REPROSAIT 4 U

Syphilis During Pregnancy

2009-12-04T19:10:00.002+07:00

What is syphilis?

Syphilis is a sexually transmitted infection (STI) that's caused by a type of bacterium called a spirochete. If left untreated, syphilis can have very serious short- and long-term consequences. Fortunately, with timely antibiotic treatment, these consequences can usually be avoided.

Syphilis is transmitted by direct contact with a sore on an infected person. The most common way to get syphilis is through vaginal, anal, or oral sex, but it's also possible to get it by kissing someone with a syphilitic sore on or around the lips or in the mouth or by exposing an area of broken skin to a sore.

Syphilis can be transmitted to your baby through the placenta during pregnancy or by contact with a sore during birth.

The infection is relatively rare among women in the United States, with 1.1 cases per 100,000 women in 2007, but that number was up 10 percent from 2006. The rates are significantly higher in communities with high levels of poverty, low levels of education, and inadequate access to health care.

The number of babies in the United States born with syphilis also rose – after 14 years of decline – from 339 new cases in 2005 to 382 cases in 2006 to 430 cases in 2007.

What are the symptoms?

Syphilis progresses in stages, with symptoms that differ from one stage of the disease to the next and from person to person. In some cases, the symptoms aren't noticeable and you may not know you have the disease until you're tested.

In the first stage, known as primary syphilis, the characteristic symptom is a painless and highly infectious sore (or sores) with raised edges called a CHANCRE. The chancre shows up at the site of infection, usually about three weeks after you're exposed to the bacteria, though it may appear earlier or up to three months later.

Because the chancre may be inside your vagina or your mouth, you might never see it. A chancre could also show up on your labia, perineum, anus, or lips, and your lymph nodes may be enlarged in the area where the sore develops.
If you get appropriate treatment at this stage, the infection can be cured. If you're not treated, the sore lasts three to six weeks and then heals by itself. However, the spirochetes are likely to continue to multiply and spread throughout the bloodstream. When this happens, the disease progresses to the next stage, called secondary syphilis.

In the secondary stage, syphilis can have a variety of symptoms that show up in the weeks or months after the sore first appeared, but again, they might not be noticeable.

Most people with secondary syphilis develop a non-itchy rash, commonly on their palms and soles, though it may also appear on other parts of the body. You might also have lesions in your mouth and vagina, as well as painless but infectious wart-like sores in the genital area, flu-like symptoms, weight loss, and hair loss. The infection is still curable with treatment at this stage.

Without treatment, the symptoms generally clear up on their own within a few months, but the infection stays in your body. The bacteria continue to multiply during this latent phase and can cause very serious problems years later.

In fact, about 1 in 3 people who don't get proper treatment will progress to what's called tertiary syphilis. This late stage of the disease can develop up to 30 years after you were first infected and can cause serious heart abnormalities. Damaging and potentially lethal lesions can develop in your bones, on your skin, and in a host of organs. Fortunately, most people get treated early enough these days that very few end up with tertiary syphilis.

Syphilis can also infect your central nervous system – your brain and spinal cord. This is called neurosyphilis, and it can occur at any stage of the disease. Early on, it may cause problems like meningitis.

Late neurosyphilis can lead to seizures, blindness, hearing loss, dementia, psychosis, spinal cord problems, and eventually death.

How can syphilis affect my pregnancy and my baby's health?

Syphilis can travel from your bloodstream across the placenta and infect your baby anytime during pregnancy. It can also infect your baby during delivery. If your syphilis is detected and treated early, you and your baby will most likely be fine.
If you don't get treated, there's a very high chance that your baby will be infected, particularly if you're in the early stages of the disease, when it's most infectious. About 40 percent of pregnant women with untreated early syphilis end up having a miscarriage, a stillbirth, or a baby who dies soon after birth. Syphilis also increases the risk of preterm birth and intrauterine growth restriction.

Some babies infected with syphilis whose mothers are not treated in a timely fashion during pregnancy develop problems before birth that are visible on an ultrasound. These problems might include an overly large placenta, fluid in their abdomen and severe swelling, and an enlarged liver or spleen.

An infected baby may have other abnormalities at birth, such as a skin rash and lesions around the mouth, genitals, and anus; abnormal nasal secretions; swollen lymph glands; pneumonia; and anemia.
Most babies don't have these symptoms initially, but without treatment they develop some symptoms within the first month or two after birth. And whether or not there are obvious symptoms early on, if the disease isn't treated, babies born with syphilis may end up with more problems years later, such as bone and teeth deformities, vision and hearing loss, and other serious neurological problems.

That's why it's critical for women to be tested and treated during pregnancy, and for any baby who may have syphilis at birth to be fully evaluated and treated as well.

Will I be tested for syphilis during my pregnancy?

Yes. Even though the infection is relatively rare, it's considered vitally important to detect and treat syphilis during pregnancy. The CDC recommends that all pregnant women be screened for the infection at their first prenatal visit, and some states require that all women be tested again at delivery.

If you live in a community where syphilis is prevalent or you're otherwise at high risk, you should be tested again at 28 weeks and at delivery. You'll also be retested for syphilis if you've contracted another STI during your pregnancy or if you or your partner develops symptoms of syphilis.
Because it takes about four to six weeks after exposure to get a positive result from the blood test, the result may be negative if you're tested too soon.

So if you had high-risk sex a few weeks before your test or your partner recently had symptoms, tell your practitioner so you can be tested again in a month. If your screening test is positive, the lab will perform a more specific test on your blood sample to tell for sure whether you have syphilis.

Having syphilis makes you more susceptible to HIV if you're exposed to it, so if you test positive for syphilis, you should also be tested (or retested) for HIV and other STIs.

And if you have primary syphilis, you'll need to be tested for HIV again in three months

How is syphilis treated during pregnancy?

Penicillin is the only antibiotic that's both safe to take during pregnancy and able to successfully treat both mother and baby for syphilis. If you have syphilis, you'll get treated with one or more injections of penicillin, depending on the stage of the disease and whether you have neurosyphilis. (If you have any symptoms of neurosyphilis, you'll have a spinal tap to check for it.) If you're allergic to penicillin, you'll need to be desensitized to the drug first, so you can receive it.

In many pregnant women, treatment for syphilis causes a temporary reaction that may include fever, chills, headache, and muscle and joint aches. These symptoms tend to appear several hours after treatment and go away on their own in 24 to 36 hours.

The treatment may also cause some changes in your baby's heart rate, and if you're in the second half of your pregnancy, it may cause contractions. (If you notice any contractions or a decrease in fetal movement, you should call your caregiver immediately. In some cases, your caregiver may opt to treat you in the hospital so you can be monitored.)

Your partner will also need to be tested, and he'll be treated if he's positive or has had sexual contact with you in the last three months, even if his blood test is negative. You need to refrain from sexual contact until both of you have been treated. After treatment, you'll have regular blood tests to make sure the infection has cleared and you haven't been reinfected, and you'll have an ultrasound to check on your baby.

How can I avoid getting syphilis?

Have sex only with a partner who has sex only with you and has tested negative for syphilis. While condoms can prevent transmission of HIV and other STIs, they only offer protection from syphilis if the sore is on your partner's penis – they won't protect you from sores that aren't covered by the condom.

Remember, too, that you can get syphilis if a partner's sore touches any of your mucous membranes (such as in your mouth or vagina) or broken skin (a cut or scrape).

If you've had syphilis once, that doesn't mean you can't get it again. You can become reinfected.

If there's a possibility that you've been exposed to syphilis or any other STI during pregnancy, or you or your partner has any symptoms, tell your practitioner right away so you can be tested and treated if necessary.

STDs and Pregnancy - Fact Sheet

2009-12-04T18:43:00.002+07:00

Can Pregnant Women Become Infected With STDs

Yes, women who are pregnant can become infected with the same sexually transmitted diseases (STDs) as women who are not pregnant. Pregnancy does not provide women or their babies any protection against STDs. The consequences of an STD can be significantly more serious, even life threatening, for a woman and her baby if the woman becomes infected with an STD while pregnant. It is important that women be aware of the harmful effects of STDs and knows how to protect themselves and their children against infection.

How Common Are STDs In Pregnant Women

Some STDs, such as genital herpes and bacterial vaginosis, are quite common in pregnant women in the United States. Other STDs, notably HIV and syphilis, are much less common in pregnant women. The table below shows the estimated number of pregnant women in the United States who are infected with specific STDs each year.

STDs	Estimated Number Of Pregnant Women
Bacterial Vaginosis	1.080.000
Herpes Simplex Virus 2	880-.000
Chlamydia	100.000
Trichomoniasis	124.000
Gonorrhoea	13,200
Hepatitis B	16.000
HIV	6.400
Syphilis	< 1.000

How Do STDs Affect A Pregnant Women and Her Baby

STDs can have many of the same consequences for pregnant women as women who are not pregnant. STDs can cause cervical and other cancers, chronic hepatitis, pelvic inflammatory disease, infertility, and other complications. Many STDs in women are silent; that is, without signs or symptoms.

