The document discusses treatment of hot flashes. It begins with an introduction that describes the clinical manifestations, pathophysiology, rates, and risk factors of hot flashes. It then covers assessment methods and scoring systems used to evaluate hot flash severity. The majority of the document discusses treatment options, including both hormonal therapies like estrogen, progestin, and tibolone, as well as non-hormonal options such as SSRIs, gabapentin, and lifestyle changes. Estrogen, specifically, is described as the most effective treatment for reducing the frequency and severity of hot flashes.
India is the highest TB burden country accounting for more than one-fourth of the global incidence .Genital TB is found in 5-10% of women with infertility problems, with low rates in Australia (1%) and high rates of up to 19% in India (ICMR,2011)
Recurrent pregnancy loss is a significant redroductive medical problem, influencing 2%–5% of couples. ... Throughout the years, proof based medications, for example, surgical correction of uterine abnormalities or asprin and heparin for antiphospholipid syndrome have improved the results for couples with repetitive pregnancy loss.
Secondary amenorrhea is the absence of menses for more than three cycles or six months in women who previously had menses. Pregnancy is the most common cause. The document outlines the step-by-step process for evaluating secondary amenorrhea, including ruling out pregnancy, assessing medical history, performing a physical exam, basic lab tests, and follow-up testing and evaluation if initial results require further investigation. Treatment options are provided for common causes like hyperprolactinemia, ovarian failure, hyperandrogenism, and Asherman's syndrome.
This document discusses hydrosalpinx, which is a distended fallopian tube filled with fluid caused by distal blockage. The main causes are pelvic inflammatory disease from infections like chlamydia. Symptoms can include pelvic pain and infertility. Diagnosis involves ultrasound, HSG, CT or MRI. Treatment depends on whether fertility is desired. For fertility, salpingectomy before IVF improves live birth rates by removing toxic fluid. Tubal surgery may help mild cases. IVF is main treatment if fertility desired. Leaving a non-painful hydrosalpinx in situ is also an option if not trying to conceive.
1) Intrahepatic cholestasis of pregnancy (ICP) is a liver disorder that causes pruritus (itching) without a rash and occurs in the second half of pregnancy.
2) Diagnosis involves elevated fasting bile acids and liver enzymes as well as ruling out other causes. Ursodeoxycholic acid is the first line treatment to improve symptoms and liver function.
3) ICP can lead to fetal complications like stillbirth so careful monitoring and early delivery may be considered for severe cases. Management involves treatment with UDCA and rifampicin as well as lifestyle changes to reduce symptoms.
Urinary tract infections during pregnancy can cause complications if left untreated. There are several types of urinary tract infections that can occur, including asymptomatic bacteriuria, acute cystitis, and acute pyelonephritis. Left untreated, these infections have been linked to adverse outcomes like preterm birth and low birth weight. Proper diagnosis involves urine testing and culture. Treatment involves antibiotics, hydration, and pain medications when needed. Screening is important for detecting asymptomatic infections which can later cause issues if not treated.
India is the highest TB burden country accounting for more than one-fourth of the global incidence .Genital TB is found in 5-10% of women with infertility problems, with low rates in Australia (1%) and high rates of up to 19% in India (ICMR,2011)
Recurrent pregnancy loss is a significant redroductive medical problem, influencing 2%–5% of couples. ... Throughout the years, proof based medications, for example, surgical correction of uterine abnormalities or asprin and heparin for antiphospholipid syndrome have improved the results for couples with repetitive pregnancy loss.
Secondary amenorrhea is the absence of menses for more than three cycles or six months in women who previously had menses. Pregnancy is the most common cause. The document outlines the step-by-step process for evaluating secondary amenorrhea, including ruling out pregnancy, assessing medical history, performing a physical exam, basic lab tests, and follow-up testing and evaluation if initial results require further investigation. Treatment options are provided for common causes like hyperprolactinemia, ovarian failure, hyperandrogenism, and Asherman's syndrome.
This document discusses hydrosalpinx, which is a distended fallopian tube filled with fluid caused by distal blockage. The main causes are pelvic inflammatory disease from infections like chlamydia. Symptoms can include pelvic pain and infertility. Diagnosis involves ultrasound, HSG, CT or MRI. Treatment depends on whether fertility is desired. For fertility, salpingectomy before IVF improves live birth rates by removing toxic fluid. Tubal surgery may help mild cases. IVF is main treatment if fertility desired. Leaving a non-painful hydrosalpinx in situ is also an option if not trying to conceive.
1) Intrahepatic cholestasis of pregnancy (ICP) is a liver disorder that causes pruritus (itching) without a rash and occurs in the second half of pregnancy.
2) Diagnosis involves elevated fasting bile acids and liver enzymes as well as ruling out other causes. Ursodeoxycholic acid is the first line treatment to improve symptoms and liver function.
3) ICP can lead to fetal complications like stillbirth so careful monitoring and early delivery may be considered for severe cases. Management involves treatment with UDCA and rifampicin as well as lifestyle changes to reduce symptoms.
Urinary tract infections during pregnancy can cause complications if left untreated. There are several types of urinary tract infections that can occur, including asymptomatic bacteriuria, acute cystitis, and acute pyelonephritis. Left untreated, these infections have been linked to adverse outcomes like preterm birth and low birth weight. Proper diagnosis involves urine testing and culture. Treatment involves antibiotics, hydration, and pain medications when needed. Screening is important for detecting asymptomatic infections which can later cause issues if not treated.
1. Antiphospholipid syndrome (APS) is an autoimmune disorder characterized by arterial or venous thrombosis or pregnancy morbidity in the presence of antiphospholipid antibodies.
2. The diagnosis requires one clinical criterion of vascular thrombosis or pregnancy complications and one laboratory criterion of positive testing for antiphospholipid antibodies on two occasions at least 12 weeks apart.
3. Treatment during pregnancy involves low-dose aspirin and heparin starting at a positive pregnancy test through 34 weeks gestation to reduce the risk of pregnancy complications like miscarriage, preeclampsia, and intrauterine growth restriction.
1. The document discusses various methods for evaluating tubal patency in infertile patients, including hysterosalpingography (HSG), laparoscopy, and tests like Chlamydia antibody testing.
2. HSG is the most common screening test but has limitations like radiation exposure and false positives. Findings on HSG like mucosal rugae can provide prognostic information.
3. Laparoscopy allows direct visualization but is more invasive. It remains the gold standard for diagnosing conditions like endometriosis.
4. For treatment, IVF is now often preferred over surgery for moderate to severe tubal damage, while laparoscopic surgery may be considered for milder issues
The document discusses risks and management considerations for a woman who is pregnant again after a previous Cesarean section. It defines terms like Cesarean section, ERCS, VBAC, and TOLAC. It notes risks in the current pregnancy like abortion, preterm labor, and scar rupture. It explains that classical Cesarean scars are more difficult to appose than lower segment scars. The integrity of the scar must be assessed to determine whether a trial of labor is possible or an elective repeat Cesarean section is required based on factors like the previous surgery, complications, and interval since the last pregnancy. Management includes elective hospitalization from 36 weeks for classical scars or 38 weeks for lower segment sc
MANAGEMENT OF VAULT PROLAPSE BY DR SHASHWAT JANIDR SHASHWAT JANI
This document discusses the management of vault prolapse, which is the descent of the vaginal cuff after a hysterectomy. It defines vault prolapse and lists risk factors. Conservative management includes pessaries but surgery is often needed. Surgical options include vaginal approaches like sacrospinous ligament fixation or abdominal approaches like sacral colpopexy. The document compares techniques and factors to consider in surgical planning like prolapse severity and patient factors. Prevention techniques like culdoplasty at time of hysterectomy are also discussed.
This document discusses various skin conditions that can occur during pregnancy, categorized as physiologic changes, preexisting conditions exacerbated by pregnancy, and dermatoses specific to pregnancy. Some key conditions covered include melasma, striae gravidarum, pemphigoid gestationis (herpes gestationis), pruritic urticarial papules and plaques of pregnancy (PUPPP), intrahepatic cholestasis of pregnancy, impetigo herpetiformis, and atopic eruptions of pregnancy. Many of these conditions involve rashes or lesions on the abdomen and resolve after delivery, when hormone levels return to normal. Their management may involve topical or oral corticosteroids, anti
This document summarizes information about premature ovarian failure (POF). It defines POF as amenorrhea, hypoestrogenism, and elevated gonadotropins in women under age 40. POF prevalence is 1-4% under age 40, increasing to 1% by age 30 and 4% by age 40. Causes include genetic factors, autoimmunity, environmental exposures, infections, and iatrogenic factors. Symptoms include menopausal symptoms and long term risks of osteoporosis and cardiovascular disease. Diagnosis involves lab tests of hormones and imaging. Treatment is hormone replacement therapy. Annual follow up is needed to monitor treatment and screen for other related conditions.
This document discusses galactorrhea, which is the spontaneous flow of milk from the breasts in non-lactating women. It defines galactorrhea and outlines its causes, which can include inhibition of prolactin-inhibiting factor, stimulation of prolactin-releasing factor, increased prolactin production, drugs, hypothyroidism, and idiopathic factors. The document provides details on diagnostic evaluation, treatment options, medications used to treat hyperprolactinemia like bromocriptine, quinagolide, and cabergoline, and considerations for pregnancy and breastfeeding.
