about various fee codes and supports available through the General Practice Services Committee (GPSC) for general practitioner (GP) attachment of patients in British Columbia, Canada. It outlines a physician-patient "compact" agreeing that the physician will provide the best possible care, coordinate specialty care, offer timely access, and communicate openly with patients. It also lists 5 GP attachment fee codes, including fees for telephone management, complex care management, and patient conferences. Referral sources for unattached complex patients are also mentioned.
Empowering the vaginal atrophy dialogue multi_therapeuticIhsaan Peer
This document discusses a presentation on empowering the vaginal atrophy dialogue. It begins with disclosing the faculty presenter's relationships with commercial interests and notes that the program received financial support from Novo Nordisk. It then lists learning objectives which include describing vaginal atrophy prevalence, pathophysiology, treatment recommendations, and counseling women about options. Several slides provide details on vaginal atrophy symptoms, effects on quality of life, and treatment options like local estrogen therapy.
This document defines vaginismus and discusses its diagnosis and treatment. It begins by defining vaginismus and tracing the evolution of its definition. It notes that vaginismus is characterized by involuntary contraction of pelvic floor muscles that interfere with penetration. The document discusses prevalence, types, potential causes, diagnosis through history and examination, and classification. It outlines treatment approaches including exploration of underlying phobias or beliefs, sex education, muscle relaxation exercises, and systematic vaginal desensitization using graduated insertion of trainers under controlled relaxation. The goal of treatment is to help women gain control of pelvic floor muscles and replace pain with pleasure through a multidisciplinary approach.
The truth behind vaginismus disease by Alkhima MacarompisUntroshlich
Vaginismus is a condition where the vaginal muscles involuntarily tighten, making penetration painful or impossible. It has physical and psychological causes. Physically, it can be triggered by events like childbirth or sexual trauma that cause the body to anticipate pain during penetration. Psychologically, factors like fear, anxiety, past abuse or negative sexual experiences can contribute. Diagnosis involves ruling out other conditions through examination and history. Treatment involves both physical exercises with dilators to gradually desensitize the muscles, as well as psychological therapy to address underlying causes. Controlled studies show desensitization therapy is effective, with success rates up to 95%.
This document summarizes a presentation on menopause management strategies. It discusses common symptoms women experience related to menopause like sleep disturbances, genitourinary changes, and sexual dysfunction. It reviews non-hormone and hormone-based treatment approaches and the evidence for their risks and benefits based on recent studies. Specific management strategies are provided for symptoms like sleep issues, vaginal dryness, and low sexual desire. The presentation aims to help providers make individualized clinical decisions for managing menopause symptoms.
This document discusses various women's health issues and disorders and how yoga can help address them. It covers:
1) Common health disorders women face such as PMS, dysmenorrhea, amenorrhea, and issues related to pregnancy, menopause, and infertility.
2) How stress physically and psychologically impacts the body.
3) Yoga practices like Surya Namaskar and meditation that aim to relax the body, slow the breath, and calm the mind for stress management.
The document provides information on yoga techniques for treating various women's health disorders and menstrual issues. It outlines integrated yoga modules involving breathing practices, yoga poses, relaxation techniques, and meditation/pranayama that can help with conditions like heavy or painful periods, irregular cycles, PMS, infertility, menopause, and incontinence. The modules are designed to stimulate, relax, and balance the body and mind.
1. Sexual dysfunction (SD) can be both a cause and consequence of infertility, with infertility potentially exacerbating any pre-existing SD.
2. Taking a comprehensive sexual history is important for infertility patients to avoid unnecessary investigations and treatments when SD is the cause.
3. Studies from other countries have found high rates of SD like premature ejaculation, erectile dysfunction, and dyspareunia in infertile male and female patients. Addressing SD is important when managing infertile couples.
Clarifying pelvic organ prolapse reality vs misconceptions to substantiate POP incidence, understand women’s pelvic health issues, evolve clinician best practices, and generate early detection.
Urinary incontinence is common among women and has a profound negative impact on quality of life. The UCSF Women's Continence Center aims to improve treatment for incontinence through comprehensive clinical care, innovative research, and education. Their research focuses on developing novel treatments, identifying risk factors, and studying the long term outcomes of current surgical and nonsurgical therapies.
8.Assessment of Female Reproductive.pptxMesfinShifara
The document provides information on assessing the female reproductive system, including:
1. An overview of the objectives, introduction, external and internal structures, equipment used, and general examination procedures.
2. Descriptions of inspecting and palpating the external genitalia, speculum examination of the internal genitalia, and collecting specimens.
3. Details on performing a bimanual examination to assess the vagina, cervix, uterus and adnexa. The document outlines the normal findings and abnormalities to look for during the physical examination.
The uterine cycle, also known as the menstrual cycle, is a complex series of events that occurs in the female reproductive system, primarily involving the uterus and ovaries. The cycle is divided into three main phases: the menstrual phase, the proliferative phase, and the secretory phase. The uterine cycle is tightly regulated by hormonal changes, primarily those involving estrogen and progesterone. The uterine cycle is a dynamic and intricately regulated process essential for reproductive health. It plays a central role in the preparation of the uterus for potential pregnancy and is influenced by hormonal fluctuations throughout the menstrual cycle.
Sexual health is an important topic for many cancer patients and survivors, and unfortunately, it can often be overlooked by providers.
In this webinar, Dr. Sharon Bober, Founding Director of the Sexual Health Program at the Dana-Farber, will discuss how to navigate a variety of sexual health issues that often come up for colorectal cancer patients and survivors. Tune in live to the webinar to ask questions and gain insight on sexual health and tips on how to manage.
This document discusses women's health issues and focuses on gender differences in health, miscarriage, termination of pregnancy (abortion), and treatment after miscarriage.
The key points are:
1) Women are more likely than men to be diagnosed and treated for various health problems, but also live longer on average. Gender plays a role in health beliefs, behaviors, and experiences.
2) Miscarriage occurs in 15-20% of known pregnancies, and research shows it can result in grief, anxiety, depression, and a reassessment of past and future experiences. How miscarriage is managed medically also impacts women's experiences.
3) Abortion is legal in many countries up to a certain
This document discusses menopause, providing information on its epidemiology, physiology, signs and symptoms, diagnosis, management, and the pharmacist's role. It defines menopause as the permanent cessation of menses for 12 consecutive months due to declining estrogen levels. The average age of menopause is around 52 in the US and 50 in Nigeria. Symptoms include hot flashes, vaginal dryness, and bone loss. Treatment involves lifestyle changes, hormonal therapies like estrogen, and medications for specific symptoms. The pharmacist's role is to educate patients on management options and their risks and benefits.
assignment manpreet mam.power point presentationKittyTuttu
The document discusses menopause and its psychological and social impacts. It defines menopause and outlines its phases. It then examines common psychological changes like headaches, irritability and fatigue. Social factors like relationships, education and culture are also explored. Finally, the document summarizes research on management approaches, including hormone replacement therapy, antidepressants, lifestyle modifications and social support.
Static and Acoustic Characteristics of Various Compressive Strength Concrete ...journal ijrtem
ABSTRACT:Steel fiber reinforced concrete (SFRC) was developed in volume fraction up to 1.5%. The static and acoustic behaviors of these composites under various loads were investigated. The mechanical properties such as: compressive and flexural strength were enhanced up by reinforcing with steel fiber. Moreover sonic parameters of these composites such as pulse velocity weredetermined usingultra sonic technique. The results showed that pulse velocity inversely proportional to subjected load, and enhanced with curing age. Keywords:Acoustic, Characteristics, Concrete Composites, Compressive Strength, Static
The document summarizes a study that examined how race, lifestyle choices, and socioeconomic factors impact menopause symptoms. The Study of Women's Health Across the Nation (SWAN) studied over 3,000 women between 1996-2002. It found that African American women reported the highest rates of vasomotor symptoms like hot flashes, while Asian women reported the lowest. Factors found to increase vasomotor symptoms were older age, less education, obesity, smoking, and anxiety. Race, lifestyle, and socioeconomic status all influenced menopause experiences and symptom severity.
