GnRH agonists can be used to treat several benign gynecological disorders by inducing a hypoestrogenic state. They work by initially stimulating the pituitary gland but then downregulating it, decreasing FSH and LH levels and sex steroid production. This document discusses their use for: 1) endometriosis, 2) uterine fibroids, 3) thinning the endometrium prior to ablation, 4) pituitary downregulation in IVF, and 5) adenomyosis. For fibroids and endometriosis, GnRH agonists reduce symptoms and shrink lesions over 3-6 months to facilitate surgery. "Add-back" hormone therapy can prevent side effects of hypoestrogenism. For breast
UNEXPLAINED INFERTILITY &INTRAUTERINE INSEMINATION Dr. Sharda jain Lifecare...Lifecare Centre
UNEXPLAINED INFERTILITY &INTRAUTERINE INSEMINATION DR. SHARDA JAIN , DR. JYOTI AGARWAL
DR. JYOTI BHASKAR
DEFINITION
Unexplained infertility means that couple does not conceive after 1year of unprotected vaginal sexual intercourse, with basic infertility evaluation showing no obvious abnormality.
INCIDENCE
15%to 20% of infertile couples
UNEXPLAINED IS PRIMARILY A
DIAGNOSIS OF EXCLUSION
Invited Lecture delivered by Dr Sujoy Dasgupta in a CME, sponsored by Serum Institute of India Pvt Ltd in the Convocation Ceremony of Interns at Sagor Dutta Medical College
UNEXPLAINED INFERTILITY &INTRAUTERINE INSEMINATION Dr. Sharda jain Lifecare...Lifecare Centre
UNEXPLAINED INFERTILITY &INTRAUTERINE INSEMINATION DR. SHARDA JAIN , DR. JYOTI AGARWAL
DR. JYOTI BHASKAR
DEFINITION
Unexplained infertility means that couple does not conceive after 1year of unprotected vaginal sexual intercourse, with basic infertility evaluation showing no obvious abnormality.
INCIDENCE
15%to 20% of infertile couples
UNEXPLAINED IS PRIMARILY A
DIAGNOSIS OF EXCLUSION
Invited Lecture delivered by Dr Sujoy Dasgupta in a CME, sponsored by Serum Institute of India Pvt Ltd in the Convocation Ceremony of Interns at Sagor Dutta Medical College
Role Of AMH In Infertility , Dr. Sharda Jain , Life Care Centre Lifecare Centre
Role Of AMH In Infertility , Advantage of AMH , Fecundity / Infertility & AMH , Infertility and AMH ,Prediction of pregnancy chances in couples presenting with infertility , AMH in IVF
ESHRE Guideline on Recurrent Pregnancy Loss (RPL)Sujoy Dasgupta
Dr Sujoy Dasgupta invited to deliver a lecture on "RPL- ESHRE Guideline" in the Annual Conference of RCOG (Royal College of Obstetricians and Gynaecologists) IRC (International Representative Committee) India East held on 20-21 May, 2023
Selective progesterone receptor modulators (SPRMs)
Stimulates growth :
Up regulating epidermal growth factor (EGF)
Down regulating tumour necrosis factor-alpha expression
Inhibits growth :
Downregulating insulin-like growth factor-1 (IGF-1) expression
NO EFFECT ON ESTRADIOL LEVELS
Mifepristone : 5 or 10 mg per day for 1 year
Ulipristal acetate: 5-10mg/day for 13 weeks
Pro apoptotic and anti-proliferative effects on fibroid cells
PANEL DISCUSSION
MANAGEMENT OF PCOS - WOMB to TOMB
MODERATOR : Sharda Jain
PANELISTS : Dr.Chitra setia
Dr Puneet Arora
Dr. Ila Gupta
Dr. Rupam Arora
Dr. Archana Sharma
Dr. Sangeeta Gupta
Dermatologists
Dr. V.K. Upadhyay
Dr. S. Kandhari
Anti-Müllerian Hormone (AMH) is critical for physiologic involution of the Mullerian ducts during sexual differentiation in the male foetus.
In women,AMH is a product of the small antral follicles in the ovaries and serves to function as an autocrine and paracrine regulator of follicular maturation
Significant increase in live birth rate is found when IUI is done with stimulation compared with IUI in natural cycle in women with Unexplained Infertility .