STDs can be passed from a pregnant woman to the baby before, during, or after the baby’s birth. Some STDs (like syphilis) cross the placenta and infect the baby while it is in the uterus (womb). Other STDs (like gonorrhea, chlamydia, hepatitis B, and genital herpes) can be transmitted from the mother to the baby during delivery as the baby passes through the birth canal. HIV can cross the placenta during pregnancy, infect the baby during the birth process, and unlike most other STDs, can infect the baby through breastfeeding.

A pregnant woman with an STD may also have early onset of labor, premature rupture of the membranes surrounding the baby in the uterus, and uterine infection after delivery.

The harmful effects of STDs in babies may include stillbirth (a baby that is born dead), low birth weight (less than five pounds), conjunctivitis (eye infection), pneumonia, neonatal sepsis (infection in the baby’s blood stream), neurologic damage, blindness, deafness, acute hepatitis, meningitis, chronic liver disease, and cirrhosis. Most of these problems can be prevented if the mother receives routine prenatal care, which includes screening tests for STDs starting early in pregnancy and repeated close to delivery, if necessary. Other problems can be treated if the infection is found at birth.

Should Pregnant Women Be Tested For STDs ?

Yes, STDs affect women of every socioeconomic and educational level, age, race, ethnicity, and religion. The CDC 2006 Guidelines for Treatment of Sexually Transmitted Diseases recommend that pregnant women be screened on their first prenatal visit for STDs which may include:

In addition, some experts recommend that women who have had a premature delivery in the past be screened and treated for bacterial vaginosis at the first prenatal visit.

Pregnant women should ask their doctors about getting tested for these STDs, since some doctors do not routinely perform these tests. New and increasingly accurate tests continue to become available. Even if a woman has been tested in the past, she should be tested again when she becomes pregnant.

Can STDs Be Treated During Pregnancy ?

Chlamydia, gonorrhea, syphilis, trichomoniasis, and bacterial vaginosis (BV) can be treated and cured with antibiotics during pregnancy. There is no cure for viral STDs, such as genital herpes and HIV, but antiviral medication may be appropriate for pregnant women with herpes and definitely is for those with HIV. For women who have active genital herpes lesions at the time of delivery, a cesarean delivery (C-section) may be performed to protect the newborn against infection. C-section is also an option for some HIV-infected women. Women who test negative for hepatitis B, may receive the hepatitis B vaccine during pregnancy.

How Can Pregnant Women Protect Themselves Against Infection ?

The surest way to avoid transmission of sexually transmitted diseases is to abstain from sexual contact, or to be in a long-term mutually monogamous relationship with a partner who has been tested and is known to be uninfected.

Latex condoms, when used consistently and correctly, are highly effective in preventing transmission of HIV, the virus that causes AIDS. Latex condoms, when used consistently and correctly, can reduce the risk of transmission of gonorrhea, chlamydia, and trichomoniasis Correct and consistent use of latex condoms can reduce the risk of genital herpes, syphilis, and chancroid only when the infected area or site of potential exposure is protected by the condom. Correct and consistent use of latex condoms may reduce the risk for genital human papillomavirus (HPV) and associated diseases (e.g. warts and cervical cancer).

URINARY TRACT INFECTIONS in PREGNANCY

2009-12-04T16:37:00.002+07:00

What is a UTI?

A urinary tract infection (UTI) is caused when the urinary system becomes infected by bacteria.

UTIs are common in women aged between 20 and 50.

About 50 per cent of women will have at least one UTI during their lifetime.

If left untreated, UTIs can be quite painful - and even dangerous because the infection can travel upwards and reach the kidneys. If a kidney infection is left untreated during pregnancy it could make you very poorly and could lead to your baby being born with a low birth weight or being born prematurely.

The changes your body goes through during pregnancy make you more susceptible to UTIs. Progesterone relaxes the muscles of your ureters, the tubes that connect your kidneys to your bladder. This slows down the flow of urine from your kidneys to your bladder. Your enlarging uterus (womb) has the same effect. This is an ideal opportunity for bacteria because they have more time to grow before they're flushed out.

Symptoms of a UTI can include:

Pain or a burning sensation when passing urine
Pain in your pelvis, the lower part of your abdomen, the lower part of your back, or in your side (usually only one side)
A feeling that you are unable to urinate fully
Shaking
Raised temperature
Feeling hot and cold by turns
Nausea and vomiting
Frequent need to go to the toilet
Uncontrollable urge to pass urine (incontinence)
Cloudy, bloody, or bad-smelling urine
Change in the amount of urine passed (either more or less)
Pain during sexual intercourse

I've always been susceptible to urinary tract infections. What will happen if I get one while I'm pregnant?

UTIs can be safely treated with antibiotics during pregnancy. You will probably be prescribed a three to seven-day course. Talk to your GP or midwife as soon as you notice any symptoms because an untreated UTI can lead to a kidney infection, which may in turn cause premature labour.

What can I do to avoid getting an infection?

Taking the following precautions should reduce the risk of getting a UTI:

After going to the toilet, wipe yourself from front to back to prevent bacteria from the back passage being spread to the front passage.
Wash thoroughly between your legs every day, but avoid strong soaps, douches, antiseptic creams, and feminine hygiene products (urethra) that can kill the "good" bacteria and irritate your sensitive urinary tract.
Empty your bladder completely when you go to the toilet.
Go to the toilet soon after having sexual intercourse.
Avoid long or very frequent baths.
Wear cotton knickers and avoid tights.
Change underwear and tights every day.
Treat constipation promptly, as this may increase your risk of getting a UTI.
Have plenty of liquids, especially water, to drink.
Drink cranberry juice, if you suffer from UTIs repeatedly. Cranberry juice can reduce levels of bacteria in the urinary tract and prevent new bacteria from taking hold, so helping to prevent minor infections (sprays or powders). Don't drink cranberry juice if you are taking warfarin.

GROUP B STREPTOCOCCUS INFECTION and PREGNANCY

2009-12-04T16:14:00.002+07:00

What is Group B streptococcus?

Group B streptococcus, or GBS, also known as group B strep, is one of many different bacteria that normally live in our bodies. Approximately one third of us "carry" GBS in our intestines without knowing.

About a quarter of women also have it in their vagina (RCOG 2003:1). Most don't know it's there, as it doesn't usually cause problems or symptoms.

However, in rare cases GBS can cause serious illness and even death in newborn babies.

Although these cases are unusual, GBS is the most common cause of severe infection in newborns, particularly in the first week after birth (known as an early onset infection) (RCOG 2003:1). In the UK, about 340 babies a year develop a GBS infection.

How do I know if I carry GBS?

If you do carry GBS, you won't necessarily know as there aren't usually any ill effects. There is a test available for GBS, but this isn't done routinely in pregnancy (see Why isn't there a national screening programme for GBS? below).

Pregnant women often find out that they have GBS by chance, when they have a vaginal swab taken to check for something else. Also, GBS can come and go, so even if you've had a positive test earlier in pregnancy, you may not have GBS as you approach delivery.

It's important for pregnant women and their carers to know when babies are most likely to develop a GBS infection and what the signs of GBS infection in babies are.

Now I'm pregnant, what should I know about GBS?

Most babies exposed to GBS before or during birth suffer no ill effects. However, around one in 2000 babies in the UK develops a GBS infection (Heath et al cited by RCOG 2003:1; RCOG 2003:3). Sadly, about one in 10 of these babies die.

It isn't clear why some babies develop an infection while others don't. What is clear is that most GBS infection in newborn babies can be prevented.
Women in higher-risk situations can be given intravenous antibiotics either from the start of labour or from when their waters break (whichever comes first) until their baby is born.

Caesareans are not recommended to prevent GBS infection in babies as they don't eliminate the risk of GBS to the baby (GBSS 2007a).
Very occasionally GBS causes infection of the uterus or urinary tract in new mothers.

Is my baby at risk of developing GBS infection?

The Royal College of Obstetricians and Gynaecologists has identified a number of factors that help to predict whether your baby is more likely to develop a GBS infection (RCOG 2003:3-6).

These include, if:

You go into labour prematurely (before 37 weeks of pregnancy)
Your waters break 18 hours or more before you have your baby
You have a raised temperature (38 degrees C / 100 degrees F or higher) during labour
You have previously had a baby infected with GBS
You have been found to carry GBS in your vagina and/or rectum during your current pregnancy
GBS has been found in your urine during this pregnancy (this should be treated when diagnosed, but even if you have been treated, extra precautions should still be considered during labour - see How should my labour and delivery be managed?, below).

How should my labour and delivery be managed?