This document provides an overview of premature ejaculation (PE). It begins by listing the moderators and their departments. It then discusses the definition of PE, prevalence rates, causes including genetic, neurological and other factors. Evaluation involves measuring intravaginal ejaculatory latency time (IELT). Treatments discussed include both medical options like SSRIs, tramadol, topical anesthetics as well as behavioral therapies and surgical options. PE is portrayed as a multifactorial condition with contributions from biological, psychological and relationship factors.
Navigating secondary infertility with homoeopathy: An evidence-based case reportDrAnandaKumarPingali
This case study provides a detailed account of treating secondary infertility in a female patient through an individualized homoeopathic regiment. The study's subject was a 36-year-old woman who had struggled with fertility following several treatments, including hormonal intervention and IVF, without success. Following a personalized selection of Homoeopathic treatment using the Murex remedy, the subject experienced gradual overall health improvement and eventually confirmed pregnancy. This case suggests a potential role of Homoeopathy in managing infertility, particularly in situations where conventional therapeutic approaches have been unsatisfactory. This evidence-based report serves to underline the effectiveness of homoeopathy in treating female infertility and the importance of further research to evaluate this approach's efficacy meticulously. It suggests that Homoeopathy might offer an alternative or adjunct to conventional treatment, characterized by cost-effectiveness, minimal invasive procedures, and alleviated risk of side-effects.
This document provides a review of laser vaginal rejuvenation. It discusses the historical background of vaginal tightening procedures dating back over 1000 years. It then outlines the modern development of vaginal rejuvenation as a marketed cosmetic procedure beginning in 2002. The document reviews the various types of vaginal rejuvenation procedures now offered and the laser technique in particular. It notes that while vaginal rejuvenation aims to enhance sexual function and appearance, the efficacy and safety of these procedures needs more research.
Similar to Empowering the vaginal atrophy dialogue multi_therapeutic2 (20)
This document discusses the diagnostic and treatment approaches to venous thromboembolism (VTE), which includes deep vein thrombosis (DVT) and pulmonary embolism (PE). It provides details on evaluating patients using Wells criteria and D-dimer testing to determine pre-test probability and decide between imaging with CT pulmonary angiogram or VQ scan. For confirmed VTE, treatment options include warfarin, novel oral anticoagulants (NOACs), inferior vena cava filters or thrombolytics. The document reviews best practices for treating isolated distal DVT, catheter-related thrombosis, and selecting appropriate long-term anticoagulation therapy.
1. Peak expiratory flow (PEF) monitoring is more useful for established asthma patients than for initial diagnosis.
2. Asthma control is lost if PEF drops below 80% of personal best or predicted value, or if diurnal PEF variation is over 20% over one week.
3. PEF should be measured sitting or standing using the best of three blows from maximum inhalation with less than two seconds pause before blowing.
The document discusses the "Allergic March" which refers to the predictable progression of allergic symptoms often seen in children, starting with atopic dermatitis, followed by allergic rhinitis, and then the potential development of asthma. It provides an overview of this concept, citing a source that describes the "Allergic March" as a series of common allergic conditions that can appear either individually or together and often correspond with increasing age.
1) α1-Antitrypsin deficiency is a genetic disorder characterized by low levels of α1-antitrypsin protein, which protects the lungs from damage. This predisposes patients to early-onset pulmonary disease like emphysema and COPD.
2) While α1-antitrypsin deficiency is one of the most common inherited conditions, affecting about 1 in 2000 to 5000 people, it often goes undiagnosed. Prompt diagnosis allows lifestyle changes and specific augmentation therapy to slow lung disease progression.
3) Augmentation therapy, administering weekly intravenous α1-antitrypsin protein supplements, can significantly reduce the decline in lung function for patients with α1-
This document provides information and guidance on billing for uninsured medical services provided by general practitioners in British Columbia. It discusses what constitutes uninsured and third party services, and how to appropriately bill WorkSafeBC, ICBC, and the Office of the Superintendent of Motor Vehicles for services provided. Examples are given for various common scenarios. Guidance is also provided on billing patients directly for other uninsured services like medical-legal reports, travel advice, and cosmetic procedures. The document stresses the importance of billing appropriately to avoid audit issues and to demonstrate the full value of medical services. It introduces the Society of General Practitioners' uninsured services billing package which is designed to assist physicians with uninsured billing.
This document outlines the vision and goals of the Patient's Medical Home (PMH) model in Canada. The PMH aims to establish family practices that serve as a patient-centered medical home, providing comprehensive and coordinated care for patients. It describes 10 goals of the PMH approach, including making every patient part of a practice with a personal family doctor, providing timely access to care, and supporting practices through governance and other stakeholders. The document also discusses insights from studies in the US and Canada on factors that can improve quality and lower costs within the PMH model.
Sat 0810-gallagher-end-of-life-care- -parkIhsaan Peer
This document discusses end of life care options in British Columbia from the perspective of Dr. Romayne Gallagher, a physician director of palliative care. It provides an overview of palliative care and its benefits compared to physician assisted dying. While palliative care aims to relieve suffering, physician assisted dying is not considered a part of palliative care by definitions from the WHO. The document outlines concerns about assessing mental competence for physician assisted dying and potential risks of legalizing the practice.
Dr. Kendall Ho presented his top 10 favorite health apps. He discussed criteria for selecting apps such as usefulness, ease of use, safety, cost, and privacy. Some of his top picks were My Fitness Pal for calorie and weight tracking, Sleep Time for sleep monitoring, Heart Rate for heart rate tracking, and Mindshift for managing anxiety. He encouraged both doctors and patients to consider using health apps and to communicate about them.
This document discusses an initial approach to investigating infertility. It emphasizes that accurately assessing ovarian reserve in all patients is critical, especially through anti-Mullerian hormone levels. Higher maternal age is associated with increased embryo aneuploidy rates and decreased fertility success. For patients with longstanding unexplained infertility, more intervention is generally needed beyond initial testing.
Sat 1420-prescribing-exercise- -arbutusIhsaan Peer
This document discusses prescribing exercise and physical activity. It outlines the many benefits of exercise, current guidelines for exercise duration and intensity, and findings that most adults and youth do not meet activity guidelines. While primary care providers are well positioned to counsel on physical activity, evidence suggests their efforts have modest effects. The document recommends assessing patients' activity levels using a physical activity vital sign, setting incremental goals, and providing community resources for support. Primary care providers can bill for conducting physical activity counseling.
Here are 3 additional references on subacute thyroiditis:
1. Fatourechi V. Subacute thyroiditis. Best Pract Res Clin Endocrinol Metab. 2011;25(2):265-275.
2. Fatourechi V, Aniszewski JP, Fatourechi GZ, et al. Clinical features and outcome of subacute thyroiditis in an incidence cohort: Olmsted County, Minnesota, study. J Clin Endocrinol Metab. 2003;88(5):2100-2105.
3. Kung AW, Pun KK. Subacute (de Quervain's) thyroiditis. Best Pract Res Clin Endocrinol Met
Sun 0900-discipline-the-trouble-with-time-outs-mac namara---parkIhsaan Peer
The document discusses the problems with using time-outs and separation-based discipline with children. It notes that facing separation has a profound emotional impact on children, especially younger ones, and can undermine the parent-child attachment relationship. While time-outs may seem effective at changing misbehavior, this is actually because the threat of separation triggers a child's innate need to maintain proximity with their caregiver. The document recommends alternative, attachment-based principles of discipline that focus on preserving the emotional connection between parent and child.
Sun 0945-acute-urinary-retention- -parkIhsaan Peer
This document discusses acute urinary retention (AUR) and its causes. It notes that AUR is a significant complication of benign prostatic hyperplasia (BPH) and can be precipitated by certain medications or acute changes. Risk factors include older age and larger prostate size. Studies show that alpha-blockers and 5-alpha reductase inhibitors can significantly reduce the risk of AUR. The document recommends urology referral for cases of AUR with hematuria or those that are unresolved.