GENITAL TUBERCULOSIS - HOW TO DIAGNOSE & WHEN TO TREAT BY DR SHASHWAT JANIDR SHASHWAT JANI
This document discusses tuberculosis (TB) as a major threat in developing countries. It notes that 95% of TB cases occur in developing nations, with India having high rates of 40% of adults infected and 500,000 deaths annually. Diagnosis of female genital TB is challenging and requires a high index of suspicion along with investigations like imaging, endoscopy, biopsy and laboratory tests. Laparoscopy may reveal tubercles, adhesions and caseation. Proper diagnosis is important for effective treatment of this serious condition that threatens public health.
This document discusses systemic lupus erythematosus (SLE) during pregnancy. It notes that SLE occurs more frequently in women, especially during childbearing years. Pregnancy can cause flares in 40-60% of cases, most likely immediately postpartum. Good pregnancy outcomes require quiescent SLE for at least 6 months before conception with no active renal involvement or antiphospholipid antibodies. Management involves preconception counseling and multidisciplinary monitoring of disease activity and fetal wellbeing. Corticosteroids are the treatment of choice for flares.
This document provides an overview of endometrial carcinoma, including its epidemiology, risk and protective factors, classification, clinical presentation, diagnosis, staging, treatment, prognosis, and prevention. Endometrial carcinoma is the most common gynecological cancer and occurs most often in postmenopausal women. Risk factors include older age, early menarche, late menopause, nulliparity, obesity, and unopposed estrogen exposure. Treatment involves surgery, with additional chemotherapy, radiation, or hormonal therapy depending on the stage and grade of cancer. Prognosis depends on histologic grade and stage, with 5-year survival rates ranging from 83% for stage I to 27% for stage IV disease.
1) Recurrent pregnancy loss is defined as three or more consecutive pregnancy losses before 20 weeks of gestation. A thorough investigation should be conducted to identify potentially treatable causes.
2) Common etiological factors include uterine anomalies, immunological issues such as antiphospholipid syndrome, endocrine disorders such as thyroid disease or diabetes, genetic factors, and thrombophilic disorders.
3) Evaluation involves a detailed history, physical exam, ultrasound, hormonal and immunological testing. Uterine anomalies require hysteroscopy or laparoscopy. Treatment depends on the underlying cause but may include surgery, medication, lifestyle changes, or cerclage. The goal is to identify modifiable risk factors.
This document provides an overview of pruritis of pregnancy. It discusses several conditions that can cause pruritis during pregnancy including PUPPP (pruritic urticarial papules and plaques of pregnancy), PEMPHIGOID GESTATIONIS (herpes gestationis), and intrahepatic cholestasis of pregnancy. For each condition, it covers epidemiology, pathogenesis, clinical features, diagnosis, management, and prognosis. The document also reviews two literature studies on the prevalence and impact of pruritis during pregnancy, finding that approximately one-third of women experience pruritis and it can significantly reduce quality of life.
Asherman's syndrome is a condition characterized by fibrosis and/or adhesions of the endometrium that can also involve the myometrium. It is most commonly caused by overzealous postpartum curettage. Clinical features include menstrual disturbances, infertility, recurrent pregnancy loss, and pregnancy complications. Diagnosis is made through hysterosalpingography or hysteroscopy. Treatment involves hysteroscopic lysis of adhesions followed by use of balloon catheters or IUDs to separate endometrial walls and exogenous estrogen to promote re-epithelialization.
Premature ovarian failure is defined as ovarian failure occurring spontaneously before age 40. It is characterized by amenorrhea and elevated FSH and low estrogen levels. The incidence is approximately 1 in 1000 before age 30 and 1% just before age 40. Causes include genetic factors, autoimmune conditions, chemotherapy or radiation exposure, tuberculosis, smoking, and metabolic or surgical issues. Clinically, it presents with amenorrhea, hot flashes, and symptoms of low estrogen. Diagnosis is based on amenorrhea for 3 months and elevated FSH levels on two occasions one month apart. Management involves treating any underlying cause, hormone replacement therapy to prevent osteoporosis and cardiovascular disease, and in some cases ovulation induction or egg donation for
Presentation on the description of normal and abnormal uterine bleeding, menstrual cycle, FIGO classification with PALM-COEIN, common differentials of AUB, assessment, diagnosis, and management.
This document provides information on Asherman's syndrome (AS), including:
- AS is an acquired uterine condition caused by scarring inside the uterine cavity from procedures or infections.
- Diagnosis is via hysteroscopy or sonohysterography and symptoms include abnormal bleeding or infertility.
- Treatment involves removing adhesions via hysteroscopy or dilation and curettage, followed by measures to prevent re-adhesion and restoration of the endometrium with hormones or stem cells.
- Prevention focuses on avoiding unnecessary procedures inside the uterus that could cause scarring.
Pruritus affects upto 20% of pregnant women.
There are conditions unique to pregnancy that involve pruritus as a leading symptom.
This is called dermotoses of pregnancy.
May produce risk to mother and foetus.
Approach to skin lesions in pregnancy: Pruritus related to pregnancy, Pruritus not related to pregnancy
This document discusses menopausal hormone therapy (MHT), also known as hormone therapy (HT). It defines key terms and outlines the history and background of MHT, including findings from the Women's Health Initiative trial in the late 1990s that raised safety concerns and led to a decline in MHT use. The document discusses guidelines for evaluating candidates for MHT and outlines potential benefits and risks to consider for individual patients. It also provides tables listing FDA-approved MHT drug products available in the US, including oral, transdermal, and vaginal estrogen therapies alone or in combination with progestogens.
This document provides guidelines for the use of anti-D immunoglobulin (anti-D Ig) for Rhesus D prophylaxis. It discusses the history and pathogenesis of Rh isoimmunization, appropriate dosing and administration of anti-D Ig, sensitizing events requiring prophylaxis, and the implementation of routine antenatal anti-D prophylaxis programs. The guidelines aim to prevent RhD alloimmunization in RhD-negative women by outlining evidence-based best practices for anti-D Ig administration.
This document discusses the treatment of hot flashes. It begins by describing the clinical manifestations, pathophysiology, prevalence, and risk factors of hot flashes. It then discusses methods of assessing hot flash severity, including hot flash scores, the Greene Climacteric Score, and the Modified Kupperman Index. The main treatment approaches covered are hormonal therapies like estrogen, progestin, and tibolone, and non-hormonal options such as SSRIs, SNRIs, and complementary therapies. Hormonal therapies are generally the most effective treatment but have risks, so non-hormonal alternatives are considered when hormones are not appropriate.
1. The document reviews the impact of hysterectomy on sexual function based on various studies.
2. While hysterectomy was historically thought to impair sexuality, most studies found sexual function was unchanged or improved after hysterectomy.
3. Subtotal hysterectomy was associated with less impairment of sexual response than total hysterectomy and a reduction in dyspareunia.
1. Antiphospholipid syndrome (APS) is an autoimmune disorder characterized by arterial or venous thrombosis or pregnancy morbidity in the presence of antiphospholipid antibodies.
2. The diagnosis requires one clinical criterion of vascular thrombosis or pregnancy complications and one laboratory criterion of positive testing for antiphospholipid antibodies on two occasions at least 12 weeks apart.
3. Treatment during pregnancy involves low-dose aspirin and heparin starting at a positive pregnancy test through 34 weeks gestation to reduce the risk of pregnancy complications like miscarriage, preeclampsia, and intrauterine growth restriction.
1. The document discusses various methods for evaluating tubal patency in infertile patients, including hysterosalpingography (HSG), laparoscopy, and tests like Chlamydia antibody testing.
2. HSG is the most common screening test but has limitations like radiation exposure and false positives. Findings on HSG like mucosal rugae can provide prognostic information.
3. Laparoscopy allows direct visualization but is more invasive. It remains the gold standard for diagnosing conditions like endometriosis.
4. For treatment, IVF is now often preferred over surgery for moderate to severe tubal damage, while laparoscopic surgery may be considered for milder issues
The document discusses risks and management considerations for a woman who is pregnant again after a previous Cesarean section. It defines terms like Cesarean section, ERCS, VBAC, and TOLAC. It notes risks in the current pregnancy like abortion, preterm labor, and scar rupture. It explains that classical Cesarean scars are more difficult to appose than lower segment scars. The integrity of the scar must be assessed to determine whether a trial of labor is possible or an elective repeat Cesarean section is required based on factors like the previous surgery, complications, and interval since the last pregnancy. Management includes elective hospitalization from 36 weeks for classical scars or 38 weeks for lower segment sc
MANAGEMENT OF VAULT PROLAPSE BY DR SHASHWAT JANIDR SHASHWAT JANI
This document discusses the management of vault prolapse, which is the descent of the vaginal cuff after a hysterectomy. It defines vault prolapse and lists risk factors. Conservative management includes pessaries but surgery is often needed. Surgical options include vaginal approaches like sacrospinous ligament fixation or abdominal approaches like sacral colpopexy. The document compares techniques and factors to consider in surgical planning like prolapse severity and patient factors. Prevention techniques like culdoplasty at time of hysterectomy are also discussed.