If you don't fall into one of the higher-risk groups, above, your baby is very unlikely to develop a GBS infection.

If you are higher-risk, research shows that having intravenous antibiotics from the start of your labour or from when your waters break until your baby is born can prevent most GBS infections in newborn babies.

Ideally, you should have intravenous antibiotics for at least two hours before your baby is born and every four hours during labour (RCOG 2003:6). There are some risks with taking antibiotics for you and your baby so your doctor will discuss your particular case with you to see whether treatment is the best option for you.

If you have two or more of the above risk factors then your doctor is much more likely to recommend treatment during labour to reduce the risk of your baby developing an infection (RCOG 2003:6).

If you are having a planned caesarean there is no need for intravenous antibiotics unless your waters have broken or labour has already started (RCOG 2007:6).
If your baby is at higher risk of developing a GBS infection, once he is born:

He should be examined by a paediatrician immediately
If both you and he are completely healthy, and you had full treatment with intravenous antibiotics during labour, he may be given intravenous antibiotics
If both you and he are healthy, but you have not received full treatment with intravenous antibiotics during labour, he may be started on intravenous antibiotics until he's given the all clear
If you or he shows signs of GBS infection, he should be started on intravenous antibiotics immediately

The best way to treat newborns at risk of GBS infection is an area that doctors are still researching, which is why in some cases your baby may or may not be given antibiotics.

What are the risks of treatment?

Most women and babies can safely be given penicillin as the antibiotic treatment for GBS without any ill-effects. However, a small number of people are allergic to penicillin and could have a severe allergic reaction (anaphylaxis), which can be fatal.

Women who are known to be allergic to penicillin can be given another antibiotic instead (RCOG 2003:6).

Other less severe side-effects of antibiotic treatment include diarrhoea and nausea. However, there are concerns that antibiotics may affect the balance of a baby's bacterial flora in the gut (RCOG 2003:1).
These adverse effects make some doctors more cautious about using antibiotics if there is not a clear need to do so, particularly for newborns. Some prefer a "watch and wait" approach for the first 12 hours after birth before starting a course of antibiotics that may not be needed (RCOG 2003:7-10).

What are the signs of GBS infection in a baby?

GBS infections in babies are usually "early-onset" (within seven days of birth), with 90 per cent occurring within 12 hours of birth (RCOG 2003:7-8).
In many cases, symptoms of GBS infection in babies can be recognised at or soon after birth (RCOG 2003:7).

Typical signs of early-onset GBS infection include:

Grunting
Poor feeding
Lethargy
Irritability
Low blood pressure
Abnormally high or low temperature, heart rate and/or breathing rate
(GBSS 2007b)

Although more unusual, GBS infections can also develop when the baby is seven or more days old ("late-onset" GBS), usually as meningitis with septicaemia.

Some warning signs of late-onset GBS infection may include:

Fever
Poor feeding and/or vomiting
Drowsiness
(GBSS 2007b)

Signs of meningitis in babies may include, as well as any of the signs listed above:

Shrill or moaning cry or whimpering
Dislike of being handled, fretful or irritable
Tense or bulging fontanelle (soft spot on head)
Floppy and listless or stiff with jerky movements
Blank, staring or trance-like expression
Being difficult to wake
Low or high breathing rate
Turns away from bright lights
Skin that is pale, blotchy or turning blue
(GBSS 2007b; DH 2006)

Red or purple spots that do not fade under pressure (such as when pressed firmly with the side of a glass) are a sign of septicaemia (DH 2006).

Early diagnosis and treatment are vital in late-onset GBS infection or meningitis. If your baby shows any of the signs above, call your GP immediately.

If your GP isn't available, go straight to your nearest accident and emergency department. The risk of your baby developing GBS decreases with age; GBS infections in babies are rare after one month of age and virtually unknown after three months (GBSS 2007).

Most babies survive with treatment, but meningitis can leave some babies with long term problems - visit The Meningitis Trust for more information.

Why isn't there a national screening programme for GBS?

There are strict criteria that have to be met before a national screening programme for any disease can be introduced (UK NSC 2003). These include weighing up factors such as the accuracy of a screening test and the risks versus benefits of treatment.
In the case of GBS, experts are not convinced that a lab test screening programme would do more good than harm. Reasons for this include:

Current lab testing through the NHS in the UK is not reliable enough to recommend that all pregnant women be swabbed and tested during late pregnancy
There are concerns that the widespread use of antibiotics during labour could increase the risks of severe allergic reactions (anaphylaxis) and make the labour and newborn period too medicalised
The rates of bacteria resistant to antibiotics could increase
Newborns affected by antibiotics during labour may possibly be more likely to develop allergies and have poor immune systems (RCOG 2003:1-4)

I'm carrying GBS - what now?

If you have been affected by GBS in a previous pregnancy, or you are found to be carrying it in your current pregnancy, talk to your midwife or obstetrician and agree a pregnancy and birth plan that will protect your baby from the infection.

In the vast majority of cases your pregnancy can be managed so your baby is protected and born healthy and free from GBS.

Your baby is not at risk of catching GBS from breastfeeding (RCOG 2003:8) so there is no need to change your plans if you intend to breastfeed your baby.

SWINE FLU and PREGNANCY

2009-12-04T15:28:00.002+07:00

What is swine flu (H1N1)?

Swine flu (H1N1) is a highly contagious type of flu, with symptoms similar to seasonal flu. Swine flu has spread so quickly because it is a new virus, so most of us have not built up any immunity to it. The H1N1 virus is called swine flu because it is thought to originate from pigs.
Swine flu was first reported in Mexico in April 2009. Two months later, the World Health Organisation (WHO) raised a worldwide pandemic alert. This means that the disease has spread to many countries around the world.

How does swine flu spread?

Swine flu spreads in the same way as other flu viruses, through droplets from the coughs and sneezes of people who are infected. It spreads easily, particularly in enclosed spaces where there is close contact between people (WHO 2009).

What are the symptoms of swine flu?

Swine flu affects people differently. Most people who catch the virus have only mild symptoms (BMJ 2009a), but some people develop complications such as dehydration, pneumonia (an infection in the lungs) or difficulty breathing (NHS Choices 2009a).
There is evidence that pregnant women are four times more likely to develop complications from swine flu than non-pregnant women (DH 2009a). However, for most pregnant women the symptoms of swine flu are similar to ordinary flu. These are:

sudden fever
tiredness
sore throat
runny nose
cough
headache
muscle and joint pain

Swine flu can also cause:

Acute abdominal pain
Diarrhoea
Vomiting (NHS Choices 2009b)

A fever caused by swine flu can be very high, reaching above 39 degrees C (102.2 degrees F), which is more than two degrees above your normal body temperature.

I'm pregnant. Am I more at risk of catching swine flu?

Pregnant women are not known to be more at risk of catching swine flu. However, if you do catch the flu you have a greater risk of developing complications (RCOG/DH 2009). This is because your immunity to infection is slightly lowered to stop your body rejecting your unborn baby. This also makes it particularly important that you are careful to protect yourself (see below) (CDC 2009b).

Can I be vaccinated against swine flu?

A vaccine for swine flu is available.

Pregnant women will be a priority in the early stages of the vaccination programme (NHS Choices 2009a).

The vaccine is given to pregnant women in two doses, with a three-week interval. It is recommended that all pregnant women have the swine flu vaccine (BMJ 2009b).

Are there other ways I can protect myself against swine flu?

You can reduce your risk of infection by avoiding unnecessary travel and keeping away from crowds. Wherever possible, try to avoid contact with people who have flu-like symptoms or you know have swine flu (Directgov 2009c).

Unless you have swine flu symptoms, you can carry on attending your antenatal appointments. You should also follow the hygiene rules recommended for everyone:

Cover your nose and mouth with a disposable tissue when you cough and sneeze and throw it away after using it (Directgov 2009b).
If you don't have a tissue to hand, cover your mouth with the inner part of your elbow when you cough or sneeze. This will avoid passing the infection to your hand and will minimise spreading the disease (WHO 2009).
After coughing and sneezing, wash your hands with warm water and soap. Rub both sides of your soapy hands for at least for 15 seconds and rinse with lots of water. If soap and water are not available, use alcohol-based disposable hand wipes or gel sanitisers (CDC 2009a).
Don't touch your eyes, nose or mouth, because the germs spread very quickly (WHO 2009).
Wash your hands frequently. The virus can live for up to 24 hours on surfaces such as doorknobs and telephones (NHS Choices 2009a).
Eat a healthy diet, including plenty of fresh fruit, vegetables and wholegrain foods that will give you the minerals and antioxidant vitamins that help to fight infections (BDA 2009).

Could swine flu affect my developing baby?

We know that with ordinary seasonal flu, your baby is well protected against the virus within your uterus (womb). Swine flu is a new strain of flu, so we don't yet know everything about it, but the risk of infection for your developing baby is not thought to be high (RCM 2009).