1. The document provides an overview of four patient cases presenting with palpitations. It reviews the approach to evaluating patients with palpitations, including obtaining a history, ECG, Holter monitor or event monitor depending on symptom frequency.
2. For Case 1, a Holter monitor showed ventricular tachycardia, indicating a need for an ICD. Case 2's Holter demonstrated SVT, leading to ablation. Case 3's normal Holter did not explain symptoms but an event monitor was ordered due to underlying cardiomyopathy. Case 4 required further workup.
3. The document emphasizes correlating rhythms to symptoms to make a diagnosis, and considering risk of malignant arrhythmias to guide management.
This document summarizes key information from a medical report on prescribing dabigatran for a patient with renal impairment. It finds that for patients with a creatinine clearance of 15-30 mL/min, the recommended dose of dabigatran is 75 mg taken twice daily. Dabigatran is primarily cleared renally and its effects can be greater when renal impairment and P-gp inhibitors are combined. For patients on hemodialysis or with bleeding, dialysis can help reverse the effects of dabigatran. Clinical trials found dabigatran 110 mg and 150 mg doses were non-inferior to warfarin for stroke prevention in atrial fibrillation. The doctor
This document provides an overview of evaluating and treating migraines through a case study of a patient named Peter. It begins by introducing Peter and categorizing his headaches as migraines without aura based on the diagnostic criteria. It then discusses differentiating between primary and secondary headaches, classifying primary headaches, and diagnosing the specific disorder. The document outlines considerations for developing a treatment plan, including non-pharmacological and pharmacological acute and preventive options. It emphasizes the importance of individualizing treatment based on a patient's needs and goals of therapy.
Practical application of anticoagulation therapy af and vte april 12Ihsaan Peer
This document provides an overview of anticoagulation therapy for atrial fibrillation and venous thromboembolism. It discusses the risks of stroke in atrial fibrillation and limitations of warfarin therapy. It also summarizes trials comparing new oral anticoagulants such as dabigatran, rivaroxaban, and apixaban to warfarin. The document concludes that based on trial results, the new oral anticoagulants are preferred over warfarin for stroke prevention in atrial fibrillation according to Canadian guidelines.
DR Gill allergen immunotherapy apr 2nd, 2014Ihsaan Peer
This document provides an overview of allergen immunotherapy for primary care physicians. It discusses the epidemiology and pathophysiology of allergic rhinitis and guidelines for treatment, including the roles of subcutaneous immunotherapy and sublingual immunotherapy tablets. It reviews the long-term efficacy of immunotherapy in reducing asthma incidence and severity, preventing new sensitizations, and maintaining effects after discontinuation of treatment. It also provides details on administering subcutaneous immunotherapy and available sublingual immunotherapy tablet options.
The document discusses optimizing treatment for patients with post-menopausal osteoporosis (PMO) including identifying patients at high risk for fracture using tools like the CAROC guidelines, considering treatment for moderate risk patients based on certain risk factors, and evaluating treatment options based on mechanisms of action, efficacy, safety profiles, and patient preferences. The goal is to reduce fractures and their consequences through early diagnosis and appropriate evidence-based treatment.
“Psychiatry and the Humanities”: An Innovative Course at the University of Mo...Université de Montréal
“Psychiatry and the Humanities”: An Innovative Course at the University of Montreal Expanding the medical model to embrace the humanities. Link: https://www.psychiatrictimes.com/view/-psychiatry-and-the-humanities-an-innovative-course-at-the-university-of-montreal
Histololgy of Female Reproductive System.pptxAyeshaZaid1
Dive into an in-depth exploration of the histological structure of female reproductive system with this comprehensive lecture. Presented by Dr. Ayesha Irfan, Assistant Professor of Anatomy, this presentation covers the Gross anatomy and functional histology of the female reproductive organs. Ideal for students, educators, and anyone interested in medical science, this lecture provides clear explanations, detailed diagrams, and valuable insights into female reproductive system. Enhance your knowledge and understanding of this essential aspect of human biology.
Breast cancer: Post menopausal endocrine therapyDr. Sumit KUMAR
Breast cancer in postmenopausal women with hormone receptor-positive (HR+) status is a common and complex condition that necessitates a multifaceted approach to management. HR+ breast cancer means that the cancer cells grow in response to hormones such as estrogen and progesterone. This subtype is prevalent among postmenopausal women and typically exhibits a more indolent course compared to other forms of breast cancer, which allows for a variety of treatment options.
Diagnosis and Staging
The diagnosis of HR+ breast cancer begins with clinical evaluation, imaging, and biopsy. Imaging modalities such as mammography, ultrasound, and MRI help in assessing the extent of the disease. Histopathological examination and immunohistochemical staining of the biopsy sample confirm the diagnosis and hormone receptor status by identifying the presence of estrogen receptors (ER) and progesterone receptors (PR) on the tumor cells.
Staging involves determining the size of the tumor (T), the involvement of regional lymph nodes (N), and the presence of distant metastasis (M). The American Joint Committee on Cancer (AJCC) staging system is commonly used. Accurate staging is critical as it guides treatment decisions.
Treatment Options
Endocrine Therapy
Endocrine therapy is the cornerstone of treatment for HR+ breast cancer in postmenopausal women. The primary goal is to reduce the levels of estrogen or block its effects on cancer cells. Commonly used agents include:
Selective Estrogen Receptor Modulators (SERMs): Tamoxifen is a SERM that binds to estrogen receptors, blocking estrogen from stimulating breast cancer cells. It is effective but may have side effects such as increased risk of endometrial cancer and thromboembolic events.
Aromatase Inhibitors (AIs): These drugs, including anastrozole, letrozole, and exemestane, lower estrogen levels by inhibiting the aromatase enzyme, which converts androgens to estrogen in peripheral tissues. AIs are generally preferred in postmenopausal women due to their efficacy and safety profile compared to tamoxifen.
Selective Estrogen Receptor Downregulators (SERDs): Fulvestrant is a SERD that degrades estrogen receptors and is used in cases where resistance to other endocrine therapies develops.
Combination Therapies
Combining endocrine therapy with other treatments enhances efficacy. Examples include:
Endocrine Therapy with CDK4/6 Inhibitors: Palbociclib, ribociclib, and abemaciclib are CDK4/6 inhibitors that, when combined with endocrine therapy, significantly improve progression-free survival in advanced HR+ breast cancer.
Endocrine Therapy with mTOR Inhibitors: Everolimus, an mTOR inhibitor, can be added to endocrine therapy for patients who have developed resistance to aromatase inhibitors.
Chemotherapy
Chemotherapy is generally reserved for patients with high-risk features, such as large tumor size, high-grade histology, or extensive lymph node involvement. Regimens often include anthracyclines and taxanes.
Know the difference between Endodontics and Orthodontics.Gokuldas Hospital
Your smile is beautiful.
Let’s be honest. Maintaining that beautiful smile is not an easy task. It is more than brushing and flossing. Sometimes, you might encounter dental issues that need special dental care. These issues can range anywhere from misalignment of the jaw to pain in the root of teeth.
Computer in pharmaceutical research and development-Mpharm(Pharmaceutics)MuskanShingari
Statistics- Statistics is the science of collecting, organizing, presenting, analyzing and interpreting numerical data to assist in making more effective decisions.
A statistics is a measure which is used to estimate the population parameter
Parameters-It is used to describe the properties of an entire population.
Examples-Measures of central tendency Dispersion, Variance, Standard Deviation (SD), Absolute Error, Mean Absolute Error (MAE), Eigen Value
Giloy in Ayurveda - Classical Categorization and SynonymsPlanet Ayurveda
Giloy, also known as Guduchi or Amrita in classical Ayurvedic texts, is a revered herb renowned for its myriad health benefits. It is categorized as a Rasayana, meaning it has rejuvenating properties that enhance vitality and longevity. Giloy is celebrated for its ability to boost the immune system, detoxify the body, and promote overall wellness. Its anti-inflammatory, antipyretic, and antioxidant properties make it a staple in managing conditions like fever, diabetes, and stress. The versatility and efficacy of Giloy in supporting health naturally highlight its importance in Ayurveda. At Planet Ayurveda, we provide a comprehensive range of health services and 100% herbal supplements that harness the power of natural ingredients like Giloy. Our products are globally available and affordable, ensuring that everyone can benefit from the ancient wisdom of Ayurveda. If you or your loved ones are dealing with health issues, contact Planet Ayurveda at 01725214040 to book an online video consultation with our professional doctors. Let us help you achieve optimal health and wellness naturally.