This document discusses various skin conditions that can occur during pregnancy, categorized as physiologic changes, preexisting conditions exacerbated by pregnancy, and dermatoses specific to pregnancy. Some key conditions covered include melasma, striae gravidarum, pemphigoid gestationis (herpes gestationis), pruritic urticarial papules and plaques of pregnancy (PUPPP), intrahepatic cholestasis of pregnancy, impetigo herpetiformis, and atopic eruptions of pregnancy. Many of these conditions involve rashes or lesions on the abdomen and resolve after delivery, when hormone levels return to normal. Their management may involve topical or oral corticosteroids, anti
This document summarizes information about premature ovarian failure (POF). It defines POF as amenorrhea, hypoestrogenism, and elevated gonadotropins in women under age 40. POF prevalence is 1-4% under age 40, increasing to 1% by age 30 and 4% by age 40. Causes include genetic factors, autoimmunity, environmental exposures, infections, and iatrogenic factors. Symptoms include menopausal symptoms and long term risks of osteoporosis and cardiovascular disease. Diagnosis involves lab tests of hormones and imaging. Treatment is hormone replacement therapy. Annual follow up is needed to monitor treatment and screen for other related conditions.
This document discusses galactorrhea, which is the spontaneous flow of milk from the breasts in non-lactating women. It defines galactorrhea and outlines its causes, which can include inhibition of prolactin-inhibiting factor, stimulation of prolactin-releasing factor, increased prolactin production, drugs, hypothyroidism, and idiopathic factors. The document provides details on diagnostic evaluation, treatment options, medications used to treat hyperprolactinemia like bromocriptine, quinagolide, and cabergoline, and considerations for pregnancy and breastfeeding.
GENITAL TUBERCULOSIS - HOW TO DIAGNOSE & WHEN TO TREAT BY DR SHASHWAT JANIDR SHASHWAT JANI
This document discusses tuberculosis (TB) as a major threat in developing countries. It notes that 95% of TB cases occur in developing nations, with India having high rates of 40% of adults infected and 500,000 deaths annually. Diagnosis of female genital TB is challenging and requires a high index of suspicion along with investigations like imaging, endoscopy, biopsy and laboratory tests. Laparoscopy may reveal tubercles, adhesions and caseation. Proper diagnosis is important for effective treatment of this serious condition that threatens public health.
This document discusses systemic lupus erythematosus (SLE) during pregnancy. It notes that SLE occurs more frequently in women, especially during childbearing years. Pregnancy can cause flares in 40-60% of cases, most likely immediately postpartum. Good pregnancy outcomes require quiescent SLE for at least 6 months before conception with no active renal involvement or antiphospholipid antibodies. Management involves preconception counseling and multidisciplinary monitoring of disease activity and fetal wellbeing. Corticosteroids are the treatment of choice for flares.
This document provides an overview of endometrial carcinoma, including its epidemiology, risk and protective factors, classification, clinical presentation, diagnosis, staging, treatment, prognosis, and prevention. Endometrial carcinoma is the most common gynecological cancer and occurs most often in postmenopausal women. Risk factors include older age, early menarche, late menopause, nulliparity, obesity, and unopposed estrogen exposure. Treatment involves surgery, with additional chemotherapy, radiation, or hormonal therapy depending on the stage and grade of cancer. Prognosis depends on histologic grade and stage, with 5-year survival rates ranging from 83% for stage I to 27% for stage IV disease.
1) Recurrent pregnancy loss is defined as three or more consecutive pregnancy losses before 20 weeks of gestation. A thorough investigation should be conducted to identify potentially treatable causes.
2) Common etiological factors include uterine anomalies, immunological issues such as antiphospholipid syndrome, endocrine disorders such as thyroid disease or diabetes, genetic factors, and thrombophilic disorders.
3) Evaluation involves a detailed history, physical exam, ultrasound, hormonal and immunological testing. Uterine anomalies require hysteroscopy or laparoscopy. Treatment depends on the underlying cause but may include surgery, medication, lifestyle changes, or cerclage. The goal is to identify modifiable risk factors.
This document provides an overview of pruritis of pregnancy. It discusses several conditions that can cause pruritis during pregnancy including PUPPP (pruritic urticarial papules and plaques of pregnancy), PEMPHIGOID GESTATIONIS (herpes gestationis), and intrahepatic cholestasis of pregnancy. For each condition, it covers epidemiology, pathogenesis, clinical features, diagnosis, management, and prognosis. The document also reviews two literature studies on the prevalence and impact of pruritis during pregnancy, finding that approximately one-third of women experience pruritis and it can significantly reduce quality of life.
Asherman's syndrome is a condition characterized by fibrosis and/or adhesions of the endometrium that can also involve the myometrium. It is most commonly caused by overzealous postpartum curettage. Clinical features include menstrual disturbances, infertility, recurrent pregnancy loss, and pregnancy complications. Diagnosis is made through hysterosalpingography or hysteroscopy. Treatment involves hysteroscopic lysis of adhesions followed by use of balloon catheters or IUDs to separate endometrial walls and exogenous estrogen to promote re-epithelialization.
Premature ovarian failure is defined as ovarian failure occurring spontaneously before age 40. It is characterized by amenorrhea and elevated FSH and low estrogen levels. The incidence is approximately 1 in 1000 before age 30 and 1% just before age 40. Causes include genetic factors, autoimmune conditions, chemotherapy or radiation exposure, tuberculosis, smoking, and metabolic or surgical issues. Clinically, it presents with amenorrhea, hot flashes, and symptoms of low estrogen. Diagnosis is based on amenorrhea for 3 months and elevated FSH levels on two occasions one month apart. Management involves treating any underlying cause, hormone replacement therapy to prevent osteoporosis and cardiovascular disease, and in some cases ovulation induction or egg donation for
Presentation on the description of normal and abnormal uterine bleeding, menstrual cycle, FIGO classification with PALM-COEIN, common differentials of AUB, assessment, diagnosis, and management.
This document provides information on Asherman's syndrome (AS), including:
- AS is an acquired uterine condition caused by scarring inside the uterine cavity from procedures or infections.
- Diagnosis is via hysteroscopy or sonohysterography and symptoms include abnormal bleeding or infertility.
- Treatment involves removing adhesions via hysteroscopy or dilation and curettage, followed by measures to prevent re-adhesion and restoration of the endometrium with hormones or stem cells.
- Prevention focuses on avoiding unnecessary procedures inside the uterus that could cause scarring.
Pruritus affects upto 20% of pregnant women.
There are conditions unique to pregnancy that involve pruritus as a leading symptom.
This is called dermotoses of pregnancy.
May produce risk to mother and foetus.
Approach to skin lesions in pregnancy: Pruritus related to pregnancy, Pruritus not related to pregnancy
This document discusses menopausal hormone therapy (MHT), also known as hormone therapy (HT). It defines key terms and outlines the history and background of MHT, including findings from the Women's Health Initiative trial in the late 1990s that raised safety concerns and led to a decline in MHT use. The document discusses guidelines for evaluating candidates for MHT and outlines potential benefits and risks to consider for individual patients. It also provides tables listing FDA-approved MHT drug products available in the US, including oral, transdermal, and vaginal estrogen therapies alone or in combination with progestogens.
This document provides guidelines for the use of anti-D immunoglobulin (anti-D Ig) for Rhesus D prophylaxis. It discusses the history and pathogenesis of Rh isoimmunization, appropriate dosing and administration of anti-D Ig, sensitizing events requiring prophylaxis, and the implementation of routine antenatal anti-D prophylaxis programs. The guidelines aim to prevent RhD alloimmunization in RhD-negative women by outlining evidence-based best practices for anti-D Ig administration.
This document discusses the treatment of hot flashes. It begins by describing the clinical manifestations, pathophysiology, prevalence, and risk factors of hot flashes. It then discusses methods of assessing hot flash severity, including hot flash scores, the Greene Climacteric Score, and the Modified Kupperman Index. The main treatment approaches covered are hormonal therapies like estrogen, progestin, and tibolone, and non-hormonal options such as SSRIs, SNRIs, and complementary therapies. Hormonal therapies are generally the most effective treatment but have risks, so non-hormonal alternatives are considered when hormones are not appropriate.
1. The document reviews the impact of hysterectomy on sexual function based on various studies.
2. While hysterectomy was historically thought to impair sexuality, most studies found sexual function was unchanged or improved after hysterectomy.
3. Subtotal hysterectomy was associated with less impairment of sexual response than total hysterectomy and a reduction in dyspareunia.
The document discusses the management of overactive bladder for gynecologists. It defines overactive bladder based on symptoms of urgency, with or without urge incontinence, usually with frequency and nocturia. It notes that overactive bladder significantly impacts quality of life through physical, psychological, social, sexual, and occupational problems. Treatment options include lifestyle changes, behavioral therapy, medications, minimally invasive procedures, and surgery. Common medications used are anticholinergic agents like trospium chloride, oxybutynin, tolterodine, solifenacin, and darifenacin.