Fever in early pregnancy is known to slightly increase the risk of neural tube defects, such as spina bifida, so it's important to control a high temperature. A very small number of pregnant women with swine flu develop complications, such as pneumonia, that can lead to miscarriage or their baby being born early. These risks are greater during the second and third trimesters of pregnancy.

The vast majority of pregnant women with swine flu make a full recovery and go on to have a healthy baby at full-term (HPA 2009).

How long do people stay contagious?

People who have the swine flu virus can be contagious for up to seven days after the onset of the illness. Children, especially younger ones, may be contagious for longer (CDC 2009a).

What should I do if I or somebody in my family has symptoms of swine flu?

If you're pregnant, call your doctor immediately to explain what's happening and tell her you are pregnant (CDC 2009b). Swine flu can be more severe in people with compromised immune systems, so she will also need to know if you, or anyone else in your family, have any other health problems (NHS Choices 2009b). Your doctor may prefer to give you a diagnosis over the phone, because the virus is highly contagious (NHS Choices 2009a).

If you think someone in your family has swine flu, log onto the National Pandemic Flu Service, which can dispense antiviral drugs. If you are pregnant or your child is under one, this service will not be suitable for you and you will still need to speak to your doctor (Directgov 2009).
You can also call NHS Direct on 0845 4647 for advice.

How can swine flu be treated?

Fever is one of the symptoms of swine flu, so if you have a high temperature it's important to control it. Try your best to cool yourself down with a fan or tepid sponge. You can safely take paracetamol-based cold remedies (RCOG 2009). However, if you are pregnant, you should not take aspirin or anti-inflammatory drugs such as ibuprofen (NHS Choices 2009c).

There is no cure for swine flu, but antiviral drugs will relieve the symptoms and help you to recover faster. They will also reduce the likelihood of you developing complications. It's recommended that pregnant women are offered antiviral treatment if it's suspected they have swine flu, even before it's been confirmed (RCOG/DH 2009).

Most pregnant women will be prescribed the antiviral drug Relenza. This antiviral is inhaled, so reaches the throat and lungs and does not build up in your blood stream (NHS Choices 2009d). If you have a health condition that makes it difficult for you to inhale a preparation, such as asthma, you will be offered Tamiflu (DH 2009b).
The risk of taking antiviral treatments in pregnancy is extremely small, and much smaller than the risks posed by the symptoms of swine flu (NHS Choices 2009a).

GENITAL HERPES IN PREGNANCY

2009-12-04T13:26:00.002+07:00

Most women with genital herpes give birth to healthy babies. However, if you suffer from genital herpes there is a very small risk that your baby will catch the infection and if she does the results can be serious, even fatal. That's why it is important to tell your midwife if you or your partner have ever had an outbreak of genital herpes or if you think you have any of the symptoms. Extra care can then be taken of you and your baby.

What is genital herpes?

Genital herpes is caused by the herpes simplex virus which also causes cold sores around and in the mouth. Genital herpes is usually caused by herpes simplex virus type 2 (HSV-2), while cold sores are usually caused by herpes simplex virus type 1 (HSV-1). However, genital herpes can also be caused by HSV-1. Once you have been infected with a herpes virus it stays in your body for life, only becoming active every now and again.

How might genital herpes affect my pregnancy?

If you had genital herpes before you became pregnant then the risk of your baby becoming infected is very low, even if you have an outbreak during your pregnancy or during labour. This is because your body has had time to develop antibodies to the herpes simplex virus and this immunity is passed on to your baby during pregnancy. Your baby will continue to be immune for up to three months after the birth.

If you catch genital herpes for the first time in the first or second trimester of your pregnancy, there is a slight risk that it will affect your developing baby. The infection has been linked to :

Miscarriage,
Intrauterine growth retardation (IUGR),
Premature labour,
Microcephaly (where the baby's brain is underdeveloped) and
Hydrocephaly (where fluid builds up around the baby's brain) but this happens very rarely.

Your doctor will probably refer you to a genitourinary medicine (GUM) clinic where you will be given a 5-day course of an oral antiviral medicine, usually acyclovir.

The ACYCLOVIR wll help you to reduce your discomfort and speed up the healing or your sores. It is safe to use in pregnancy.

Your baby is at greater risk if you catch genital herpes for the first time in late pregnancy before you have had time to develop antibodies to the virus and to pass this immunity on to your baby. Your baby can catch the virus through direct contact with an active sore, which is weeping or inflamed, during birth. If a baby catches the infection at birth it is called neonatal herpes. About four in ten babies develop neonatal herpes when born vaginally to women with a first infection when they come to give birth.
In the UK, only one or two babies in 100,000 catch neonatal herpes, but it can be very serious and even fatal. Neonatal herpes can cause infection in a baby's skin, eyes or mouth and may damage the brain or other organs. If your baby does catch neonatal herpes, effective treatment with antiviral medicine for you and your baby can help prevent and minimise long term damage to your baby's health.

Will I need to have a caesarean?

If you suspect you have an active genital herpes infection in the last trimester of pregnancy it is vital that you tell your midwife or doctor. If you have never had herpes before then you will probably be advised to have a planned caesarean section, particularly if you have your first outbreak in the last six weeks of pregnancy. This is to minimise the risk of transmitting the virus to your baby.
If you want to go ahead with a vaginal delivery, then your obstetrician will try to avoid any invasive procedures such as ventouse or forceps and will give you intravenous acyclovir during labour and delivery as this may reduce the risk of your baby catching herpes. Your newborn baby will also be given acyclovir.
If it is not your first infection, you will probably be given acyclovir daily for the last four weeks of pregnancy. You will not be advised to have a caesarean as your baby will probably have immunity to the virus.

Can I breastfeed if I have herpes?

The herpes virus is not transmitted through breastmilk so having herpes shouldn't stop you from breastfeeding, providing you don't have any sores on your breasts. Make sure that sores elsewhere on your body are covered and wash your hands frequently and carefully. If you are taking acyclovir, it will be excreted in your breastmilk but is not thought to be harmful.

What are the symptoms of a genital herpes infection?

Symptoms vary a lot from person to person. What most people do find is that symptoms are usually worse, and last longer, the first time they have a herpes outbreak. Symptoms of a primary or first infection may include:

painful sores over your genitals and buttocks

itching
stinging when passing urine
vaginal discharge
swollen glands in the groin area
flu-like symptoms including fever, headache and muscle aches

A primary episode can last two to three weeks.
With a second or later infection you may get no symptoms at all or just a small area of irritation. If it is not your first outbreak, it will probably be over within three to five days.
Whether or not you have symptoms, it is important to remember that you are still contagious during a herpes recurrence. In fact, most infections occur when the person passing it on has no noticeable symptoms. This is why it is important to tell your midwife if you or your partner suspect you may have had a herpes outbreak in the past.

How can I avoid catching the virus while I am pregnant?

If your partner has genital herpes you need to be particularly careful when you are pregnant. As the virus can be transmitted without your partner knowing that he is having an outbreak there are no foolproof methods to avoid catching herpes. In fact, the virus is most infectious when, or just before, symptoms appear. You can catch herpes from penetrative and non-penetrative sex (vaginal or anal), from oral sex, and by sharing sex toys. Condoms may help to reduce the risk of catching herpes from your partner, or you may want to avoid sex altogether. You should also be aware that you can catch genital herpes from your partner if he has oral herpes and performs oral sex.

LISTERIA and PREGNANCY

2009-12-04T07:27:00.002+07:00

During pregnancy, it is important to be aware of what you put inside your body. You should be aware of what is good to eat and also what is not so good to eat. Listeria is a type of bacteria that can be found in some contaminated foods. Listeria can cause problems for both you and your baby. Although listeriosis (the illness from ingesting Listeria) is rare, pregnant women are more susceptible to it than non-pregnant healthy adults.

What is Listeria?

Listeria monocytogenes is a type of bacteria that is found in water and soil. Vegetables can become contaminated from the soil, and animals can also be carriers. Listeria has been found in uncooked meats, uncooked vegetables, unpasteurized milk, foods made from unpasteurized milk, and processed foods.

Listeria is killed by pasteurization and cooking. There is a chance that contamination may occur in ready-to-eat foods such as hot dogs and deli meats because contamination may occur after cooking and before packaging.¹

What are the risks of a pregnant woman getting listeriosis?

According to the Center of Disease Control (CDC), an estimated 2,500 persons become seriously ill each year in the United States and among these, 500 will die. According to research, pregnant women account for 27% of these cases. CDC claims that pregnant women are 20 times more likely to become infected than non-pregnant healthy adults.

How will I know if I have listeriosis?