Role Of AMH In Infertility , Dr. Sharda Jain , Life Care Centre Lifecare Centre
Role Of AMH In Infertility , Advantage of AMH , Fecundity / Infertility & AMH , Infertility and AMH ,Prediction of pregnancy chances in couples presenting with infertility , AMH in IVF
ESHRE Guideline on Recurrent Pregnancy Loss (RPL)Sujoy Dasgupta
Dr Sujoy Dasgupta invited to deliver a lecture on "RPL- ESHRE Guideline" in the Annual Conference of RCOG (Royal College of Obstetricians and Gynaecologists) IRC (International Representative Committee) India East held on 20-21 May, 2023
Selective progesterone receptor modulators (SPRMs)
Stimulates growth :
Up regulating epidermal growth factor (EGF)
Down regulating tumour necrosis factor-alpha expression
Inhibits growth :
Downregulating insulin-like growth factor-1 (IGF-1) expression
NO EFFECT ON ESTRADIOL LEVELS
Mifepristone : 5 or 10 mg per day for 1 year
Ulipristal acetate: 5-10mg/day for 13 weeks
Pro apoptotic and anti-proliferative effects on fibroid cells
PANEL DISCUSSION
MANAGEMENT OF PCOS - WOMB to TOMB
MODERATOR : Sharda Jain
PANELISTS : Dr.Chitra setia
Dr Puneet Arora
Dr. Ila Gupta
Dr. Rupam Arora
Dr. Archana Sharma
Dr. Sangeeta Gupta
Dermatologists
Dr. V.K. Upadhyay
Dr. S. Kandhari
Anti-Müllerian Hormone (AMH) is critical for physiologic involution of the Mullerian ducts during sexual differentiation in the male foetus.
In women,AMH is a product of the small antral follicles in the ovaries and serves to function as an autocrine and paracrine regulator of follicular maturation
Significant increase in live birth rate is found when IUI is done with stimulation compared with IUI in natural cycle in women with Unexplained Infertility .
In ART, GnRH antagonists are effective in preventing a premature LH surge and induce a shorter and more cost-effective ovarian stimulation compared to the long agonist protocol.
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
Best Ayurvedic medicine for Gas and IndigestionSwastikAyurveda
Here is the updated list of Top Best Ayurvedic medicine for Gas and Indigestion and those are Gas-O-Go Syp for Dyspepsia | Lavizyme Syrup for Acidity | Yumzyme Hepatoprotective Capsules etc
- Video recording of this lecture in English language: https://youtu.be/kqbnxVAZs-0
- Video recording of this lecture in Arabic language: https://youtu.be/SINlygW1Mpc
- 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
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Basavarajeeyam is a Sreshta Sangraha grantha (Compiled book ), written by Neelkanta kotturu Basavaraja Virachita. It contains 25 Prakaranas, First 24 Chapters related to Rogas& 25th to Rasadravyas.
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journey
Role of GnRH agonist in benign gynaecological disorders
1. Role of GnRH agonist in benign
gynaecological disorders
Aboubakr Elnashar
Benha University Hospital, Egypt
ABOUBAKR ELNASHAR
2. Contents
GnRHa
Administration
Use in benign gynaecological disorders
1. Endometriosis
2. Uterine fibroids.
3. Thinning agent in DUB (prior to
endometrial ablation).
4. Pituitary down-regulation (in long
protocol of IVF and induction of
ovulation).
5. Adenomyiosis
ABOUBAKR ELNASHAR
3. GNRH AGONISTS
Produced by
Modification of the native GnRH decapeptide at 6 &
10 positions
Glp-His-Trp-Ser-Tyr-Gly-Leu-Arg-Pro-Gly-NH2
LHRH
Glp-His-Trp-Ser-Tyr-Ser(But)-Leu-Arg-Pro-Azgly-NH2
Goserelin
100 times more potent than natural LHRH
ABOUBAKR ELNASHAR
4. Mechanism:
After initial agonistic action (flare response),
down-regulation & desensitization of the
pituitary: hypogonadotrophic, hypogonadal
state.
ABOUBAKR ELNASHAR
5. Effects of GnRha
Within 12 h of administration:
[flare effect lasting 24-48 h]
: 5 fold increase of FSH,
10 fold rise in LH &
4 fold elevation in E2.
Continuous administration
: opposite effects:
internalization of the agonist /receptor
complex & decrease in the number of
receptors
(down-regulation).
: paradoxical suppression of the
pituitary Gnt synthesis & liberation
(desensitization). ABOUBAKR ELNASHAR
6. The decreased levels of FSH & LH:
1. Arrest of follicular development &
2. Decrease in sex steroid levels to castrate levels.
Postmenopausal E2 levels are commonly reached
after 21 days.