50% of women ovulate using clomiphene citrate (CC) at a dosage of 50 mg/day, while another 25% ovulate if the dosage is increased to 100 mg/day. Most CC-induced pregnancies occur within the first 3 cycles. There is no benefit to increasing the dosage once ovulation occurs or continuing CC for more than 6 months. CC should be discontinued if a patient remains anovulatory after the dosage has been increased to 100 mg over 3 consecutive cycles. Metformin, aromatase inhibitors like letrozole, and adjuvants including N-acetyl cysteine and corticosteroids can be considered as alternatives or adjuvants to CC for ovulation induction in women who do not respond to
Clomiphene citrate or aromatase inhibitors for superovulation in women with u...Aboubakr Elnashar
Clomiphene citrate or aromatase inhibitors for
superovulation in women with unexplained infertility
undergoing intrauterine insemination:
a prospective
randomized trial
This document discusses prediction and prevention of ovarian hyperstimulation syndrome (OHSS) in non-IVF cycles. It defines OHSS and describes its degrees of severity. Risk factors for OHSS include polycystic ovary syndrome (PCOS) history and high antral follicle count (AFC) or anti-Müllerian hormone (AMH) levels. Prevention strategies discussed include using a low-dose gonadotropin protocol, monitoring estrogen levels and ultrasound findings closely, triggering with a gonadotropin-releasing hormone agonist instead of hCG, and administering hydroxyethyl starch or cabergoline. The document emphasizes that primary prevention through risk assessment and modified stimulation protocols is crucial to avoiding
This document discusses abnormal uterine bleeding (AUB). It defines AUB and normal menstruation. It describes various clinical types of AUB and potential causes. Evaluation involves history, examination, and investigations. Treatment options include medical approaches like hormonal therapies and surgical procedures like endometrial ablation. Dysfunctional uterine bleeding is discussed in depth as the most common cause of AUB.
This document discusses different types of ovarian stimulation protocols used in IVF. It begins by describing 4 main types of stimulation: natural/modified natural cycles involving little to no medication; mild stimulation involving low dose FSH/HMG; conventional stimulation using standard FSH/HMG doses; and high stimulation. It then covers the drugs used for ovarian stimulation, including gonadotropins and GnRH analogues. The rest of the document discusses specific GnRH agonist and antagonist protocols, methods of triggering ovulation including hCG and GnRH agonists, and criteria for cycle cancellation.
Hepatitis B in Pregnancy discusses the epidemiology, natural history, transmission, impact on pregnancy, and management of HBV infection during pregnancy. It notes that perinatal transmission is the primary mode of HBV transmission in many areas. The document recommends immunoprophylaxis for infants using HBIG and vaccination to reduce transmission risk from 70-90% to 5-10%. For HBV-infected women, antiviral therapy late in pregnancy can further lower transmission risk, though does not ensure prevention. Correct infant immunization allows for breastfeeding.
The document discusses luteal phase support (LPS) in assisted reproductive technology (ART) cycles. It notes that abnormal luteal function can occur after controlled ovarian stimulation, necessitating LPS. It reviews various LPS options including human chorionic gonadotropin and progesterone administered via different routes. Vaginal progesterone is found to effectively increase endometrial levels while intramuscular progesterone yields the highest serum levels. The document concludes that LPS is necessary to optimize ART outcomes and that intramuscular or vaginal progesterone are equally effective options.
The document discusses infertility issues for women over 40. It notes that 15% of women now delay childbearing until after age 40. Ovarian aging leads to a decline in both egg quantity and quality with increasing female age. After age 40, evaluation should include tests of ovarian reserve like AMH, AFC, and FSH. IVF is the best treatment option for these women, though success rates decline sharply after age 43. Oocyte donation is the only effective treatment for infertility caused by declining egg quality due to age.
This document discusses transvaginal ultrasound assessment of the female reproductive system for infertility diagnosis and treatment. It covers evaluation of the uterus, including endometrial thickness, uterine anomalies, fibroids, adenomyosis, and other abnormalities. It also discusses ovarian assessment including volume, antral follicle count, polycystic ovary syndrome, cysts, and diminished ovarian reserve. Key diagnostic features of structures like the corpus luteum are also summarized. The document provides guidance on using ultrasound to evaluate infertility and monitor treatment.
This document discusses screening and treatment strategies for cervical intraepithelial neoplasia (CIN). It recommends a see-and-treat single visit approach using cryotherapy, cold coagulation, or LEEP for lesions suggestive of significant CIN. Ablative treatments like cryotherapy are preferred for lesions entirely in the ectocervix while excisional treatments like LEEP are used for endocervical lesions or when histology is needed. Cold coagulation and LEEP have high success rates of over 95% for treating CIN while maintaining low risks. The document provides details on techniques, eligibility criteria, advantages, and disadvantages of different screening, diagnostic and treatment approaches for CIN.
The document discusses the tension-free vaginal tape (TVT) procedure for stress urinary incontinence. It provides details on TVT techniques, outcomes, and complications from various studies. TVT was found to have high success rates of 80-90% in curing or improving stress urinary incontinence, including in recurrent cases and those with intrinsic sphincter deficiency. Complication rates for TVT were low, with bladder perforation being the most common issue. TVT was also found to improve urge incontinence symptoms in some mixed incontinence cases. The results indicate TVT is an effective and lasting minimally invasive treatment for stress urinary incontinence.
Oocyte retrieval involves three key steps:
1) Anesthetizing the patient using either conscious sedation with a paracervical block or general anesthesia. 2) Guiding an ultrasound-monitored needle into each follicle to aspirate the follicular fluid and oocyte. 3) Using a suction pump set to 90-120 mmHg for mature follicles and 40-60 mmHg for immature follicles to aspirate the fluid and oocyte without damaging the cumulus-oocyte complex. Precautions like antibiotics and monitoring for bleeding are important to minimize risks of complications.
The document discusses different surgical procedures for treating female stress urinary incontinence (SUI), including tension-free vaginal tape (TVT) and transobturator tape (TOT). It summarizes studies comparing the two procedures, finding that TOT has fewer complications than TVT, as it does not require penetrating the retropubic space. However, both procedures are shown to be safe and effective treatments for SUI, with high patient satisfaction and cure rates.
This document provides an overview of ultrasonography of the normal and abnormal uterus. It describes the techniques, anatomy, measurements, and appearances of the uterus throughout the menstrual cycle. Common abnormalities such as fibroids, adenomyosis, endometrial polyps and cancers are outlined. Details on evaluating the endometrium, myometrium, cervical abnormalities and intrauterine devices are provided. Ultrasonography is an important tool for assessing the uterus but has limitations and often requires correlation with clinical history and other imaging modalities.
This document discusses monitoring of the ART (assisted reproductive technology) cycle. It describes various methods for monitoring, including ultrasound to measure follicle growth and endometrial thickness, as well as using ultrasound combined with serum estradiol levels. The key objectives of monitoring are outlined, such as predicting ovarian response, monitoring pituitary suppression, evaluating gonadotropin dose, preventing OHSS, determining the optimal time for hCG administration, and avoiding cycle cancellation. Indicators for when to adjust gonadotropin dosage or cancel the cycle are provided. Ultrasound is identified as the most practical monitoring method and combining it with estradiol is particularly useful for high-risk patients.
1) Embryo transfer is the final step in IVF where embryos are placed in the uterus. Careful technique is important for success.
2) Factors that can affect the success of embryo transfer include embryo selection, the timing of the transfer, cervical infections, endometrial thickness and pattern, and experience of the provider.
3) During the procedure, gentle technique, ultrasound guidance, and depositing embryos slightly below the uterine fundus can help maximize the chances of implantation and pregnancy. Meticulous attention to factors before, during, and after embryo transfer is crucial.
This document defines premenstrual syndrome and discusses its prevalence, etiology, diagnosis, and management. Some key points include:
- PMS involves physical, psychological, and behavioral symptoms that occur during the luteal phase of the menstrual cycle and go away during menstruation.
- About 15% of women have no PMS symptoms, 50% have mild symptoms, 30% have moderate symptoms, and 5-10% have severe symptoms.
- Management includes lifestyle changes, dietary supplements, exercise, stress reduction, hormonal treatments, antidepressants, and in severe cases, surgery. Cognitive behavioral therapy provides long-term benefits.
This document discusses the management of various medical conditions that are commonly associated with infertility and may impact assisted reproductive technology (ART) outcomes. It covers conditions like obesity, polycystic ovary syndrome, diabetes, thyroid disease, and systemic lupus erythematosus. For each condition, it provides guidance on evaluation, treatment optimization before ART, protocols for ovarian stimulation, monitoring during ART cycles, prevention of ovarian hyperstimulation syndrome, and management during pregnancy. The goal is to counsel patients, minimize health risks, and improve the success rates of ART for patients with these associated conditions.
A 55-year-old man was found unconscious at home after ingesting kratom and alcohol. At the emergency department, he was comatose with low vital signs. Treatment with naloxone had no effect. He was given supportive care and woke up 10 hours later, admitting to ingesting kratom and whiskey. Kratom contains compounds that are opioid receptor agonists and can cause respiratory depression, especially in combination with alcohol. Supportive care is the primary treatment for kratom toxicity.
A 55-year-old man was found unconscious at home after ingesting kratom and alcohol. At the emergency department, he was comatose with low vital signs. Treatment with naloxone had no effect. He was given supportive care and woke up 10 hours later, admitting to ingesting kratom and whiskey. Kratom contains compounds that are opioid receptor agonists and can cause respiratory depression, especially in combination with other depressants like alcohol.
This document discusses the history and physiology of labor analgesia. It provides an overview of the controversy around pain relief during labor and outlines both non-pharmacological and pharmacological options. Regional techniques like epidural analgesia are highlighted as the most effective methods with minimal effects on the fetus when used properly. The goals of labor analgesia and factors to consider when selecting drugs and techniques are also summarized.
This document provides an overview of menopause, including definitions, physiological changes, diagnosis, and treatments. It discusses the average age of menopause and influential factors. It defines menopause, premature ovarian failure, and the menopausal transition period. It then covers changes to the hypothalamus-pituitary-ovarian axis, ovaries, endometrium, central thermoregulation, and other areas. It provides details on evaluating abnormal uterine bleeding and discusses treatment options like hormone replacement therapy, antidepressants, clonidine, gabapentin, and complementary therapies.