Symptoms of listeriosis may show up 2-30 days after exposure. Symptoms in pregnant women include mild flu-like symptoms, headaches, muscle aches, fever, nausea, and vomiting. If the infection spreads to the nervous system it can cause stiff neck, disorientation, or convulsions. Infection can occur at any time during pregnancy, but it is most common during the third trimester when your immune system is somewhat suppressed. Be sure to contact your health care provider if you experience any of these symptoms.

Can listeriosis harm my baby?

If you are pregnant and are infected with listeriosis, you could experience:

Miscarriage
Premature delivery
Infection to the newborn
Death to the newborn (about 22% of cases of perinatal listeriosis result in stillbirth or neonatal death)

Early treatment may prevent fetal infection and fetal death.

How is listeriosis treated?

Listeriosis is treated with antibiotics during pregnancy. These antibiotics, in most cases, will prevent infection to the fetus and newborn. These same antibiotics are also given to newborns with listeriosis.

What can I do to protect my baby from listeriosis?

Following these guidelines can greatly reduce your chances of contracting Listeriosis.

Eat hard cheeses instead of soft cheeses: The CDC has recommended that pregnant women avoid soft cheeses such as feta, Brie, Camembert, blue-veined cheesesl and Mexican style cheeses such as queso fresco, queso blanco and panela.

Hard cheeses such as cheddar and semi-soft cheeses such as mozzarella are safe to consume. Pasteurized processed cheese slices and spreads such as cream cheese and cottage cheese can also be safely consumed. The most important thing to do is read the labels!

Be cautious when eating hot dogs, luncheon meats, or deli meats unless they are properly reheated to steaming( or 160 degrees F.): Eating out at certain restaurants that provide deli meat sandwiches is not recommended for pregnant women since they do not reheat their deli meats. Restaurants such as Subway recommends that pregnant women eat the following non-luncheon meat items such as meatball, steak and cheese, roasted chicken, and tuna (limit 2 servings a week).

Do not eat refrigerated pates or meat spreads.

Do not eat refrigerated smoked seafood unless it is contained in a cooked dish, such as a casserole.

Practice safe food handling:

Wash all fruits and vegetables
Keep everything clean including your hands and preparation surfaces
Keep your refrigerator thermometer at 40 degrees or below
Clean your refrigerator often
Avoid cross contamination between raw and uncooked foods (this includes hot dog juices)
Cook foods at proper temperatures (use food thermometers) and reheat all foods until they are steaming hot (or 160 F)

Proper Temperatures for Cooking Foods:

Chicken: 165-180 F
Egg Dishes: 160 F
Ground Meat: 160-165 F
Beef, Medium well: 160 F
Beef, Well Done: 170 F (not recommended to eat any meat cooked rare)
Pork: 160-170 F
Ham (raw): 160 F
Ham (precooked): 140 F

Refrigerate or freeze food promptly.

REPIRATORY INFECTIONS DURING PREGNANCY

2009-12-04T07:18:00.002+07:00

What is a viral respiratory infection?

A viral respiratory infection is a contagious illness that can affect your respiratory tract (breathing) and cause other symptoms.

The flu and the common cold are examples of viral respiratory infections.

Other examples of respiratory viruses are:

Chickenpox (varicella)
Fifth disease
Cytomegalovirus (say: "si-to-meg-ah-low-vi-russ")
Rubella (also called German measles)

What if I'm exposed to a viral respiratory infection when I'm pregnant?

Pregnant women can be exposed to people with viral infections at work and at home. Most of the time, the woman doesn't get infected. Even if she does, most viruses won't hurt her baby. However, some viruses can cause miscarriage or birth defects in the baby.

If you're exposed to chickenpox, fifth disease, cytomegalovirus or rubella while you're pregnant, you should tell your doctor right away. Your doctor will want to know how much contact you've had with the infected person.
Here are some questions your doctor may ask you:

Did you touch or kiss the infected person
How long were you in contact with the the infected person?
When did the infected person get sick?
Did a doctor diagnose the infected person's illness? Were any tests done?

What should I do if I'm exposed to CHICKENPOX?

Chickenpox is caused by the varicella virus and is highly contagious. It can be serious during pregnancy. Sometimes, chickenpox can cause birth defects. If you've had chickenpox in the past, then it is unlikely you will catch it again and your baby will be fine. If you have not had chickenpox or if you're not sure, you should see your doctor right away. Your doctor will test your blood to see if you are immune.

Many people who don't remember having chickenpox are immune anyway. If your blood test shows that you're not immune, you can take medicines to make your illness less severe and possibly help protect your baby from chickenpox.

What should I do if I'm exposed to FIFTH disease?

Fifth disease is a common virus in children. Half of all adults are susceptible to fifth disease and can catch it from children.
Children who have fifth disease usually develop a rash on their body and have cold-like symptoms. They may have red cheeks that look like they've been slapped or pinched. Adults who get fifth disease don't usually have the "slapped cheek" rash. Adults who contract fifth disease usually have very sore joints.

If you get fifth disease early in your pregnancy, you could have a miscarriage. Fifth disease can also cause birth defects in your baby (such as severe anemia). If you're exposed to fifth disease, call your doctor. Your doctor may have you take a blood test to see if you're immune. You may also need an ultrasound exam to see if the baby has been infected.

What if I'm exposed to CYTOMEGALOVIRUS?

Cytomegalovirus usually doesn't cause any symptoms, so you probably won't know if you have it. It's the most common infection that can be passed from mother to baby.

Cytomegalovirus affects 1 of every 100 pregnant women. It can cause birth defects (such as hearing loss, development disabilities or even death of the fetus).

It's important to prevent cytomegalovirus because there's no way to treat it. Women who work in day care centers and in a health care setting have the highest risk of getting infected. Pregnant women with these jobs should wash their hands after handling diapers and avoid nuzzling or kissing the babies. If you think you've been exposed to a person who has cytomegalovirus, you should see your doctor right away.

What if I'm exposed to RUBELLA (German measles)?

Since 1969, almost all children have had the rubella vaccine, so it is a rare disease today.

At the first prenatal visit, all pregnant women should be tested to see if they're immune to rubella. Women who are not immune to rubella should get the vaccine after the baby is born. It's even better to be tested before you get pregnant, so that you can get the vaccine if you need it.

If you're exposed to rubella when you're pregnant and are not immune, severe birth defects or death of the fetus can occur. Symptoms of rubella in adults is typically joint pain and occasionally an ear infection. Talk to your doctor if you are experiencing these symptoms.

What if I'm exposed to INFLUENZA?

Influenza hardly ever causes birth defects. It can be more serious for the mother if she gets the flu while pregnant. You might get very sick. If you'll be pregnant during the flu season (from October through March), you should get a flu shot in the fall.

What about other viral infections?

Most other respiratory viruses (such as regular measles, mumps, roseola, mononucleosis ["mono"] and bronchiolitis) don't seem to increase the normal risk for birth defects. In normal pregnancies, the risk of serious birth defects is only 2% to 3%. To protect yourself from all infectious viruses, wash your hands frequently (especially after using the restroom or before a meal).

HEPATITIS IN PREGNANCY

2009-12-04T06:56:00.002+07:00

Effects of Hepatitis B Virus Infection

Hepatitis B virus is one of a number of viruses that attack and damage the liver. (Other types include hepatitis A, hepatitis C, and hepatitis D.) The liver is an organ located in your upper abdomen.

Hepatitis B virus is passed from person to person by way of infected body fluids. These body fluids include:

Blood
Semen
Vaginal fluids
Saliva

Infection with hepatitis B virus can cause major health problems. A person infected with this virus may not show any signs of being infected, but can pass it on to others.

Infection with hepatitis B virus is a special problem for pregnant women. Not only does a pregnant woman face the risks of hepatitis herself, she also can pass the virus to her baby. About 1 in every 500–1,000 pregnant women has hepatitis when she gives birth. More pregnant women may be infected but not show any signs.

The virus can be spread through sexual contact.

The virus also can be passed to someone who comes in contact with the blood of an infected person. This can occur in many different ways, for instance by sharing needles with someone who is infected with the virus. It also can be passed during childbirth.

Infected persons are at risk for many health problems. The virus infects the liver and can cause chronic (long-term) hepatitis.

Chronic hepatitis can be life threatening. Persons with chronic hepatitis have a greater chance of getting certain types of liver disease, such as cirrhosis (hardening) of the liver and cancer of the liver.

The symptoms of hepatitis can include:

Fatigue
Loss of appetite
Nausea
Jaundice (yellowing of the skin and eyes)
Dark urine
Soreness in the liver
Muscle aches

Most people who get hepatitis become immune to it after the disease runs its course. At this point, they can no longer pass it on to someone else.

Some people infected with the virus do not become immune to it, but show no sign of infection. Such people are called carriers. They still can pass the virus to someone else even though they do not have any symptoms. A woman who is a carrier can pass the virus to her baby at birth. Carriers sometimes become sick later in life.