PGx Analysis in VarSeq: A User’s PerspectiveGolden Helix
Since our release of the PGx capabilities in VarSeq, we’ve had a few months to gather some insights from various use cases. Some users approach PGx workflows by means of array genotyping or what seems to be a growing trend of adding the star allele calling to the existing NGS pipeline for whole genome data. Luckily, both approaches are supported with the VarSeq software platform. The genotyping method being used will also dictate what the scope of the tertiary analysis will be. For example, are your PGx reports a standalone pipeline or would your lab’s goal be to handle a dual-purpose workflow and report on PGx + Diagnostic findings.
The purpose of this webcast is to:
Discuss and demonstrate the approaches with array and NGS genotyping methods for star allele calling to prep for downstream analysis.
Following genotyping, explore alternative tertiary workflow concepts in VarSeq to handle PGx reporting.
Moreover, we will include insights users will need to consider when validating their PGx workflow for all possible star alleles and options you have for automating your PGx analysis for large number of samples. Please join us for a session dedicated to the application of star allele genotyping and subsequent PGx workflows in our VarSeq software.
NAVIGATING THE HORIZONS OF TIME LAPSE EMBRYO MONITORING.pdfRahul Sen
Time-lapse embryo monitoring is an advanced imaging technique used in IVF to continuously observe embryo development. It captures high-resolution images at regular intervals, allowing embryologists to select the most viable embryos for transfer based on detailed growth patterns. This technology enhances embryo selection, potentially increasing pregnancy success rates.
Pictorial and detailed description of patellar instability with sign and symptoms and how to diagnose , what investigations you should go with and how to approach with treatment options . I have presented this slide in my 2nd year junior residency in orthopedics at LLRM medical college Meerut and got good reviews for it
After getting it read you will definitely understand the topic.
- Video recording of this lecture in English language: https://youtu.be/Pt1nA32sdHQ
- Video recording of this lecture in Arabic language: https://youtu.be/uFdc9F0rlP0
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
Travel Clinic Cardiff: Health Advice for International TravelersNX Healthcare
Travel Clinic Cardiff offers comprehensive travel health services, including vaccinations, travel advice, and preventive care for international travelers. Our expert team ensures you are well-prepared and protected for your journey, providing personalized consultations tailored to your destination. Conveniently located in Cardiff, we help you travel with confidence and peace of mind. Visit us: www.nxhealthcare.co.uk
3. Disclosure of Commercial Support
This program has received financial support from
Novo Nordisk in the form of an educational grant
Potential for conflict(s) of interest:
Dr. Unjali Malhotra has received an honorarium from
Novo Nordisk whose product(s) are being discussed in
this program
Novo Nordisk distributes, licenses a product that will be
discussed in this program: Estradiol 10 μg (Vagifem® 10)
4. Mitigating Potential Bias
Material was developed and reviewed by
independent third-party experts who were
responsible for vetting the program’s needs
assessment results and subsequent content
development to ensure accuracy and fair balance
5. Learning Objectives
After this session, participants will be able to:
Describe the prevalence and pathophysiology of
vaginal atrophy
Discuss women’s attitudes about vaginal atrophy
Examine the effects of vaginal atrophy and its treatment
on intimate relationships
Manage vaginal atrophy using the latest treatment
recommendations
Counsel post-menopausal women about vaginal
atrophy and treatment options
6. Pre-Test Questions
1. In vaginal atrophy :
A. Vaginal pH decreases
B. Blood flow is maintained
C. Parabasal cells predominate in the epithelium
D. Inflammation is always absent
7. Pre-Test Questions
2. Post-menopausal Canadian women:
A. Have a good understanding of vaginal atrophy and its
associated symptoms
B. Are aware of the chronic nature of the condition
C. Are likely to use over-the-counter products before
discussing symptoms with their physicians
D. More than 40% would be willing to use local vaginal
estrogen to treat vaginal atrophy symptoms
E. All of the above
F. C and D
8. Pre-Test Questions
3. Local estrogen therapy:
A. Effectively manages symptoms
B. Reverses atrophic changes
C. Has a positive impact on intimate relationships
D. All of the above
E. A and B
9. Pre-Test Questions
4. How comfortable are you discussing
treatment options for vaginal atrophy with
post-menopausal women?
A. Very uncomfortable
B. Somewhat uncomfortable
C. Somewhat comfortable
D. Very comfortable
10. Prevalence of Vaginal Atrophy
Up to 75% of menopausal women may experience vaginal
atrophy symptoms1,2
Approximately 50% of post-menopausal women have vaginal
atrophy symptoms that impact on sexual function and quality of
life3
Despite its prevalence, vaginal atrophy is often not recognized
by women as a chronic condition
1/3 will not seek medical advice3
The taboo status surrounding vaginal atrophy means that many
women do not receive effective treatment
1. The North American Menopause Society. Menopause. 2007;14:357-369.
2. Labrie F, et al. Menopause. 2009;16:907-22.
3. Nappi RE, Kokot-Kierepa M. Climacteric. 2012;15:36-44.
11. IMS Recommendations: Background
Post-menopausal vaginal atrophy:
A common cause of distressing symptoms due to
estrogen deficiency
Poorly recognized by healthcare professionals
Should be diagnosed and treated promptly to avoid
cascade of events that do not resolve spontaneously
IMS, International Menopause Society.
Sturdee DW, Panay N. Climacteric. 2010;13:509-22.
12. Vaginal Atrophy Pathophysiology:
Effects of Declining Estrogen
Vaginal epithelium becomes thinner, vaginal
rugae diminish
Vaginal wall appears smoother
Colonization of the vagina by lactobacillus
decreases
Vaginal pH rises above 6
Blood flow is reduced
Vagina has pale appearance and may contain
small petechiae and/or other signs of inflammation
Sturdee DW, Panay N. Climacteric. 2010;13:509-22.
13. Vaginal Atrophy: Pathophysiology
Johnston SL. Geriatrics & Aging. 2002;5(7):9-15.
Vaginal environment before menopause Vaginal environment after estrogen loss
Ovaries produce less estrogen
(or none at all)Ovaries produce estrogen
The vaginal lining is thick and moist The vaginal lining becomes thin and dry
There is
decreased blood
flow to vaginal
tissues
There is good blood
flow to vaginal
tissues
Vaginal walls are elastic
Vaginal fluid is secreted during sexual activity
Vaginal elasticity decreases
There is less secretion of fluids during
sexual activity
The vagina narrows and shortens
14. Vaginal Atrophy Pathophysiology:
Cellular Changes
Thick, healthy,
well-estrogenized
lining of the vagina
in premenopausal women
Thin, dry lining of vagina
due to menopause
(after estrogen loss)
superficial
parabasal
intermediate
The North American Menopause Society. Menopause. 2007;14:357-69.
After menopause, there is an increase in
parabasal and intermediate cells and a
substantial decrease in superficial cells
Intermediate and superficial cells
predominate in premenopausal
women; minimal parabasal cells
16. Viva Survey Results: What Do Post-menopausal
Canadian Women Know About Vaginal Atrophy?
Most women thought vaginal dryness, itching,
burning, soreness, or pain during intercourse were
merely symptoms of menopause
Only 7% of Canadian women associated these
symptoms with vaginal atrophy
VIVA, Vaginal Health: Insights, Views & Attitudes.
Frank SM, et al. Menopause Int. 2012 Nov 30. [Epub ahead of print]
17. VIVA Survey Results: How Many Women
Experience Symptoms of Vaginal Atrophy?