Menopause is the permanent cessation of menstrual periods, occurring on average at age 51. Hormone therapy can relieve menopausal symptoms but carries risks like endometrial cancer and blood clots. Options include oral or transdermal estrogen with or without progestin. Non-hormonal treatments include black cohosh, exercise, and lifestyle changes. Hormone therapy is generally recommended for short-term use to treat moderate to severe symptoms.
This document provides an overview of an integrative fertility enhancement program that takes a holistic approach. It discusses evaluating and treating causes of infertility using acupuncture, herbal medicine, lifestyle changes, and integrating with conventional fertility treatments. The two main phases are preparation to treat underlying imbalances and a trial phase to promote ovulation and uterine lining growth. Treatment protocols address stress, hormones, menstrual cycles and specific conditions. Research supports acupuncture for improving fertility and IVF outcomes.
This document discusses different types of headaches and their treatment. It begins by defining primary and secondary headaches. Primary headaches include tension headaches, migraines, and cluster headaches. Migraines can be triggered by various factors and cause nausea. Secondary headaches have an underlying cause like head trauma. Treatment discussed includes acetaminophen, NSAIDs, and lifestyle changes. Medication overuse headaches are also addressed. The document provides guidance on treating specific headache types and exclusions for self-treatment.
This patient likely has chronic tension-type headache. The key features are bilateral, pressing quality pain not worsened by activity and no associated nausea, visual changes or neurologic deficits. Stress is a common trigger. Naproxen provides relief indicating an inflammatory component. Preventive options include amitriptyline or tizanidine.
1) Normal body temperature is around 36.8°C orally, with variations throughout the day and based on factors like age, sex, and meal consumption. Common sites to take a temperature include the mouth, axilla, rectum and ear.
2) A fever is defined as a temperature above the normal daily variation that occurs with an increased hypothalamic set point. Types of fevers include continuous, intermittent, remittent, relapsing, and irregular.
3) Hyperthermia differs from fever in that the hypothalamic set point is unchanged, resulting in an uncontrolled rise in body temperature beyond what the body can dissipate. Causes include heat stroke, certain drug reactions, and
This document discusses alternatives to hormone replacement therapy for menopausal symptoms. It notes that 36% of adults in the U.S. use some form of alternative therapy and 46% of women use alternative therapies for menopausal symptoms. Some alternatives discussed include lifestyle changes like diet, exercise, and smoking cessation. Herbal supplements like black cohosh and St. John's Wort are mentioned as well as acupuncture, stress reduction techniques, and homeopathy. However, the document states that many alternative therapies have not been well-studied and there is a lack of evidence about their efficacy and safety.
Patient preparation before IVF involves counseling, evaluation of fertility factors, and management of associated conditions. Key parts of the evaluation include semen analysis, tests of ovarian reserve like AMH, and ultrasound exams. Conditions like obesity, diabetes, thyroid disease, and endometriosis must be addressed prior to starting IVF treatment to optimize outcomes. Hysteroscopy is not routinely recommended before the first IVF cycle but may be beneficial for women with recurrent implantation failure.
The thyroid gland is located in the neck and produces the hormones T4 and T3, which facilitate growth, metabolism, and other functions. Hypothyroidism occurs when there is underproduction of thyroid hormones, while hyperthyroidism is overproduction. Common causes include Graves' disease, multinodular goiter, or toxic adenoma. Treatment depends on the specific condition but may involve antithyroid drugs, radioactive iodine, or surgery to control thyroid hormone levels. Precise diagnosis and ongoing monitoring are important for effective management of thyroid disorders.
This document provides guidelines for the management of premenstrual syndrome (PMS). It defines PMS and classifies it according to the International Society for Premenstrual Disorders (ISPMD) consensus. Core premenstrual disorders are the most common type. The document discusses the prevalence, etiology, diagnosis and treatment of PMS, including complementary therapies, cognitive behavioral therapy, hormonal treatments like combined oral contraceptives, and non-hormonal medications like SSRIs. Treatment is often multidisciplinary and aims to reduce symptoms and improve quality of life.
This document discusses integrative fertility enhancement treatments including acupuncture and herbal medicine. It covers topics like the human reproductive system, hormones involved in the menstrual cycle, fertility enhancement programs with two phases of treatment, objectives and protocols for each phase, hormonal imbalances, causations of infertility, individualized treatment plans, food and herbal recommendations, prenatal vitamins, and male factors of infertility.
This document provides an overview of an integrative fertility enhancement program that uses acupuncture and herbal medicine. The program has two phases - a preparation phase to treat causes of infertility, and a trial phase to promote ovarian function and increase uterine lining. The document discusses hormonal imbalances, causes of infertility according to traditional Chinese medicine, individualized treatment plans, protocols for stress relief and stimulating follicles, and how acupuncture and herbal medicine can benefit fertility and IVF outcomes.
This document discusses SLE (systemic lupus erythematosus) and infertility. It notes that SLE commonly affects women of childbearing age and can impact fertility through several mechanisms, including disease activity, medications like cyclophosphamide that may cause ovarian failure, and hormonal or renal issues. The document provides details on evaluating and managing infertility risks for SLE patients, such as using lower doses of cyclophosphamide or gonadotropin-releasing hormone agonists to protect fertility, and outlines fertility preservation and assisted reproduction options while controlling lupus disease activity and other risks. The conclusion emphasizes the need to consider how to minimize all factors that may increase infertility risk when managing reproductive-aged women with SLE.
WHAT IS NEW IN ESHRE 2022 AND FIGO 2022 FOR GENERAL GYNAECOLOGISTAboubakr Elnashar
The document summarizes key information from the ESHRE 2022 and FIGO 2022 conferences. It discusses several topics including:
- The ESHRE conference included 97 sessions with 317 oral and 801 poster presentations.
- The FIGO classification system for ovulatory disorders was updated, categorizing disorders into 4 types based on their hypothalamic, pituitary, ovarian, or PCOS origin.
- Subtle distal fallopian tube abnormalities may be treated with laparoscopy, leading to a 46.58% natural pregnancy rate.
- Children born after frozen embryo transfer have a higher risk of childhood cancer than those born after fresh embryo transfer or spontaneously.
1. Hepatitis B in pregnancy can impact both mother and child. Vertical transmission from mother to child is a major risk, occurring in 30% of cases without intervention.
2. Diagnosis involves screening all pregnant women for HBsAg. For HBsAg positive mothers, further testing of HBV DNA viral load, HBeAg status, and liver enzymes can assess risk of transmission.
3. Prevention of mother-to-child transmission focuses on antiviral therapy starting at 28 weeks for mothers with high viral load, administration of HBIG and HBV vaccines within 12 hours of birth, and completion of the vaccine series for the infant.
Hepatitis C and pregnancy can affect both mother and fetus. While pregnancy does not typically affect the course of HCV infection, HCV can increase maternal risks like gestational diabetes and postpartum hemorrhage. It may also increase fetal risks such as preterm delivery and low birthweight. Management includes screening all pregnant women for HCV, treating the mother if needed to reduce viral load and risk of transmission, and monitoring the fetus for complications. Delivery by cesarean is not routinely recommended, and breastfeeding is considered safe if nipples are intact.
A 32-year-old woman presented with primary infertility of 1.5 years. Ultrasound and MRI findings indicated adenomyosis. Adenomyosis can be associated with infertility by decreasing chances of conception and increasing risk of miscarriage. The patient underwent failed ovulation induction and IUI cycles. The document discusses recommended treatment protocols including IVF with a long agonist or antagonist protocol, as well as potential surgical options like conservative surgery if additional IVF cycles fail. Conservative surgery may improve fertility in women under 40 who desire future pregnancy.
The document is a lecture on the treatment of endometriosis-associated infertility according to 2022 ESHRE guidelines. It discusses various treatment options including medical treatment with hormonal therapies, surgery, assisted reproductive technologies (ART), and fertility preservation. Key recommendations include that ovarian suppression should not be used to improve fertility. Surgery and ART may be considered depending on the stage of endometriosis and patient factors. Extensive counseling is recommended when discussing fertility preservation options.
This document summarizes guidelines for managing adnexal masses from the SOGC in 2020. It discusses examining patients with adnexal masses through history, physical exam, investigations including ultrasound, lab tests, cancer antigen 125 levels, and the risk of malignancy index. Ultrasound is emphasized for distinguishing benign from malignant features, with IOTA criteria outperforming RMI. Referral to a gynecologic oncologist is recommended for suspected malignancy based on sonographic features, family history, clinical findings or indeterminate ultrasound results.
This document discusses controversies in aesthetic gynecology procedures. It begins by defining aesthetic gynecology as procedures that alter female genital appearance or structure for non-medical reasons. The document then outlines the increasing popularity of these procedures in recent years. It notes both opponents and proponents of these procedures and their differing views on issues like patient autonomy and lack of evidence. The document concludes by summarizing various medical organizations' ethical guidelines, which state that the safety and effectiveness of many aesthetic gynecology procedures have not been established and caution is warranted.
This document discusses a lecture on hormonal assays in clinical gynecology given by Prof. Aboubakr Elnashar. It provides information on various hormones including prolactin, TSH, AMH, FSH, LH, estrogens, progesterone, and androgens. For each hormone, the document discusses their source, reference ranges, clinical uses, and conditions they may be associated with. It also provides summaries of key points about each hormone test and their roles in evaluating endocrine conditions like infertility, menstrual disorders, and menopause.