Effects During Pregnancy

When a pregnant woman is infected with hepatitis B virus, there is a chance she will infect her fetus. Whether the baby will get the virus depends on when infection occurred. If it was early in pregnancy, the chances are less than 10% that the baby will get the virus. If it was late in pregnancy, there is up to a 90% chance that the baby will be infected.

Hepatitis can be severe in babies. It can threaten their lives. Even babies who appear well may be at risk for serious health problems.

Infected newborns have a high risk (up to 90%) of becoming carriers. They, too, can pass the virus to others. When they become adults, these carriers have a 25% risk of dying of cirrhosis of the liver or liver cancer.

Testing for the Virus

A blood test can show whether someone has been infected with hepatitis B virus. For the test, a small sample of blood is taken and tested for a special protein—called an antigen—that is found in blood infected with the virus.

If your test result is negative, it means you were not infected with the virus at the time the test was done. If your test result is positive, it means you have been infected with the virus and can infect others. This includes your baby if you are pregnant. Your doctor will want to do more tests to learn whether your liver is still healthy. A positive test result means that your children, your sexual partner(s), and others living in your household are at risk of infection. They should be told about testing and vaccination. They will need to decide whether to have them done.

All pregnant women should be tested for the virus. The test should be done early enough in pregnancy to allow time to prepare treatment for the baby and to test family members if your test result is positive.

Prevention of Hepatitis B Virus

There are steps you can take to try to prevent being infected with hepatitis B virus. One thing you can do is practice safe sex. The use of condoms during sex helps to prevent infection with hepatitis B virus and other sexually transmitted diseases (STDs), such as human immunodeficiency virus (HIV), the virus that causes acquired immunodeficiency syndrome (AIDS).

Do not share needles used to inject drugs. Sharing needles greatly increases your chances of getting the virus.

Another way to prevent the virus is to get the hepatitis B virus vaccine. A vaccine is a type of medicine you are given—as a shot in most cases—to keep you from getting a certain type of disease. The hepatitis B virus vaccine triggers the body's immune system to make antibodies. These antibodies then fight off the virus when you are exposed to it. The vaccine will not protect against other types of hepatitis and will not help people who already are infected with hepatitis B virus.

The vaccine is safe for use during pregnancy. There is no risk of getting hepatitis or other diseases, such as AIDS, from the vaccine. It is given in three doses: the first dose is followed by a second dose in 1 month and a third dose in 6 months.

In some cases, your doctor also may give you hepatitis B immune globulin (HBIG). It contains antibodies to the virus. This will protect you against the virus until the vaccine triggers your body to make its own antibodies. HBIG also can be used in pregnancy.

Anyone can become infected with hepatitis B virus. Some people, though, are at increased risk of infection (see box). All teenagers aged 13–18 years who have not already been vaccinated should get the vaccine to protect themselves, their sexual partners, and any children they may have later.

All infants should get the hepatitis B virus vaccine. If you are pregnant and have the virus, your baby will receive HBIG soon after birth. Your baby also will receive the first dose of vaccine. Two more doses of the vaccine will be given later—one at 1–2 months of age and one at 6 months of age. This plan is an effective way to prevent babies from becoming hepatitis B virus carriers.

If you had a negative test result, your baby should get the first dose of vaccine before you leave the hospital. If it cannot be given by then, it should be given within 2 months of birth. Check with the baby's doctor to find out when the second and third dose should be given.

If you were not tested, your baby should get the first dose of vaccine and then you should be tested. The rest of your baby's treatment depends on whether your test results are positive or negative.

Finally...

Infection with hepatitis B virus can damage your health. The test is a safe, easy way to learn whether you have been infected with the virus. If your test results are negative, but you are at increased risk for getting the virus, you should receive the hepatitis B virus vaccine to protect you.

Infection with the virus also can harm your baby. For that reason, all pregnant women should be tested for the virus. If you have a positive test result, your baby will be treated right after birth. All newborns should receive the vaccine.

WHO IS AT RISK ?

Some people are at increased risk for hepatitis B virus. You may need to be vaccinated if you have one or more of these risk factors:

Inject illegal drugs

Are seeking care for a sexually transmitted disease

Are infected with HIV

Have had multiple sexual partners within the past 6 months

Are a health care or public safety worker

Live or have sex with someone who is infected with the virus

Work or live in a home for the disabled

Have certain types of liver or kidney problems.

Have received treatment (clotting factors) for a bleeding disorder

Travel to countries where HBV infection is common

Are in prison

CYTOMEGALOVIRUS

2009-12-04T05:40:00.002+07:00

Cytomegalovirus (CMV) [si-to-MEG-uh-lo-vi-rus] is a virus that infects most people worldwide.
CMV spreads from person to person by direct contact.
Although CMV infection is usually harmless, it can cause severe disease in persons with weakened immune systems.
There is no treatment for CMV infection.
Prevention centers on good personal hygiene, especially frequent handwashing.

What is cytomegalovirus?

Cytomegalovirus, or CMV, is a common virus that infects most people worldwide.
CMV infection is usually harmless and rarely causes illness. A healthy immune system can hold the virus in check. However, if a person's immune system is seriously weakened in any way, the virus can become active and cause CMV disease.

What is the infectious agent that causes cytomegalovirus infection?

Cytomegalovirus is a member of the herpesvirus family. Other members of the herpesvirus family cause chickenpox, infectious mononucleosis, fever blisters, and genital herpes. These viruses all share the ability to remain alive, but dormant, in the body for life.

A first infection with CMV usually causes no symptoms. The virus continues to live in the body silently without causing obvious damage or illness. It rarely becomes active for the first time or reactivates (causes illness again in the same person) unless the immune system weakens and is no longer able to hold the virus in check.

Where is cytomegalovirus found?

CMV is found worldwide. The virus is carried by people and is not associated with food, water, or animals.

How do people get infected with cytomegalovirus?

CMV is spread from person to person. Any person with a CMV infection, even without symptoms, can pass it to others. In an infected person, the virus is present in many body fluids, including urine, blood, saliva, semen, cervical secretions, and breast milk.

CMV can be spread by any close contact that allows infected body fluids to pass to another person. CMV can spread in households and child-care centers through hand-to-mouth contact with infected body fluids. CMV can spread by sexual contact, blood transfusions, organ transplants, and breastfeeding. CMV can also be passed from an infected pregnant woman to her fetus or newborn.

Who is at risk for cytomegalovirus?

Anyone can become infected with CMV. Almost all people have been exposed to CMV by the time they are adults, but the virus usually does not make otherwise healthy people sick. However, some people are at increased risk for active infection and serious complications:

Babies born to women who have a first-time CMV infection during pregnancy
Pregnant women who work with infants and children
Persons with weakened immune systems, including cancer patients on chemotherapy, organ transplant recipients, and persons with HIV infection

What are the signs and symptoms of cytomegalovirus?

Active infection in otherwise healthy children and adults can cause prolonged high fever, chills, severe tiredness, a generally ill feeling, headache, and an enlarged spleen.

Most infected newborns have no symptoms at birth, but, in some cases, symptoms will appear over the next several years. These include mental and developmental problems and vision or hearing problems. In rare cases, a newborn can have a life-threatening infection at birth. Infants and children who get CMV infection after birth have few, if any, symptoms or complications. When symptoms do appear, they include lung problems, poor weight gain, swollen glands, rash, liver problems, and blood problems.

People with weakened immune systems can have more serious, potentially life-threatening illnesses, with fever, pneumonia, liver infection, and anemia. Illnesses can last for weeks or months and can be fatal. In persons with HIV infection, CMV can infect the retina of the eye (CMV retinitis) and cause blindness.

How soon after exposure do symptoms appear?

Most exposed people never develop symptoms. In those who do, the time between exposure and symptoms is about 3 to 12 weeks.

How is cytomegalovirus diagnosed?

There are special laboratory tests to culture the virus, but testing requires 2 to 3 weeks and is expensive. Blood tests can help diagnose infection or determine if a person has been exposed in the past.

How long does disease from CMV infection last?

The duration of disease varies, depending on the type of infection and the age and health of the infected person.
Serious CMV infections that were acquired before birth can cause developmental problems that can affect a child for a lifetime.
CMV infections in transplant recipients, cancer patients, and persons with HIV infection can be life threatening and require many weeks of hospital treatment. On the other hand, infections in young adults might cause symptoms for only 2 to 3 weeks.

What is the treatment for cytomegalovirus?

There is no specific treatment or cure for CMV infection.

Anti-virus medicines can be helpful in treating CMV retinitis in persons with HIV infection.

How common is cytomegalovirus?

CMV is common worldwide. An estimated 80% of adults in the United States are infected with CMV. CMV is also the virus most often transmitted to a developing fetus before birth.

Is cytomegalovirus an emerging infectious disease?