VIVA, Vaginal Health: Insights, Views & Attitudes.
Frank SM, et al. Menopause Int. 2012 Nov 30. [Epub ahead of print]
50% of Canadian women experienced vaginal symptoms
59% rated these symptoms as moderate or severe
18. Discussion Question
Which of the following is not a symptom of
vaginal atrophy?
A.Dryness
B.Incontinence
C.Pain during intercourse
D.Itching
E.Vaginal discharge
F.All are symptoms of vaginal atrophy
19. Recognizing the Symptoms of
Vaginal Atrophy
The most common vaginal atrophy symptoms reported in
the IMS recommendations1
are the same as those reported
by women in the VIVA survey2
Dryness (estimated 75%)1
Dyspareunia (estimated 38%)1
Vaginal itching, discharge, pain (estimated 15%)1
Urinary symptoms associated with vaginal atrophy:1
Dysuria, nocturia, and urgency
Urinary incontinence
Recurrent urinary tract infections
IMS, International Menopause Society. VIVA, Vaginal Health: Insights, Views & Attitudes.
1. Sturdee DW, Panay N. Climacteric. 2010;13:509-22.
2. Nappi RE, Kokot-Kierepa M. Climacteric. 2012;15:36-44.
20. VIVA Survey Results: Which Symptoms of Vaginal
Atrophy Do Canadian Women Experience?
VIVA, Vaginal Health: Insights, Views & Attitudes.
Frank SM, et al. Menopause Int. 2012 Nov 30. [Epub ahead of print]
Dryness was by far the most commonly experienced symptom
of vaginal atrophy
21. In Her Own Words…
About Her Symptoms
Play video
Joan Boone
TRANSCRIPT OF VIDEO CLIP: “Vaginal atrophy has so many symptoms, but not every woman has
every symptom. The ones I had were dryness, a loss of natural moisturizer; I had painful intercourse,
and I had really just the driest feeling, so it was uncomfortable.”
23. IMS Recommendations: Be Aware That
Women Are Suffering in Silence
Women are often reluctant to consult/complain about
vaginal atrophy, and they may feel their doctors are also
uninterested or uncomfortable talking about this issue1,2
The Canadian cohort of the VIVA survey also
demonstrated this3
IMS, International Menopause Society. VIVA, Vaginal Health: Insights, Views & Attitudes.
1. Sturdee DW, Panay N. Climacteric. 2010;13:509-22.
2. Nappi RE, Kokot-Kierepa M. Climacteric. 2012;15:36-44.
3. Frank SM, et al. Menopause Int. 2012 Nov 30. [Epub ahead of print]
“We don’t have a pink Viagra for women,” says Dr. Rossella Nappi.
“… maybe it’s less easy to treat VA because it’s easy to speak about
ED, and it’s not so easy to talk about VA. We should talk about ED
and VA together for a better life of the couple.” ZOOMER Magazine, March 2013
24. Canadian Women Are Suffering in Silence
52% of women with
vaginal atrophy waited
≥6 months before seeing
a healthcare provider
56% of women
experiencing vaginal
atrophy had symptoms
≥3 years
Length of time women experienced
symptoms of vaginal discomfort
Frank SM, et al. Menopause Int. 2012 Nov 30. [Epub ahead of print]
25. CLOSER Survey Results: Effects of Vaginal
Atrophy on How a Woman Feels About Herself
51% of women felt upset that their body doesn’t work
as well anymore
41% of women felt they had lost their youth
33% of women were concerned that vaginal atrophy
would never go away
27% women had lost confidence in themselves
as a sexual partner and no longer felt
sexually attractive
CLOSER, CLarifying Vaginal Atrophy’s Impact On SEx and Relationships.
Nappi RE. European Menopause and Andropause Society (EMAS) Annual Congress, March 2012.
Gingras L, et al. SOGC 68th
Annual Conference. June 2012. Poster 486.
26. 58%
49%
35%
23%
62%61%
28%
14%
22%
76%
0%
10%
20%
30%
40%
50%
60%
70%
80%
Less sex Less satisfying
sex
Put off having
sex
Stopped
having sex
altogether
Avoided
intimacy
Respondents,%
Women
Men
CLOSER, CLarifying Vaginal Atrophy’s Impact On SEx and Relationships.
Gingras L, et al. SOGC 68th
Annual Conference. June 2012. Poster 486.
CLOSER Survey: Effects of Vaginal Discomfort
on Intimate Relationships (Canadian Data)
27. VIVA Survey Results: Who Would Canadian
Women Turn to if They Experienced Vaginal
Discomfort?
60% of women were comfortable discussing
vaginal atrophy with their doctor
72% of Canadian women would talk to their
primary care physician if they experienced vaginal
discomfort
30% would speak to their gynecologist
The Physician-Patient conversation about
vaginal atrophy needs to be routine
VIVA, Vaginal Health: Insights, Views & Attitudes.
Frank SM, et al. Menopause Int. 2012 Nov 30. [Epub ahead of print]
29. IMS Recommendations:
Getting the Conversation Started
Talk about vaginal dryness since patients may be reluctant to
do so1
Consider that relationship/sexual issues may present as
vaginal discomfort1
In the CLOSER Survey, 27% of Canadian women said vaginal
atrophy made them lose confidence in themselves as a sexual
partner2
Remember that women using systemic estrogen can still
develop vaginal atrophy symptoms1
Some urinary symptoms occur concurrently with vaginal
atrophy and also respond positively to vaginal estrogen
therapy1
IMS, International Menopause Society.
1. Sturdee DW, Panay N. Climacteric. 2010;13:509-22.
2. Gingras L, et al. SOGC 68th
Annual Conference. June 2012. Poster 486.
30. IMS Recommendations:
Getting the Conversation Started
Ask questions such as:
“Around the time of menopause, some women may
experience vaginal dryness, which may make intercourse
uncomfortable. Have you noticed this type of change?”
Be sensitive to the presence of an able sexual partner
“Are you bothered by vaginal itching or vaginal burning?”
“Have you noticed a change in vaginal discharge?”
“Do you sometimes or often have vaginal yeast infections?”
“Do you sometimes or often have urinary tract infections?”
“Have you ever taken any vaginal lubricants or moisturizers
to relieve vaginal dryness or itching?”
IMS, International Menopause Society.
Sturdee DW, Panay N. Climacteric. 2010;13:509-22.
31. VIVA Survey Results: Canadian Women More Likely to
Use OTC Products Than Treat Underlying Cause
HRT, hormone replacement therapy. OTC, over-the-counter. VIVA, Vaginal Health: Insights, Views & Attitudes.
Frank SM, et al. Menopause Int. 2012 Nov 30. [Epub ahead of print]
32. IMS Recommendations and
VIVA Survey: Treatment Options
Women need to be informed about effective
treatment options for vaginal atrophy1
VIVA survey data revealed women’s lack of
knowledge about treatment options
Close to 1 in 10 women believed there is no effective
treatment for vaginal discomfort2
In Canada, 42% of women were unaware of local
estrogen treatments3
IMS, International Menopause Society. VIVA, Vaginal Health: Insights, Views & Attitudes.
1. Sturdee DW, Panay N. Climacteric. 2010;13:509-22.
2. Nappi RE, Kokot-Kierepa M. Climacteric. 2012;15:36-44.
3. Frank SM, et al. Menopause Int. 2012 Nov 30. [Epub ahead of print]
33. VIVA Survey Results: Canadian Women Willing
to Try Effective Treatment That Maintains
Normal Hormone Levels
Only 32% would consider systemic hormone replacement
therapy
43% were willing to try local estrogen treatment (LET)
24% undecided about using LET
65% Canadian women did not expect return to the vagina
of their youth, but would welcome greater comfort
VIVA, Vaginal Health: Insights, Views & Attitudes.