1. The document discusses the routine care and special considerations for antenatal care (ANC) of pregnancies achieved through in vitro fertilization (IVF).
2. Special considerations for IVF pregnancies include increased risk of complications like ovarian hyperstimulation syndrome, multiple pregnancies, and genetic abnormalities which require specialized counseling and screening.
3. ANC for IVF pregnancies should be provided by specialists familiar with both obstetrics and IVF in order to monitor for pregnancy complications and provide psychosocial support related to fertility treatments.
Unnecessary investigations in reproductive medicineAboubakr Elnashar
The document discusses unnecessary investigations in reproductive medicine. It provides examples of tests that should not be routinely performed when evaluating infertility, during IVF treatment, in cases of recurrent implantation failure, and recurrent pregnancy loss. Specific tests that are deemed unnecessary include post-coital testing, thrombophilia testing without a clinical indication, immunological testing, and advanced sperm function tests for initial infertility evaluations. The document also recommends limiting hormonal assessments during IVF cycle monitoring.
This document discusses prevention of female infertility and contains information on several topics:
1. Age-associated infertility and the decline of fertility with increasing female age. Early childbearing and egg freezing are recommended.
2. Tubal factor infertility caused by infections like pelvic inflammatory disease which can be prevented by screening and treating STDs. Adhesions from surgery can also be prevented using techniques that minimize trauma.
3. Other causes of infertility like endometriosis, ovarian issues, and uterine factors are discussed along with prevention strategies.
Individualisation of controlled ovarian stimulationAboubakr Elnashar
This document discusses individualizing controlled ovarian stimulation (COS) protocols based on a patient's ovarian reserve. It describes various ovarian reserve tests (ORTs) like AMH and AFC levels that can categorize patients' responses. Prediction models incorporating multiple factors are presented to anticipate poor or high responses and tailor gonadotropin starting doses. Treatment strategies for different POSEIDON patient groups aim to maximize oocyte yield, including increasing gonadotropin doses or adding medications like recombinant LH. Dual stimulation protocols within one cycle are also proposed.
This document discusses female infertility, including causes like endometriosis, ovarian factors, tubal factors, and uterine factors. It provides guidelines for evaluating infertility, including taking a history, physical exam, and testing. For ovarian factor infertility, it discusses assessing ovulation through symptoms, ultrasound, and progesterone testing. Causes of anovulation like PCOS are explained. Ovarian reserve can be assessed through age, antral follicle count, and AMH levels.
This document discusses maternal near miss (MNM), which refers to women who survive severe life-threatening complications during pregnancy, childbirth, or postpartum. MNM is presented as an important tool for evaluating obstetric healthcare beyond just maternal mortality. The document outlines criteria for identifying MNM cases, indicators for assessing healthcare quality using MNM data, advantages of MNM reviews for reducing maternal mortality, and findings from studies on MNM in various hospitals that identified leading complications and opportunities for improvement. MNM reviews are described as complementary to maternal death reviews for gaining insights to reduce preventable morbidity and mortality.
The document provides guidelines for the management of severe preeclampsia and eclampsia. It defines preeclampsia and eclampsia and describes criteria for severe disease. It recommends close maternal monitoring of blood pressure, labs, urine output and fetal wellbeing. It provides guidance on controlling blood pressure with antihypertensive drugs like labetalol, nifedipine and hydralazine. The goal is to prolong the pregnancy and deliver at the optimal time while preventing maternal and fetal complications.
This document provides guidelines for procedural aspects of caesarean sections (CS). It discusses topics such as: timing of planned CS to reduce neonatal risks; classification and timeframes for emergency CS categories; preoperative testing and preparation; regional anesthesia preferences; techniques to reduce infection risks and prevent transmission; surgical techniques for skin incision, uterine closure, and more; and thromboprophylaxis and accommodating women's preferences.
The document discusses caesarean scar defects, also known as uterine niches. It provides information on the prevalence, risk factors, clinical presentation, diagnosis, and management of this condition. Uterine niches are common, affecting up to 70% of those with a prior c-section, and are usually asymptomatic but can sometimes cause bleeding, pain, or infertility. Diagnosis involves ultrasound imaging to identify a triangular defect in the uterine scar with decreased or absent underlying muscle. Larger niches with less residual muscle are more likely to be symptomatic.
This document provides guidelines for managing pregnancies of unknown location (PUL). It defines PUL as a positive beta-hCG result but no pregnancy located on ultrasound. PULs have several potential outcomes including intrauterine pregnancy (IUP), ectopic pregnancy, or persistent PUL. The M6 regression model can help stratify PULs as high or low risk for ectopic pregnancy to guide treatment. Management of PUL requires close follow-up with repeated testing until a definitive diagnosis is made.
1. Aerobic vaginitis (AV), also known as desquamative inflammatory vaginitis (DIV), is an underdiagnosed vaginal discharge syndrome caused by an imbalance of the vaginal microbiota and an inflammatory response.
2. It is characterized by a lack of lactobacilli bacteria and overgrowth of aerobic bacteria like E. coli, streptococci, and staphylococci. Women present with yellowish foul-smelling discharge, irritation, and vaginal inflammation.
3. The diagnosis of AV is made through microscopic examination showing lack of lactobacilli, presence of inflammatory cells and parabasal cells, and a vaginal pH over 4.
This document provides guidelines for caring for pregnant women with COVID-19. It discusses that vertical transmission of COVID-19 from mother to baby is uncommon. It recommends continuing antenatal care with safety modifications and advises vaccination for pregnant women when risk of exposure is high. For pregnant women with COVID-19, it suggests treatments and monitoring based on symptoms and managing clinical deterioration. Guidelines are provided for intrapartum and postpartum care as well, including thromboprophylaxis. The overall goal is to provide care for both the health of the pregnant woman and baby while mitigating risk of COVID-19 transmission.
Nano-gold for Cancer Therapy chemistry investigatory projectSIVAVINAYAKPK
chemistry investigatory project
The development of nanogold-based cancer therapy could revolutionize oncology by providing a more targeted, less invasive treatment option. This project contributes to the growing body of research aimed at harnessing nanotechnology for medical applications, paving the way for future clinical trials and potential commercial applications.
Cancer remains one of the leading causes of death worldwide, prompting the need for innovative treatment methods. Nanotechnology offers promising new approaches, including the use of gold nanoparticles (nanogold) for targeted cancer therapy. Nanogold particles possess unique physical and chemical properties that make them suitable for drug delivery, imaging, and photothermal therapy.
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.
The skin is the largest organ and its health plays a vital role among the other sense organs. The skin concerns like acne breakout, psoriasis, or anything similar along the lines, finding a qualified and experienced dermatologist becomes paramount.
“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
Summer is a time for fun in the sun, but the heat and humidity can also wreak havoc on your skin. From itchy rashes to unwanted pigmentation, several skin conditions become more prevalent during these warmer months.
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.
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.
Discover the benefits of homeopathic medicine for irregular periods with our guide on 5 common remedies. Learn how these natural treatments can help regulate menstrual cycles and improve overall menstrual health.
Visit Us: https://drdeepikashomeopathy.com/service/irregular-periods-treatment/
The biomechanics of running involves the study of the mechanical principles underlying running movements. It includes the analysis of the running gait cycle, which consists of the stance phase (foot contact to push-off) and the swing phase (foot lift-off to next contact). Key aspects include kinematics (joint angles and movements, stride length and frequency) and kinetics (forces involved in running, including ground reaction and muscle forces). Understanding these factors helps in improving running performance, optimizing technique, and preventing injuries.
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.
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.
3. 1. INTRODUCTION
Clinical manifestations
Sudden sensation of heat centered on the face
and upper chest that rapidly becomes generalized.
The sensation of heat lasts 2-4 mins
Often associated with profuse perspiration and
occasionally palpitations
Often followed by chills and shivering.
AboubakrElnashar
4. Thermoregulatory dysfunction
inappropriate peripheral vasodilatation: increased
digital and cutaneous blood flow and perspiration:
rapid heat loss and a decrease in core body
temperature below normal.
Shivering then occurs as a normal mechanism to
restore the core temperature to normal
AboubakrElnashar
6. Prevalence
Before the perimenopausal transition: 14-51%
Perimenopause: 35-50%
After menopause: 30 to 80%
[NIH, 2005].
It is generally believed that hot flashes do not
occur in premenopausal women
{serum estrogen concentrations are never very low,
even during the menstrual period}. However, the
large observational SWAN study found that 20% of
premenopausal women reported hot flashes
[Gold et al, 2009].
AboubakrElnashar
7. In a longitudinal study of women traversing the
perimenopausal transition, annual serum FSH
concentrations, but not other hormones (estradiol,
testosterone, DHEA-S), when collectively modeled
longitudinally, were associated with both the
prevalence and frequency of vasomotor symptoms
[Huang et al, 2009].
AboubakrElnashar
8. Duration
≥80%: ≥one year.
Untreated: stop spontaneously within a few
years of onset in most women
Persistent hot flashes
12 to 15% for women in their sixties
9% after age 70 years
The prevalence (or reporting) of hot flashes is
quite variable across cultures.
AboubakrElnashar
9. Pathophysiology
Not clearly understood
(Bachmann, 2005).
Dysfunction of central thermoregulatory centers in
the hypothalamus
Estrogens.
play a vital role
withdrawal or rapid fluctuation in levels, rather than
low concentration
(Overlie, 2002).