Yes. Increasing numbers of persons are at risk for CMV infection. Expanding use of child-care centers is increasing the risk to children and staff. Also, the number of people with weakened immune systems is growing because of increases in HIV infection, organ transplantation, and cancer chemotherapy.

How can cytomegalovirus be prevented?

CMV is widespread in the community. The best way to prevent infection is to practice good personal hygiene. Wash hands often with soap and warm water. Avoid mouth contact with the body fluids of young children.

CHLAMYDIA

2009-12-04T05:31:00.002+07:00

Chlamydia [kla-MID-ee-uh] is a sexually transmitted bacterial infection.
Chlamydia can lead to serious reproductive problems, especially in women.
Chlamydia infection is transmitted through sexual contact with an infected partner. An infected woman can also pass the infection to her newborn during vaginal delivery.
Chlamydia is often a "silent" infection. Most people with chlamydia have no symptoms and do not seek medical care.
Once diagnosed, chlamydia is easily cured with antibiotics.
Prevention centers on 1) use of condoms, and 2) early diagnosis and treatment.

What is chlamydia?

Chlamydia is a SEXUALLY TRANSMITTED DISEASE (STD) that can lead to serious reproductive problems, especially in women.

What is the infectious agent that causes chlamydia?

Chlamydia is caused by Chlamydia trachomatis, a bacterium.

How do people get chlamydia?

Chlamydia is spread by having vaginal sex with a person who has the infection. It can also be passed from an infected mother to her newborn during vaginal childbirth.

What are the signs and symptoms of chlamydia?

Chlamydia is known as a "silent" disease because three quarters of the women and half of the men infected with the bacterium have no symptoms. Thus, the infection can become very serious before a person even recognizes a problem.

Symptoms in men: Men with symptoms might have a discharge from the penis and a burning sensation when urinating. Men might also have burning and itching around the opening of the penis and/or pain and swelling in the testicles.

Symptoms in women: The few women with symptoms might have a vaginal discharge or a burning sensation when urinating. When the infection spreads to the uterus and fallopian tubes, women can have lower abdominal pain, nausea, fever, pain during intercourse, and bleeding between menstrual periods.

How soon after exposure do symptoms appear?

If symptoms do occur, they usually appear within 1 to 3 weeks of exposure.

How is chlamydia diagnosed?

There are two kinds of laboratory tests to diagnose chlamydia. One involves collecting a small amount of fluid from an infected site (cervix or penis) to detect the bacterium directly. New tests use urine samples to detect small pieces of chlamydia nucleic acid. These are not yet widely available but are making testing much easier, faster, and less painful.

Who is at risk for chlamydia?

Sexually active men and women can be exposed to chlamydia bacteria unknowingly via sexual contact with an infected person. The more sex partners a persons has, the greater the risk of chlamydia infection. Babies born to infected mothers are also at risk.

Sexually active teenagers and young women are especially susceptible to chlamydia bacteria because of the characteristics of the cells that form the inner lining of the cervix. These cells are easily invaded by chlamydia bacteria. In young women, they are exposed on the outer part of the cervix, making them more vulnerable. The cells eventually recede inside the cervix as a woman matures.

What is the treatment for chlamydia?

Chlamydia can be treated and cured with antibiotics. A single dose of azithromycin or a week of doxycycline (twice daily) are the most commonly used treatments. All sex partners must also be treated.

What complications can result from chlamydia?

Untreated, chlamydia infection can progress to serious reproductive and other health problems with both short-term and long-term consequences. Like the disease itself, the damage that chlamydia causes is often "silent."

Untreated chlamydia in men typically causes urethral infection. Infection sometimes spreads to the epididymis (a tube that carries sperm from the testis), causing pain, fever, and potentially infertility.

In women, chlamydia usually begins in the cervix. If not treated, it can spread to the fallopian tubes and cause an infection called pelvic inflammatory disease (PID). PID can cause chronic pelvic pain, infertility, and potentially fatal ectopic pregnancy (pregnancy outside the uterus). In pregnant women, there is some evidence that chlamydia infections can lead to premature delivery.

Babies who are born when their mothers are infected can get chlamydia infections in their eyes and respiratory tracts. Chlamydia is the leading cause of early infant pneumonia and conjunctivitis (pinkeye) in newborns.

How common is chlamydia?

Chlamydia is the most frequently reported infectious disease in the United States. More than 450,000 cases were reported in 1995. Under-reporting is substantial, though, because most people with chlamydia are not aware of their infections. An estimated 4 million Americans are believed to have it, mostly teenage girls.

Is chlamydia an emerging infectious disease?

Chlamydia is a very common condition in the United States. From 1984 through 1995, reported rates increased from 3.2 to 182.2 cases per 100,000 people. This trend mainly reflects increased screening, increased recognition of symptom-less infections (mainly in women), and improved reporting.

How can chlamydia be prevented?

Young, sexually active and unmarried persons should be screened for chlamydia yearly.
Anyone with symptoms should get medical advice, evaluation, and treatment right away.
Anyone found to be infected should inform all sex partners and be sure they get treated, too.
Persons being treated for chlamydia infection should not have sex of any kind until treatment is completed as directed for all partners.
Persons being treated must complete all medications. They should not stop taking prescribed medicines when symptoms disappear.

As a general rule: Sexually active women and men should always use a barrier form of contraception, such as a latex condom. Birth control pills do not protect women from chlamydia.

RUBELLA

2009-12-04T05:10:00.002+07:00

Rubella [rue-BELL-uh] is a mild but very contagious viral illness. Other names for rubella are German measles and three-day measles.

Rubella is dangerous because of its ability to harm unborn babies. Infection in a pregnant woman can result in :

miscarriage,
stillbirth, or
serious birth defects.

People get rubella by breathing in droplets that get into the air when an infected person coughs, sneezes, or talks. Rubella can also spread by direct contact with fluids from the nose or throat of an infected person.

Rubella can be prevented by immunization.

What is rubella?

Rubella is a mild but very contagious disease that is preventable with a vaccine. Other names for rubella are German measles and three-day measles.

Rubella is dangerous because of its ability to harm unborn babies. Infection of a pregnant woman can result in miscarriage, stillbirth, or serious birth defects.

What is the infectious agent that causes rubella?

Rubella is caused by the rubella virus.

Where is rubella found?

Rubella is found worldwide.

How do people get rubella?

People get rubella by breathing in droplets that get into the air when an infected person coughs, sneezes, or talks.

Rubella can also spread by direct contact with fluids from the nose or throat of an infected person.

What are the signs and symptoms of rubella?

After an incubation period of 14–21 days, German measles causes symptoms that are similar to the flu. the primary symptom of rubella virus infection is the appearance of a rash (exanthem) on the face which spreads to the trunk and limbs and usually fades after three days (that is why it is often referred to as three-day measles).

The facial rash usually clears as it spreads to other parts of the body. Other symptoms include low grade fever, swollen glands (post cervical lymphadenopathy), joint pains, headache and conjunctivitis.

The swollen glands or lymph nodes can persist for up to a week and the fever rarely rises above 38 ^oC (100.4 ^oF).

The rash of German measles is typically pink or light red. The rash causes itching and often lasts for about three days. The rash disappears after a few days with no staining or peeling of the skin. When the rash clears up, the patient may notice that his skin sheds in very small flakes wherever the rash covered it.

Forchheimer's sign occurs in 20% of cases, and is characterized by small, red papules on the area of the soft palate.

Rubella can affect anyone of any age and is generally a mild disease, rare in infants or those over the age of 40. The older the person is the more severe the symptoms are likely to be.

Up to one-third of older girls or women experience joint pain or arthritic type symptoms with rubella.

The virus is contracted through the respiratory tract and has an incubation period of 2 to 3 weeks. During this incubation period, the patient is contagious typically for about one week before he develops a rash and for about one week thereafter.

An infected person can spread the disease for as many as 5 days before the rash appears to 7 days after. Infectious children should not attend school or day care.

How soon after exposure do symptoms appear?

In most cases, symptoms appear within 16 to 18 days.

How is rubella diagnosed?

Diagnosis is by blood test or virus culture.

Who is at risk for rubella?

Anyone can get rubella, but unvaccinated, school-aged children are most at risk.

What complications can result from rubella?

Rubella is not usually a serious disease in children, but it can be very serious if a pregnant woman becomes infected. When a woman gets rubella during pregnancy, especially during the first 3 months, the infection is likely to spread to the fetus and cause CONGENITAL RUBELLA SYNDROME (CRS).

Up to 20% of the infants born to mothers infected with rubella during the first trimester of pregnancy have CRS. CRS can result in miscarriage, stillbirth, and severe birth defects.

The most common birth defects are :

Blindness,
Deafness,
Heart damage, and
Mental retardation.

What is the treatment for rubella?

There is no treatment for rubella. The illness usually runs its course in a few days.

How common are rubella and congenital rubella syndrome?