Frank SM, et al. Menopause Int. 2012 Nov 30. [Epub ahead of print]
35. IMS and SOGC Recommendations:
Vaginal Moisturizers and Lubricants
Vaginal lubricants
May be recommended for subjective symptom improvement of dyspareunia
(Level IIIC evidence)1
Do not reverse vaginal atrophy1
Are non-physiological2
Give temporary symptom relief, often followed by vaginal irritation2
Vaginal moisturizers
Polycarbophil gel is an effective treatment for symptoms of vaginal atrophy,
including dryness and dyspareunia (Level IA evidence)1
Improve lubrication2
Do not reverse vaginal atrophy3
Are less effective than topical estrogen therapy2
Are useful for women who cannot take hormones2
IMS, International Menopause Society. SOGC, Society of Obstetricians and Gynaecologists of Canada.
1. Society of Obstetricians and Gynaecologists of Canada. J Obstet Gynaecol Can. 2009;31(1 Suppl 1):S27-S30.
2. Sturdee DW, Panay N. Climacteric. 2010;13:509-22.
3. Bélisle S, et al; Menopause Guidelines Committee. J Obstet Gynaecol Can. 2006;28(2 Suppl 1):S7-S94.
36. IMS Recommendations: Principles of
Local Estrogen Therapy
Restore urogenital physiology1-3
Estrogen therapy lowers vaginal pH, thickens the epithelium,
increases blood flow, improves vaginal lubrication1
Alleviate symptoms1-3
Most women will obtain substantial relief from their
symptoms after about 3 weeks of treatment1
Some women may require 4–6 weeks before adequate
improvement is observed1
These principles are also supported by NAMS and SOGC2,3
IMS, International Menopause Society. NAMS, North American Menopause Society. SOGC, Society of Obstetricians and Gynaecologists of Canada.
1. Sturdee DW, Panay N. Climacteric. 2010;13:509-22.
2. North American Menopause Society. Menopause. 2007;14(Pt 1):357-69.
3. Bélisle S, et al; Menopause Guidelines Committee. J Obstet Gynaecol Can. 2006;28(2 Suppl 1):S7-S94.
37. IMS Recommendations:
Local Estrogen Therapy
Local estrogen therapy is preferable for vaginal atrophy when
systemic treatment is not needed for other reasons
Systemic and local therapy may be initially required for some
women
Local therapy avoids most systemic adverse events and is
probably more efficacious for vaginal problems
IMS, International Menopause Society.
Sturdee DW, Panay N. Climacteric. 2010;13:509-22.
Vaginal cream with applicator Intravaginal ring
Vaginal tablet with applicator
38. SOGC Recommendations:
Local Estrogen Therapy
SOGC Clinical Practice Guidelines
Conjugated estrogen cream, an intravaginal
sustained-release estradiol ring, or estradiol vaginal
tablets can be recommended as effective
treatment for vaginal atrophy (Level IA)
Vaginal estrogen therapy can be recommended for
the prevention of recurrent urinary tract
infections in post-menopausal women (Level IA)
SOGC, Society of Obstetricians and Gynaecologists of Canada.
Society of Obstetricians and Gynaecologists of Canada. J Obstet Gynaecol Can. 2009;31(1 Suppl 1):S27-S30.
39. Vaginal Atrophy Treatment: Local
Estrogen Therapies Available in Canada
Formulation Vaginal Tablet Vaginal Cream Vaginal Ring
Estrogen type
(trade name)
Estradiol 10 μg
(Vagifem®
10)1
Conjugated estrogens
0.625 mg/g (Premarin®
)2
Estrone 0.1%
(Estragyn®
)3
17 ß-Estradiol 2 mg
(Estring™)4
Dose • 1 vaginal tablet • Start at 0.5 g daily dose
strength
• Dose adjustments (0.5
to 2 g) may be made
based on individual
response
• 2.0 to 4.0 g per
day
• 1 ring/3 months
Dosage • Initial: daily for 2 weeks
• Maintenance: twice a
week with a 3-4 day
interval between doses
• Daily for 21 days, then 7
days off
• Daily for 25 days,
then 5 days off
• 1 ring should remain
inserted in the vagina
for 90 days
Administration • Each tablet is in a pre-
loaded applicator ready
to be inserted into the
vagina
• Cream needs to be squeezed into the
applicator and dose measured prior to
administration
• 1 ring inserted into
the vagina
1. Vagifem®
10 product monograph. 2010. 2. Premarin®
product monograph. 2012. 3. Estragyn®
product monograph. 2011; 4. Estring™ product monograph. 2009.
5. Sturdee DW, Panay N. Climacteric. 2010;13:509-22. 6. Rioux JE, et al. Menopause. 2000;7(3):156-61. 7. Ayton RA, et al. Br J Obstet Gynaecol. 1996;103(4):351-8.
All local estrogen preparations are effective5
Patient preference usually determines treatment used5
Patients prefer vaginal tablets and rings over cream6,7
40. Local Estrogen Therapy:
Effect on Vaginal Epithelium
Improvement in vaginal epithelium maturation
LOCF, last observation carried forward.
Simon J, et al. Obstet Gynecol. 2008;112(5):1053-60.
*
*
**
* **
* * *
*
* * * *
*
*
*p<0.001 10 µg estradiol vs. placebo. **p=0.007 10 µg estradiol vs. placebo.
Placebo 10 µg Estradiol 2
41. Local Estrogen Therapy:
Effect on pH
pH <5 = grade 0 (no vaginal atrophy)
pH 5–5.49 = grade 1 (mild vaginal atrophy)
pH 5.5–6.49 = grade 2 (moderate vaginal atrophy)
pH >6.49 = grade 3 (severe vaginal atrophy)
P-values describe comparisons of the change from baseline between treatment groups.
LOCF, last observation carried forward.
1. Vagifem®
10 product monograph. 2010.
2. Simon JA, et al. 18th Annual Meeting of the North American Menopause Society (NAMS). 2008.
Improvement (lowering) of vaginal pH
42. Local Estrogen Therapy:
Effect on Vaginal Health
Grading vaginal health
Evaluations of:
Vaginal secretions
Epithelial integrity
Epithelial surface thickness
Vaginal colour
Vaginal pH
Coded on 4-point scale:
No atrophy = 0
Mild atrophy = 1
Moderate atrophy = 2
Severe atrophy = 3
Simon J, et al. Obstet Gynecol. 2008;112(5):1053-60.
43. Local Estrogen Therapy:
Effect on Vaginal Health
P-values describe comparisons of the change from baseline between treatment groups.
LOCF, Last observation carried forward.
Simon J, et al. Obstet Gynecol. 2008;112(5):1053-60.
Improvement in vaginal health
p<0.001
p<0.001
p<0.001 p<0.001
p<0.001
44. Local Estrogen Therapy:
Effect on Bothersome Symptoms
p=0.053
p=0.014 p=0.003 p=0.004
P-values describe comparisons of the change from baseline between treatment groups.
LOCF, Last observation carried forward.
Simon J, et al. Obstet Gynecol. 2008;112(5):1053-60.
Change in most bothersome symptom score
0.0
0.5
1.0
1.5
2.0
2.5
Baseline 2 4 8 12 (LOCF) 52 (LOCF)
Meanscore
Mostbothersomesymptom
Weeks
Placebo 10 µg Estradiol 2
45. Local Estrogen Therapy: Effects on Sex
Life (CLOSER Survey, Canadian Data)
Canadian women with vaginal atrophy reported that
since starting local estrogen therapy:
Sex was less painful (58%)
Sex was more satisfying for them personally (43%)
They were more optimistic about the future of their sex life
(33%)
Their sex life had improved (32%)
Canadian men reported that since their partner started
local estrogen therapy for vaginal atrophy:
Sex was less painful (58%)
They look forward to having sex (59%)
CLOSER, CLarifying Vaginal Atrophy’s Impact On SEx and Relationships.
Gingras L, et al. SOGC 68th
Annual Conference. June 2012. Poster 486.
46. Local Estrogen Therapy: Effects on Sex
Life (CLOSER Survey, Canadian Data)
CLOSER, CLarifying Vaginal Atrophy’s Impact On SEx and Relationships.
Gingras L, et al. SOGC 68th
Annual Conference. June 2012. Poster 486.