{Turner syndrome who lack normal estrogen levels, do not experience hot
flashes unless first exposed to estrogen and then withdrawn from treatment}.
Neurotransmitters.
changes in neurotransmitter levels
(Pinkerton, 2009).
Norepinephrine. Serotonin.
AboubakrElnashar
10. Risk factors
In the Study of Women's Health Across the Nation
(SWAN)
Less often
Japanese and Chinese
More often
African-American compared to Caucasian
[Gold et al, 2006].
0
20
40
60
80
100
USA Canada Europe Japan Other
Asian
Africa Middle
East
Frequenciesofhotflushes(%)
Low estimate High estimate
AboubakrElnashar
11. High BMI
Although obese women have higher endogenous levels of circulating
estrone {increased peripheral conversion of androstenedione to estrone in
adipose tissue}
[whiteman, 2003].
Smoking
[Gold et al, 2000].
Less physical activity
Sociodemographic factors
less than a high school education
difficulty paying for basics
AboubakrElnashar
12. Score Calculation Interpretation
Severity score = (number of
mild hot flashes/day × 1) +
(number of moderate hot
flashes/day × 2) + (number of
severe hot flashes/day × 3) +
(number of very severe hot
flashes/day × 4)/total number
of hot flashes/day
Some trial methodologies deviate from this formula
slightly, excluding hot flashes in the very severe
category and including them in the severe category
Higher scores indicate
worse symptoms
There is no maximum
score since the score is
patient dependent for both
number and severity
2. ASSESSMENT
Hot Flash Score
AboubakrElnashar
13. Score Calculation Interpretation
Assesses four subcomponents
of both symptoms and quality
of life: psychological (possible
score 0-33), somatic (0-21),
vasomotor symptoms (0-6),
and sexual (0-3)
Total score can range
from 0-63
Higher scores indicate
worse symptoms
For the vasomotor
subscore, a score of 0-2
indicates no or mild hot
flashes and 3-6 indicates
moderate-to-severe hot
flashes
Greene Climacteric Score
AboubakrElnashar
14. Score Calculation Interpretation
Assesses 11 subcomponents: hot flashes,
sweating, insomnia, nervousness,
depression, vertigo, tiredness, joint ache,
headache, palpitations, and vaginal
dryness
All are scored from 0-3 based on
symptoms: 0 = none, 1 = weak, 2 =
moderate, 3 = strong
Hot flash score is multiplied by 4; sweating,
insomnia, and nervousness scores are multiplied
by 2; then all subcomponents are added together
for the total score
Total score
can range
from 0-51
Higher scores
indicate
worse
symptoms
Modified Kupperman Index
AboubakrElnashar
15. A. Hormonal
1. Estrogen
2. Progestin
3. Tibolone
4. Bioidentical hormones
B. Non-hormonal
I. CNS agents
1. SSRI
2. Gabapentin
II. CAM
1. Acupuncture
2. Phytoestrogen
3. Phytoprogestin
4. Lifestyle Changes
4. TREATMENT
AboubakrElnashar
16. A. Hormonal
1. ESTROGEN
Indication
Moderate-to-severe hot flashes: Short-term
[NAMS, 2010].
Long-term use for prevention of disease is no
longer recommended.
Mild hot flashes: do not usually require any
pharmacologic intervention.
AboubakrElnashar
17. Effectiveness.
Systemic ET
Most effective tt for VMS
•stop hot flashes completely in 80%
•reduce their frequency and severity in the
remainder
[Maclennan et al Cochrane Database Syst Rev 2004].
Only therapy currently approved by the FDA
(Shifren, 2010).
AboubakrElnashar
18. Route.
Oral, parenteral, topical, vaginal, or transdermal:
similar effects.
Oral:
Most popular, although
Transdermal
±safer {avoid liver’s1st pass effect}
≥convenience {less frequent administration
(once or twice weekly)}.
similar efficacy {all absorbed from GIT primarily as estrone
sulfate, which is continuously desulfated and converted to E2}: even
though oral estrogen is administered in a single daily dose, the resulting
serum E2 vary little between doses.
AboubakrElnashar
19. The effective daily dose-equivalents:
CEE and 17-beta estradiol (oral or transdermal):
equally effective for the tt of hot flashes
[Nelson, 2004, SR].
Daily dose
1 mgmicronized 17-beta-estradiol
50 mcgtransdermal 17-beta-estradiol
1.25 mgpiperazine estrone sulfate
0.625 mgconjugated equine estrogens
AboubakrElnashar
20. Lower doses ± effective in select patients.
CEE (0.3 mg),
Oral 17-beta estradiol (0.5 mg)
Transdermal 17-beta estradiol (25 mcg patch)
[Ettinger, 2005].
Transdermal estradiol [14 mcg/day]) : more
effective than placebo
[Bachmann et al, 2007].
AboubakrElnashar
22. Regimen
Continuous estrogen therapy:
recommended
{When given for 25 days of each month or for 3 of
every 4 ws: hot flashes often recur during the E free-
period}.
In women with a uterus:
E should be given with a progestin {prevent
endometrial hyperplasia}.
Doses and route of administration
can be changed relative to patient preference.
AboubakrElnashar
23. Uterus
Sequential therapy without tablet break
Regular bleeding at end of cycle
How is HRT Given?
Continuous Sequential HRT
Estrogen
Progestogen
Day 14
De Villiers TJ et al. 2013.
.
Continuous Estrogen
Estrogen
No tablet break
No bleeding as no uterus
Uterus
Continuous Combined HRT
Estrogen
Progestogen
Day 14 Combined therapy without tablet break
No bleeding at end of cycle
AboubakrElnashar
24. Estrogen contraindications:
Undiagnosed abnormal genital bleeding
Known, suspected, or history of breast cancer
Known or suspected E-dependent neoplasia
Active DVT, pulmonary embolism, or history of
these conditions
Active or recent (within the past year) arterial
thromboembolic disease (stroke or MI)
Liver dysfunction or disease
Known hypersensitivity to the ingredients of E
preparation
Known or suspected pregnancy.
AboubakrElnashar
25. When prescribing of HRT:
Timing:
Sooner is better
Maintain the beneficial action of E on the woman’s body
with an early start, whenever she needs it
Personalization:
Tailor the type, dose, and route of HRT for each individual
woman to achieve control of E-deficiency symptoms.
There will never be one preparation that suits all women.
Select the right dose for the right woman.
Balance the benefits vs. the risks
At both the initiation of therapy and over time.
With age:
Continuation and tapering the dose
AboubakrElnashar
26. 2. Progestin
Progestin alone
Somewhat effective for tt of hot flashes {inhibit GnT
secretion and increase endogenous hypothalamic
opioid peptide activity}.
Combined with E:
Protect against E-induced endometrial hyperplasia.
Slightly more effective than E alone in ameliorating
hot flashes.
AboubakrElnashar
27. When: E is contraindicated
History of venous thromboembolism or
Breast cancer.
Adverse effects:
Vaginal bleeding
Wt gain
Transient increase in hot flashes for 1-2 w
Megestrol acetate: glucocorticoid-like activity:
adrenal insufficiency after it is discontinued.
±attenuate E beneficial effects on lipids and blood
flow.
Progestins provide no meaningful increase in
estrogen’s benefits to bone. AboubakrElnashar
28. Role of Progestogens in HRT
Writing Group for the PEPI Trial. JAMA 1996;275:370–5.
PEPI Trial: multicenter RCT : Results of Endometrial Biopsy
Adding a progestogen is needed to safeguard the
endometrium
Placebo CEE
alone
CEE+MPA
sequential
CEE+MPA
continuous
119 119 118 120
Normal 98% 38% 95% 99%
Simple
hyperplasia
1% 28% 3% 1%
Complex
hyperplasia
1% 23% 2% 0%
Atypia 0% 12% 0% 0%
Adenocarcinoma 1% 0% 0% 0%
AboubakrElnashar
29. DMPA :
Single dose of 400 mg: 80% reduction of hot
flushes
Greater efficacy with fewer side effects.
AboubakrElnashar
30. 3. Tibolone
Synthetic steroid: 17 OH -7 methyl norpregn
Action
3 metabolites, each with different binding affinity to
the E, P & A receptors.
Weak estrogenic, progestagenic & androgenic
(Gonadomimetic)
It is anti E on the endometrium & E on the vagina
2.5 mg/d
AboubakrElnashar
31. Widely used in Europe and other countries for
nearly 20 years
Reduces VMS when compared to placebo
[NAMS, 2004]
Beneficial effect on BMD.
Modest effect for symptoms of sexual dysfunction.
AboubakrElnashar
32. Compared to placebo:
Tibolone:
More effective in relieving the frequency of VMS
Increased vaginal bleeding
Compared to equipotent doses of combined HT:
Tibolone
Reduced vaginal bleeding
Less effective in relieving the frequency of VMS
(Formoso et al, 2012: Cochrane Database Syst Rev)
AboubakrElnashar
33. Long term safety:
•RCT of 3098 women with breast cancer and
menopausal symptoms was halted after 3.1 y
{increased tumour recurrence} .
•RCT of 4506 of osteoporotic women with negative
mammograms
Reduction in breast cancer compared to placebo
after 2.8 y
An excess risk of stroke in women whose mean
age was over 60 y.
(Formoso et al, 2012: Cochrane Database Syst Rev)AboubakrElnashar
34. No clear evidence of a tibolone effect on
endometrial cancer compared with placebo.