The pituitary blockade persist during agonist
treatment but it is reversible after therapy.
ABOUBAKR ELNASHAR
7. Administration
• Goserelin:
SC into the anterior abdominal wall every 28 days
+/- 2 days
{1. Best route of absorption and steady dissolution
of depot
2. The trunk area is less sensitive than the thighs:
negligible pain on injection}
ABOUBAKR ELNASHAR
8. Indications in benign gynaecological
disorders
1. Endometriosis.
2. Uterine fibroids.
3. Thinning agent in DUB (prior to endometrial
ablation).
4. Pituitary down-regulation (in long protocol of IVF
and induction of ovulation).
5. Adenomyiosis
6. Before & during chemotherapy for breast cancer
to preserve ovarian functionABOUBAKR ELNASHAR
9. 1. Endometriosis
GNRHa:
An appropriate therapy of CPP, even in the
absence of laparoscopic confirmation of E,
provided that a detailed evaluation fails to
demonstrate other cause
(ACOG Recommendations Grade (B)
ABOUBAKR ELNASHAR
10. Indications
GnRHa with HT addback
should be considered as 2nd
line treatment:
No response to CHCs or
progestins
Recurrence of symptoms
after initial improvement
(SOGC, 2010)
ABOUBAKR ELNASHAR
11. Types of GnRHa
PriceEPcompanyDoseRouteNamePreparation
750
1550
540
Abbot3.75 mg/4w
11.25 mg/12 w
2.8 ml, 1 ml daily
IM, SC
IM, SC
Lupron
Lucrin
Leuprorelin
500Astrazenica3.6 mgSCZoladexGoserelin
605
266(7syr)
FerringCR: 3.75mg,
0.1mg then 0.05 mg
IM, SCDecapeptylTriptolerin
Sanofi0.5 mg then 0.2 mgNasal, SCsuperfactBuserelin
Pfaizer0.2 mg bidnasalSynarelNafarelin
ABOUBAKR ELNASHAR
12. Side effects:
GnRHa alone: symptoms of estrogen
deficiency
hot flushes
insomnia
Loss of libido,
vaginal dryness,
emotional instability, depression, headache.
loss of BMD, which is not always reversible.
ABOUBAKR ELNASHAR
13. Add-back therapy:
Aim:
To prevent demineralization of bone
& menopausal symptoms.
GnRha should not be given as a
single agent for >6 ms.
GnRHa should not be used for
any length of time in the absence of
HT addback
(SOGC, 2010).
ABOUBAKR ELNASHAR
14. Addbackrationale:There is a threshold serum estrogen concentration that
is low enough that endometriosis is not stimulated but high enough that
hypoestrogenic symptoms are prevented (Barbieri,1992).
This concentration is the same as that achieved with physiologic HT for
menopausal women.
Addback
GnRHa
Oestradiol
Endometriosis symptoms
Menopausal symptoms
ABOUBAKR ELNASHAR
16. Efficacy:
GnRHa: Pain relief 85-100%
persisting for 6-12 months
after cessation of tt.
(Winkel et al,2005 )
GnRHa Vs other hormonal tt:
No difference with respect to pain
relief or reduction in E deposits
(Cochrane library, 2005).
ABOUBAKR ELNASHAR
17. 2. Uterine fibroids
The main benefits
Decrease myoma size by about 38% and 41%
after 8 and 12 weeks respectively (hysteroscopic
myomectomy* - proper reconstruction of uterine
anatomy - decrease postoperative adhesions).
Decrease uterine size by about 32% after 12
weeks(easier surgery). Audebert AJM et al. British Journal of Obstetrics and Gynaecology 1994;
101: Suppl 10, 29–32
Benagiano G et al. Fertility and sterility 1996; 66: 223–229
ABOUBAKR ELNASHAR
18. Amenorrhoea and endometrial atrophy:
relief from excessive uterine bleeding.
restoration of normal Hb concentration.
detection of stromal fibroids.
Possibility to schedule operation and avoid emergency.
Decrease fluid absorption during hysterscopy (due to
decreased endometrial vascularization) & reduce risk of
volume overload.
Significant decrease blood loss during operation. (No
need for blood transfusion & easier surgery).
Subjective assessment scores of pain symptoms
decreased by 81% after 8 weeks of treatment.