47. In Her Own Words…
About Her Treatment
Play Video
Joan Boone
TRANSCRIPT OF VIDEO CLIP: “I find that it’s treated all my symptoms, it’s improved my vaginal health,
it’s improved my home life with my husband because I’m not having the same kind of problems that I
was previously.”
48. For Discussion
Which of the following conditions is not a
contraindication for treatment with local
estrogen therapy?
A.Undiagnosed vaginal/uterine bleeding
B.Interstitial cystitis
C.Known or suspected endometrial cancer
D.Other hormone-sensitive cancers
49. Local Estrogen Therapy:
Contraindications
Treatment is contraindicated in patients with:
Undiagnosed vaginal/uterine bleeding
Known or suspected endometrial cancer
Other hormone-sensitive cancers
Sturdee DW, Panay N. Climacteric. 2010;13:509-22.
50. Local Estrogen Therapy:
Adverse Effects
Few adverse events
Vaginal discharge, itching, irritation, and pelvic pain may be
more common with creams
Systemic effects are uncommon
Endometrial hyperplasia and breast tenderness may be
more common with creams
Women need to report vaginal bleeding and breast
tenderness, as these side effects are not anticipated with
low-dose vaginal therapy
Sturdee DW, Panay N. Climacteric. 2010;13:509-22.
51. Local Estrogen Therapy (LET):
Adverse Effects (cont’d)
No evidence of increase in VTEs with use of LET1
No evidence of increase in metastases in breast cancer
survivors using LET1
For women with a history of hormone-dependent cancer:
Management should depend on patient preference in
consultation with oncologist2
For women treated for non-hormone-dependent cancer:
Management of vaginal atrophy is similar to that for women
without a cancer history2
Data insufficient to recommend annual endometrial
surveillance in asymptomatic women2
VTE, venous thromboembolism.
1. Sturdee DW, Panay N. Climacteric. 2010;13:509-22.
2. The North American Menopause Society. Menopause. 2007;14:357-69.
52. Local Estrogen Therapy:
Is Progestin Required?
SOGC Clinical Practice Guidelines:1
Routine progestin co-therapy is not required for endometrial
protection in women receiving vaginal estrogen therapy in
appropriate dose (IIIC)
IMS recommendations:2
Conjugated estrogen and estradiol vaginal preparations may
stimulate the endometrium in a dose-related manner
Appropriate use of low doses of local estrogen does not
require additional progestin for endometrial protection
IMS, International Menopause Society. SOGC, Society of Obstetricians and Gynaecologists of Canada.
1. Society of Obstetricians and Gynaecologists of Canada. J Obstet Gynaecol Can. 2009;31(1 Suppl 1):S27-S30.
2. Sturdee DW, Panay N. Climacteric. 2010;13:509-22.
53. Local Estrogen Therapy:
Treatment Duration
There are no guidelines for therapy duration1
There are limited data on use of local estrogen beyond 6 months
Symptoms commonly return when treatment is
discontinued1
If long-term therapy is going to be implemented, low-dose
therapy should be used1
Women need to be informed that long-term treatment may
be needed1
In the VIVA survey, more than 6 in 10 women did not know that
vaginal atrophy is a chronic condition2
Treatment failure should mandate further evaluation1
VIVA, Vaginal Health: Insights, Views & Attitudes.
1. Sturdee DW, Panay N. Climacteric. 2010;13:509-22.
2. Nappi RE, Kokot-Kierepa M. Climacteric. 2012;15:36-44.
54. IMS Key Treatment Recommendations
1. Start treatment early, before irrevocable atrophic changes
have occurred
2. Continued treatment is needed to maintain the benefits
1. All local estrogen preparations are effective
2. Patient preference will usually determine the treatment
that is used
IMS, International Menopause Society.
Sturdee DW, Panay N. Climacteric. 2010;13:509-22.
55. IMS Key Treatment Recommendations
5. Additional progestin is not indicated when appropriate
low-dose, local estrogen is used, although long-term data
(more than 1 year) are lacking
6. If estrogen is ineffective or undesired, vaginal lubricants
and moisturizers can relieve symptoms due to dryness
7. It is essential that healthcare providers routinely engage
in open and sensitive discussions with post-menopausal
women about their urogenital health to ensure that
symptomatic atrophy is detected early and managed
appropriately
IMS, International Menopause Society.
Sturdee DW, Panay N. Climacteric. 2010;13:509-22.
56. Summary: Key Learning Points
Vaginal atrophy is a common, chronic condition that can have a
significant effect on a woman’s quality of life
Women suffer in silence, are reluctant to initiate a dialogue about their
symptoms, and are unaware that effective treatments are available
There is a need to normalize this condition
Treatment with local estrogen is simple and safe and can transform a
woman’s quality of life including intimate relationships
43% of Canadian women are open to treatment with local estrogen
therapy that maintains normal hormone levels
Physicians need to routinely discuss and effectively manage the
symptoms of vaginal atrophy in post-menopausal women
57. Post-Test Questions
1. In vaginal atrophy:
A. Vaginal pH decreases
B. Blood flow is maintained
C. Parabasal cells predominate in the epithelium
D. Inflammation is always absent
58. Post-Test Questions
2. Post-menopausal Canadian women:
A. Have a good understanding of vaginal atrophy and its
associated symptoms
B. Are aware of the chronic nature of the condition
C. Are likely to use over-the-counter products before
discussing symptoms with their physicians.
D. More than 40% would be willing to use local vaginal
estrogen to treat vaginal atrophy symptoms
E. All of the above
F. C and D
59. Post-Test Questions
3. Local estrogen therapy:
A. Effectively manages symptoms
B. Reverses atrophic changes
C. Has a positive impact on intimate relationships
D. All of the above
E. A and B
60. Post-Test Questions
4. How comfortable are you discussing
treatment options for vaginal atrophy with
post-menopausal women?
A. Very uncomfortable
B. Somewhat uncomfortable
C. Somewhat comfortable
D. Very comfortable
Editor's Notes
References
North American Menopause Society. The role of local vaginal estrogen for treatment of vaginal atrophy in postmenopausal women: 2007 position statement of The North American Menopause Society. Menopause. 2007;14(3):357-369.
Labrie F, Archer D, Bouchard C, et al. Intravaginal dehydroepiandrosterone (Prasterone), a physiological and highly efficient treatment of vaginal atrophy. Menopause. 2009;16(5):907-922.
Nappi RE, Kokot-Kierepa M. Vaginal Health: Insights, Views & Attitudes (VIVA) – results from an international survey. Climacteric. 2012;15:36-44.
Reference
Sturdee DW, Panay N. The International Menopause Society Writing Group. Recommendations for the management of postmenopausal vaginal atrophy. Climacteric. 2010;13:509-22.
Reference
Sturdee DW, Panay N. The International Menopause Society Writing Group. Recommendations for the management of postmenopausal vaginal atrophy. Climacteric. 2010;13:509-522.
Vaginal environment before menopause and after estrogen loss.
After the loss of estrogen:
Vaginal epithelium becomes thinner
Vaginal rugae diminish
Vaginal wall appears smoother
Vagina has pale appearance and may contain small petechiae and/or other signs of inflammation
Vaginal elasticity is reduced
Vaginal secretions decrease
Reference
Johnston SL. The Recognition and Management of Atrophic Vaginitis. Geriatrics & Aging. 2002; 5(7):9-15.
Changes to the lining of the vagina occur with menopause.
Estrogen levels decrease during and after menopause, resulting in cytological changes:
Proportion of parabasal cells increase
Proportion of superficial cells decrease
Lining of the vagina becomes thin and pale
Vaginal walls also become smoother and less elastic due to decreasing rugal folds
Reference
North American Menopause Society (NAMS). The role of local vaginal estrogen for treatment of vaginal atrophy in postmenopausal women: 2007 position statement of The North American Menopause Society. Menopause. 2007;14(3):357-69.