No evidence of a difference in long term safety
between tibolone and combined HT.
Similar concerns may exist for EP therapy but
overall benefit-risk profile
better known
more directly related to women with menopausal
symptoms.
(Formoso et al, 2012: Cochrane Database Syst Rev)
AboubakrElnashar
35. 4. Bioidentical Hormones
BH:
Molecule identical to a hormone produced by the
human body
BHRT
A set of diagnostic, prescribing, preparation and
marketing practices including compounding (the
preparation of custom-mixed hormones by a pharmacist, according to a
prescription), saliva testing, and efforts to counter the
effects of aging rather than relieving the symptoms of
menopause. AboubakrElnashar
36. FDA-Approved Products.
Various routes of administration: constant, low
levels of hormones
Proven efficacy at relieving menopausal symptoms
Endometrial safety profiles.
Non-FDA-Approved Products.
Available by prescription for those who cannot
tolerate FDA-approved products.
AboubakrElnashar
37. Individualized compounds:
Based on salivary hormone testing.
Safe and effective
Unfortunately, salivary testing has tremendous inter-
and intrapatient variability and has been found to
lack correlation with serum hormone levels
(Boothby, 2004).
No rigorous RCTs regarding safety or efficacy:
cannot be assumed to be safer than conventional
pharmaceutical E or P.
Adequate endometrial protection is needed if
compounded estrogens are prescribed
(Pinkerton, 2009).
AboubakrElnashar
38. B. Non hormonal
I. CNS agents
1. SSRI
2. Gabapentin
II. CAM
1. Acupuncture
2. Phytoestrogen
3. Phytoprogestin
4. Lifestyle Changes
AboubakrElnashar
39. B. Non hormonal
Mild hot flashes: usually do not seek or require
pharmacologic intervention.
However, women often try
{NAMS; 2004]
1. Lifestyle changes
(keeping the core body temp cool and regular exercise),
either alone or combined with
2. Nonprescription therapies
(soy foods, isoflavone supplements (from either soy or red
clover, black cohosh, or vitamin E).
Neither exercise nor nonprescription therapies
have proven benefit.
AboubakrElnashar
40. Non hormonal tts:
No FDA-approval for tt of hot flashes
Long-term studies: not available.
Short-term trials: available
Indication:
1. Women decline HT
2. E is contraindicated.
{many side effects or ineffectiveness compared with
HT: limits their routine use
AboubakrElnashar
41. I. Central Nervous System Agents
1. Selective Serotonin-Reuptake Inhibitors(SSRI).
selective serotonin norepinephrine reuptake
inhibitors (SNRIs)
RCT with the antidepressants
Venlafaxine (Effexor)
Fluoxetine (Prozac, Sarafem)
Paroxetine (Paxil), and
Desvenlafaxine (Pristiq)
: modest improvement in hot flashes compared with
placebo.
AboubakrElnashar
43. Benefits of SSRIs should be balanced against
drug side effects: nausea, diarrhea, headache,
insomnia, fatigue, and sexual dysfunction.
SSRIs must be used with caution in women with
breast cancer receiving adjuvant tamoxifen {SSRIs
and some SNRIs reduce the metabolism of
tamoxifen to its most active metabolite, endoxifen},
Reserve SSRI tt of hot flushes for women with
breast cancer receiving aromatase inhibitors or no
adjuvant tt.
AboubakrElnashar
44. 2. Gabapentin (Neurontin)
structurally related to
neurotransmitter gamma amino butyric acid
(GABA)
Mechanism of action:
unknown.
Uses:
seizure disorders
post-herpetic neuralgia
other indications as well. (Brown, 2009).
AboubakrElnashar
45. Pooled analyses (Lobrinzi et al, 2009)
of 7 trials of antidepressants and 3 trials of
Gabapentin
[Pandya et al, 2005 ].
The mean reduction in hot flash score with
placebo: 24%.
The additional hot flash score reductions Vs
placebo for
Paroxetine: 41%
Gabapentin: 36%
Venlafaxine: 33%
Fluoxetine: 13%
Although these agents do not appear to be as
effective as E for hot flashes, they are significantly
better than placebo.
AboubakrElnashar
46. II. Complementary and Alternative Medicine
(CAM)
Prevalence of use in postmenopausal women
50 to 75% [Keenan et al, 2003]
Increasing (Newton, 2002).
Higher in breast cancer patients.
Safety and efficacy
Not well established.
Soy and black cohosh: no more effective than
placebo AboubakrElnashar
47. HRT remains the most effective therapy for VMS
(Newton et al. 2006)
No significant efficacy of botanicals in reducing VMS
Baseline 3 months 6 months 12 months
0
1
2
3
4
5
6
7
8
Vasomotorsymptomsperday
Black Cohosh
Multibotanical
Multibotanical + soy
HRT: CEE +/- MPA
Placebo
AboubakrElnashar
48. Meta-analysis of 43 trials [Nelson et al, 2006]:
Mean difference in number of hot flashes/d
compared to placebo
Gabapentin: -2.05
SSRIs/SNRIs: -1.13
Clonidine: -0.95
Red clover isoflavone extracts: did not show a
significant reduction in hot flashes
AboubakrElnashar
49. Acupuncture.
10 or 12 sessions: Significant decrease in hot
flash frequency and intensity.
small study groups
data from only short-term therapy and followup.
(Borud, 2009; Kim, 2010).
MA of 5 trials comparing acupuncture to sham
acupuncture: reductions in severity and frequency of
hot flashes with both therapies.
[Cho SH, Whang, 2009].
Women with breast cancer, acupuncture: not
effective therapy for hot flashes
[Lee, 2009].
AboubakrElnashar
50. Phytoestrogens
Nonsteroidal compounds that occur naturally in
many plants, fruits, and vegetables
Action
estrogenic and antiestrogenic properties
Types:
isoflavones, coumestans, or lignans.
Two types of isoflavones, genistein and daidzein,
are found in soybeans, chickpeas, and lentils, and
are thought to be the most potent estrogens of the
phytoestrogens (although they are much weaker
than human estrogens).
No more effective than placebo for hot flashes.
AboubakrElnashar
51. 3. Lifestyle Changes
A. Practices that lower core body temperature
using a fan
dressing in layers
ingestion of cold foods and beverages.
taking cool showers
±temporarily help.
C. Meditation, smoking cessation, and weight loss
Weight loss
{obesity is a risk factor for hot flashes}. may help reduce hot
flashes [Huang et al,2010].
± helpful
AboubakrElnashar
52. C. Relaxation techniques
Paced respiration: reduce frequency.
(Irvin et al, 1996; Freedman and Woodward, 1992)
Relaxation: significant reductions in intensity,
tension, anxiety, and depression
{decreased central sympathetic tone}.
Relaxation therapy and stress management:
Not effective
[Nedrow, 2006].
Exercise:
No beneficial effect on hot flashes
{ exercise raises core body temperature, thereby
triggering hot flashes}
AboubakrElnashar
53. 4. TREATMENT OF INTRACTABLE HOT FLASHES
Define
continuing occurrence of hot flashes despite the
administration of what should be an effective dose of
E.
Treatment
1. Determine if they are taking drugs that can
decrease the absorption of E (eg, broad-
spectrum antibiotics) or
increase hepatic enzyme activity: increase the
metabolism of E (eg, barbiturates,
anticonvulsants, or tranquilizers).
Stopping or replacing these drugs may be helpful.
AboubakrElnashar
54. 2. Changing the route of E administration from oral
to transdermal may result in control of hot flashes
by bypassing the liver.
Titration of patch size until plasma estradiol levels
reach 120 pg/mL may be helpful. However, there
are no clinical trial data to support this approach.
AboubakrElnashar
55. 3. Other potential causes of flushes or night sweats
(hyperthyroidism, underlying malignancy, infection,
SSRIs)
4. Finally, for women who are receiving very high
doses of E in an unsuccessful attempt to stop their
hot flashes, stopping E altogether for one to two
weeks and then restarting at the usual dose may be
effective.
This will give the woman a chance to compare the
severity of hot flashes on and off E. She may decide
that, although the flashes have not completely
disappeared, E is beneficial and she may tolerate
the residual flashes better.
AboubakrElnashar
57. SUMMARY AND RECOMMENDATIONS
HRT remains the most effective therapy for VMS
Use lowest effective dose of E
More favorable if tt is started earlier in menopause
For postmenopausal women with moderate-to-
severe VMS (and no history of breast cancer or
CVD): short-term E therapy is the tt of choice
(Grade 2B)..
.
AboubakrElnashar
58. Short-term therapy is considered to be two to
three years and generally not more than five years.
For women with moderate-to-severe hot flashes in
whom E is contraindicated or not well tolerated, or
for women who have stopped E and are
experiencing recurrent symptoms but wish to avoid
resuming E: Gabapentin, SNRI, or SSRI (Grade
2B).
AboubakrElnashar
59. For women with predominantly nighttime
symptoms: single bedtime dose of Gabapentin
{soporific effect of gabapentin while minimizing
daytime sedation}.
For women with predominantly daytime
symptoms: SNRI/SSRI {less sedating than
Gabapentin}. These drugs should be used with caution in women
with breast cancer who are taking tamoxifen.
AboubakrElnashar
60. Since hot flashes gradually subside without
therapy in most postmenopausal women, any drug
can be gradually tapered after one to two years of
administration.
For women with breast cancer and hot flashes: no
phytoestrogens and black cohosh (Grade 2C).
AboubakrElnashar