ABOUBAKR ELNASHAR
19. Symptom relief
Patient feels better after 2nd injection.
Operation can be scheduled to accommodate waiting lists
or to suit patient’s personal plans
Improvement of patients’ haematological status before surgery
Reduction of blood loss before and during surgery
Need for fewer transfusions
Reduction in size of the fibroids before surgery9
Simpler and shorter surgery
Reduction in postoperative recovery time
Shorter hospital stay
Audebert AJM et al. British Journal of Obstetrics and Gynaecology 1994; 101: Suppl 10, 29–32
Candiani GB et al. Acta Obstet Gynecol Scand. 1990; 69: 413–415
Lumsden MA et al. British Journal of Obstetrics & Gynaecology 1994; 101(5): 438–442ABOUBAKR ELNASHAR
20. Blood picture & reduced uterine volume in
with Fibroids
Pre-treatment 3 months % change 6 months % changes
Haemoglobin ( g/dl) 7.4 13.2 +78* 13.6 +84**
Hematocrit ( %) 26.1 39.8 +52* 40.3 + 55**
Serum Iron ( Mc/dl) 21.7 53.8 +14* 60.8 +180 **
TIBC ( Mc/dl) 394 344 -13* 336 - 15**
Serum Ferritin ( ng/dl) 9.7 17.2 +77* 31.5 +225***
Uterine Volume (ml) 587 298 -49 288 -51**
R.M.Miller et al British journal of Obstetrics and Gynaecology . Feb 1992. Vol 99.
Suppl 7. Pp 37-41
*P < 0.01 compared with treatment
** p = NS compared with 3 month of treatment
***p <0.01 compared with 3 month of treatment
ABOUBAKR ELNASHAR
21. Significant reduction fibroids volume
ZOLADEX 3,6 mg reduces fibroid volume
50
100
150
200
250
300
Immediate surgery group ZOLADEX group
Meanfibroidsize(ml)
Audebert AJM et al. British Journal of Obstetrics and Gynaecology 1994;
101: Suppl 10, 29–32
Benagiano G et al. Fertility and sterility 1996; 66: 223–229
ABOUBAKR ELNASHAR
22. Dose:
Two depots of ‘Zoladex’ given with 4 weeks apart,
then ablation 0-2 weeks after the 2nd depot.
ABOUBAKR ELNASHAR
23. 5. Adenomyosis:
Although adenomyosis & endometriosis are
different diseases, both of them grow& regress in an
oestrogen-dependent fashion (Kitawaki et al,2006).
Adenomyotic tissue contains:
1. Steroid receptors
2. Aromatase& sulphatase enzymes.
Circulating &locally produced oestrogens stimulate
the growth of tissue mediated by the oestrogen
receptors.
ABOUBAKR ELNASHAR
24. To date, there is no agreement on the most
appropriate therapeutic methods for managing
women with uterine adenomyosis who want to
preserve their fertility
(Wang et al, 2009).
Hormonal treatment that aims to reduce the
proliferation of endometrial cells is promising, but
there is a paucity of well-designed studies to guide
treatment.
There is a strong need to develop pharmacological
agents that provide an efficient outcome
(Farquhar et al, 2006).
ABOUBAKR ELNASHAR
25. GnRHa: in adenomyosis (Wood et al, 2001).
Constant hypoestrogenic state
Amenorrhoea
Control of pain
Uterine shrinkage.
But, pure antiestrogen may offer some advantage in
the treatment of adenomyosis& trials are required to
assess its usefulness.
ABOUBAKR ELNASHAR
26. AI: in Leiomyoma (Parsanezhad et al,2010).
Reduction of leiomyoma& uterine volumes
GnRHa &AI concomitantly: in adenomyiosis (Kimura
et al, 2007).
Assuming aromatase production activity in the
adenomyosis lesion
This stimulated us to undergo this study
GnRHa monthly for 12 w.
ABOUBAKR ELNASHAR
27. 6. GnRHa administration before & during
combination chemotherapy for breast cancer
could preserve post-treatment ovarian function in
women below 40 years
GnRHa:
2 w before the initiation of chemotherapy
Goserelin, 3.6 mg SC
(Zoladex @, Zeneka Pharma International, UK)
ABOUBAKR ELNASHAR
28. GnRHa before & during combination
chemotherapy for breast cancer:
is feasible, well tolerated
may preserve post-treatment ovarian
function in women below 40 years. .
ABOUBAKR ELNASHAR