References
Frank SM, Ziegler C, Kokot-Kierepa M, et al. Vaginal Health: Insights, Views & Attitude (VIVA) survey – Canadian cohort. Menopause Int. 2012 Nov 30. [Epub ahead of print]
Nappi RE, Kokot-Kierepa M. Vaginal Health: Insights, Views & Attitudes (VIVA) – results from an international survey. Climacteric. 2012;15:36-44.
Reference
Frank SM, Ziegler C, Kokot-Kierepa M, et al. Vaginal Health: Insights, Views & Attitude (VIVA) survey – Canadian cohort. Menopause Int. 2012 Nov 30. [Epub ahead of print]
References
Sturdee DW, Panay N. The International Menopause Society Writing Group. Recommendations for the management of postmenopausal vaginal atrophy. Climacteric. 2010;13:509-22.
Nappi RE, Kokot-Kierepa M. Vaginal Health: Insights, Views & Attitudes (VIVA) – results from an international survey. Climacteric. 2012;15:36-44.
Reference
Frank SM, Ziegler C, Kokot-Kierepa M, et al. Vaginal Health: Insights, Views & Attitude (VIVA) survey – Canadian cohort. Menopause Int. 2012 Nov 30. [Epub ahead of print]
References
Sturdee DW, Panay N. The International Menopause Society Writing Group. Recommendations for the management of postmenopausal vaginal atrophy. Climacteric. 2010;13:509-22.
Nappi RE, Kokot-Kierepa M. Vaginal health: Insights, Views & Attitudes (VIVA) – results from an international survey. Climacteric. 2012;15:36-44.
Frank SM, Ziegler C, Kokot-Kierepa M, et al. Vaginal Health: Insights, Views & Attitude (VIVA) survey – Canadian cohort. Menopause Int. 2012 Nov 30. [Epub ahead of print]
Reference
Frank SM, Ziegler C, Kokot-Kierepa M, et al. Vaginal Health: Insights, Views & Attitude (VIVA) survey – Canadian cohort. Menopause Int. 2012 Nov 30. [Epub ahead of print]
References
Nappi RE. CLarifying vaginal atrophy’s impact On SEx and Relationships (CLOSER). European Menopause and Andropause Society (EMAS) Annual Congress, March 2012.
Gingras L, Moreau M, Manno P, et al. Impact of vulvovaginal atrophy on postmenopausal women and their partners: The Partner’s Survey. SOGC 68th Annual Conference, Ottawa, ON June 2012. Poster 486. Available at: http://posterdocuments.com/posters/v/id/486. Accessed March 17, 2013.
Reference
Gingras L, Moreau M, Manno P, et al. Impact of vulvovaginal atrophy on postmenopausal women and their partners: The Partner’s Survey. SOGC 68th Annual Conference, Ottawa, ON June 2012. Poster 486. Available at: http://posterdocuments.com/posters/v/id/486. Accessed March 17, 2013.
Reference
Frank SM, Ziegler C, Kokot-Kierepa M, et al. Vaginal Health: Insights, Views & Attitude (VIVA) survey – Canadian cohort. Menopause Int. 2012 Nov 30. [Epub ahead of print]
References
Sturdee DW, Panay N; The International Menopause Society Writing Group. Recommendations for the management of postmenopausal vaginal atrophy. Climacteric. 2010;13:509-22.
Gingras L, Moreau M, Manno P, et al. Impact of vulvovaginal atrophy on postmenopausal women and their partners: The Partner’s Survey. SOGC 68th Annual Conference, Ottawa, ON June 2012. Poster 486. Available at: http://posterdocuments.com/posters/v/id/486. Accessed March 17, 2013.
References
Sturdee DW, Panay N; The International Menopause Society Writing Group. Recommendations for the management of postmenopausal vaginal atrophy. Climacteric. 2010;13:509-22.
Frank SM, Ziegler C, Kokot-Kierepa M, et al. Vaginal Health: Insights, Views & Attitude (VIVA) survey – Canadian cohort. Menopause Int. 2012 Nov 30. [Epub ahead of print]
Reference
Frank SM, Ziegler C, Kokot-Kierepa M, et al. Vaginal Health: Insights, Views & Attitude (VIVA) survey – Canadian cohort. Menopause Int. 2012 Nov 30. [Epub ahead of print]
References
Sturdee DW, Panay N; The International Menopause Society Writing Group. Recommendations for the management of postmenopausal vaginal atrophy. Climacteric. 2010;13:509-22.
Nappi RE, Kokot-Kierepa M. Vaginal Health: Insights, Views & Attitudes (VIVA) – results from an international survey. Climacteric. 2012;15:36-44.
Frank SM, Ziegler C, Kokot-Kierepa M, et al. Vaginal Health: Insights, Views & Attitude (VIVA) survey – Canadian cohort. Menopause Int. 2012 Nov 30. [Epub ahead of print]
Reference
Frank SM, Ziegler C, Kokot-Kierepa M, et al. Vaginal Health: Insights, Views & Attitude (VIVA) survey – Canadian cohort. Menopause Int. 2012 Nov 30. [Epub ahead of print]
References
Society of Obstetricians and Gynaecologists of Canada. Chapter 5 – Urogenital Health. In: Menopause and Osteoporosis Update 2009. J Obstet Gynaecol Can. 2009;31(1 Suppl 1):S27-S30.
Sturdee DW, Panay N; The International Menopause Society Writing Group. Recommendations for the management of postmenopausal vaginal atrophy. Climacteric. 2010;13:509-22.
Bélisle S, Blake J, Basson R, et al; Menopause Guidelines Committee. Canadian Consensus Conference on Menopause, 2006 update. J Obstet Gynaecol Can. 2006;28(2 Suppl 1):S7-S94.
References
Sturdee DW, Panay N; The International Menopause Society Writing Group. Recommendations for the management of postmenopausal vaginal atrophy. Climacteric. 2010;13:509-22.
North American Menopause Society (NAMS). The role of local vaginal estrogen for treatment of vaginal atrophy in postmenopausal women: 2007 position statement of The North American Menopause Society. Menopause. 2007;14(3):357-369.
Bélisle S, Blake J, Basson R, et al; Menopause Guidelines Committee. Canadian Consensus Conference on Menopause, 2006 update. J Obstet Gynaecol Can. 2006;28(2 Suppl 1):S7-S94.
Reference
Sturdee DW, Panay N; The International Menopause Society Writing Group. Recommendations for the management of postmenopausal vaginal atrophy. Climacteric. 2010;13:509-22.
Reference
Society of Obstetricians and Gynaecologists of Canada. Menopause and Osteoporosis Update 2009. J Obstet Gynaecol Can. 2009;31(1Suppl1):S27-S30.
References
Vagifem® 10 product monograph. Mississauga, ON: Novo Nordisk Canada Inc.; September 13, 2010.
Premarin® vaginal cream product monograph. Kirkland, QC: Pfizer Canada Inc.; February 20, 2012.
Estragyn® vaginal cream product monograph. Concord, ON: Triton Pharma Inc.; July 21, 2011.
Estring™ product monograph. Kirkland, QC: Pfizer Canada Inc.; June 29, 2009.
Sturdee DW, Panay N; The International Menopause Society Writing Group. Recommendations for the management of postmenopausal vaginal atrophy. Climacteric. 2010;13:509-22.
Rioux JE, Devlin C, Gelfand MM, et al. 17 β-estradiol vaginal tablet versus conjugated equine estrogen vaginal cream to relieve menopausal atrophic vaginitis. Menopause. 2000;7(3):156-61.
Ayton RA, Darling GM, Murkies AL, et al. A comparative study of safety and efficacy of continuous low-dose oestradiol released from a vaginal ring compared with conjugated equine oestrogen vaginal cream in the treatment of postmenopausal urogenital atrophy. Br J Obstet Gynaecol. 1996;103(4):351-8.
Reference
Simon J, Nachtigall L, Gut R, et al. Effective treatment of vaginal atrophy with an ultra–low-dose estradiol vaginal tablet. Obstet Gynecol. 2008;112(5):1053-60.
References
Vagifem 10 [product monograph]. Mississauga, Ontario: Novo Nordisk Canada Inc.; 2010.
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