Since the rubella vaccine was introduced in 1969, cases of rubella and CRS in the United States have remained low. However, cases are reported in persons who were infected in countries that do not routinely provide rubella vaccination (imported rubella). Although CRS is preventable, up to 7 infants are born with CRS each year.

In unvaccinated populations, rubella is primarily a childhood disease. When children are well immunized, adolescent and adult infections become more evident. Since 1994, most rubella and CRS cases were associated with outbreaks among adults, and 75% of all rubella cases were among persons 15-44 years of age.

How can rubella be prevented?

Rubella can be prevented by IMMUNIZATION.

All children should be vaccinated to protect themselves and others from rubella. The rubella vaccine is part of the MMR (measles, mumps, rubella) vaccine series given to children beginning at 12 months of age.
To help protect unborn babies from CRS, women must be immune to rubella before they become pregnant. Reproductive-aged women should find out their immunization status and receive rubella vaccine if needed. Usually, a blood test will be done during pregnancy to determine if a woman is protected against rubella. Any pregnant woman who has been exposed to rubella should be referred to her health-care provider.

As is the case with all immunizations, there are important exceptions and special circumstances. Health-care providers should have the most current information on recommendations about the rubella vaccine.

TOXOPLASMOSIS

2009-12-03T21:53:00.002+07:00

What is toxoplasmosis?

Toxoplasmosis (toxo) is an infection caused by a single-celled parasite called Toxoplasma gondii. The infection is most commonly acquired from contact with cats and their feces or with raw or undercooked meat.

Estimates that more than 60 million people in the United States may carry the Toxoplasma parasite, but very few have symptoms because a healthy immune system usually keeps the parasite from causing illness.

What factors increase the risk of acquiring toxo?

The following situations potentially expose a person to the toxoplasma parasite and increase the risk of acquiring toxoplasmosis:

Touching your hands to your mouth after gardening, cleaning a cat's litter box, or anything that came into contact with cat feces
Eating raw or partly cooked meat, especially pork, lamb, or venison
Touching your hands to your mouth after contact with raw or undercooked meat
Organ transplantation or transfusion (this is rare)

If a woman is pregnant when she is infected with toxo, the infection can be transmitted from her to the baby with sometimes catastrophic consequences.

What are the usual symptoms of toxoplasmosis?

Although people infected with toxoplasmosis are often unaware of having this disease, typical symptoms of toxo are flulike symptoms including swollen lymph nodes and muscle aches and pains that last from a few days to several weeks. If your immune system is normal, you cannot get the infection again.

Why do some people develop severe problems from toxo?

Few people with toxo develop symptoms because the immune system usually keeps the parasite from causing illness. However, anyone with a compromised immune system is at risk for serious problems from toxo. These individuals include those undergoing chemotherapy, people with HIV/AIDS or other immune disorders, and recent organ-transplant recipients.

In these people, an infection that occurred anytime during life can reactivate and cause the severe symptoms of toxoplasmosis such as damage to the eye, brain, or other organs.

Ocular toxoplasmosis, which damages the eyes, can lead to reduced vision, blurred vision, pain (often with bright light), redness of the eye, and sometimes tearing, according to the CDC.

Can toxoplasmosis develop into a more serious illness in babies?

Yes, the immune system in infants is not fully mature until after birth.

The babies of women who were exposed to toxo within a few months of becoming pregnant or during pregnancy are at an increased risk for developing a severe case of toxo. According to the NIH (U.S. National Institutes of Health), pregnant women who newly contract the toxoplasmosis parasite have a 40% chance of transmitting it to their unborn child. Women who were first exposed to toxo more than six months before becoming pregnant are not likely to pass the infection to their children.

Most infants have no symptoms at birth, but a small percentage may be born with eye or brain damage. Unfortunately, the signs and symptoms of the disease often appear a few months after birth.

What is meant by a baby developing "a more severe case of toxo"?

Children born with toxoplasmosis can be afflicted with mental retardation, convulsions, spasticity, cerebral palsy, deafness, and severely impaired vision. The infant's head may be abnormally small (microcephaly) or abnormally large due to increased pressure on the brain (hydrocephalus).

How is toxo diagnosed in the lab?

There are many different kinds of blood tests for toxoplasmosis. The results can determine if the patient has had toxo and whether the infection is recent ("acute") or not.

How can toxoplasmosis be prevented?

Since toxo usually causes mild to no symptoms, and a healthy immune system prevents any remaining parasites in the body from causing further symptoms, most people don't need to worry about getting this disease.

However, if you have a weakened immune system or are pregnant, there are several steps you should take to prevent exposure to toxoplasmosis.

If you have a weakened immune system, get a blood test for toxoplasmosis. If your test is positive, your doctor can tell you if and when you need to take medicine to prevent the infection from reactivating.
If you are planning on becoming pregnant, you may consider being tested for toxo. If the test is positive, there is no need to worry about passing the infection to your baby (since you should have immunity against the parasite).
If you are already pregnant, you should discuss your risk of toxoplasmosis with your doctor who may order a blood sample for testing.
Wear gloves when you garden or do anything outdoors that involves handling soil since cats often use gardens and sandboxes as litter boxes. Wash your hands well with soap and warm water after outdoor activities, especially before you eat or prepare food.
Have someone else handle raw meat for you. If this is not possible, wear clean latex gloves and thoroughly wash with soap and hot water any cutting boards, sinks, knives, and other utensils that might have touched the raw meat. Wash your hands well with soap and warm water afterward.
Cook all meat thoroughly, especially pork or veal.

Am I able to keep my cat?

Yes, but if you have a weakened immune system or are pregnant, there are some steps to take to avoid being exposed to toxo according to the Cornell College of Veterinary Medicine.

Most importantly, you can help prevent your cats from getting infected with toxo. Feed them dry or canned cat food and keep them indoors. Cats can become infected by eating or being fed raw or undercooked meat that is infected with the parasite, or by eating infected prey such as birds or rodents. Any cat that is allowed access to outdoors should be kept off beds, pillows, or other furniture that you also use. Don't bring a new cat into your house that might have been an outdoor cat or might have been fed raw meat. Avoid handling stray cats and kittens. Have your cat tested for the parasite. Your vet can answer any other questions you may have regarding your cat and the risk for toxoplasmosis.

Have someone who is healthy and not pregnant change your cat's litter box. If this is not possible, wear gloves and clean the litter box daily (the parasite found in cat feces needs a few days after being passed to become infectious). Wash your hands well with soap and warm water afterward.

Once infected with toxo, is my cat always able to spread the infection to me?

No, cats can only spread toxo in their feces for a few weeks after they are first infected with the parasite. Like humans, cats rarely have symptoms when first infected, so most people don't know if their cat has been exposed to toxo. In fact, most infected cats appear healthy. There are no good tests available to determine if your cat is passing toxo in its feces.

What is the treatment for toxoplasmosis?

Once the diagnosis of toxoplasmosis is confirmed, you and your doctor should discuss whether treatment is necessary. In an otherwise healthy person who is not pregnant, treatment is not needed. Symptoms will usually go away within a few weeks. For pregnant women or people who have weakened immune systems, drugs are available to treat the parasite that causes toxoplasmosis.

Toxoplasmosis At A Glance

Toxoplasmosis (toxo) is a disease caused by a parasite.
Toxo is acquired from contact with cats and their feces.
Toxo is also acquired from eating or touching raw or partly cooked meat.
Symptoms can range from none to very severe.
A woman who contracts toxo right before or during pregnancy can transmit it to her baby with catastrophic consequences.
People with immune deficiencies are at high risk for developing severe signs and symptoms of toxo.

RECTOCELE

2009-12-01T05:19:00.002+07:00

The rectum is the temporary storage area for bowel motions, and makes up the last 20cm or so of the large bowel.

A rectocele occurs when the rectum pushes the back wall of the vagina forward, causing a prominent bulge into the vagina.

Risk factors include difficult childbirth and the use of forceps during delivery, but women who have never had children can also develop rectocele.

The degree of severity varies; for example, in mild cases the rectocele may be felt as a small bulge high inside the vagina while, in severe cases, the bulge may be hanging outside of the vagina. Milder cases can be treated by measures such as management of constipation, Kegel exercises to strengthen the pelvic floor and the insertion of a vaginal pessary to prop up the pelvic organs. Surgery may be needed in severe cases.

Symptoms

The symptoms of rectocele may be vaginal, rectal or both, and can include:

A sensation of pressure within the pelvis
The feeling that something is falling down or falling out within the pelvis
Symptoms are worsened by standing up and eased by lying down
Lower abdominal pain
Lower back pain
A bulging mass felt inside the vagina
Vaginal bleeding that’s not related to the menstrual cycle
Painful or impossible vaginal intercourse
Constipation
Problems with passing a bowel motion, since the stool becomes caught in the rectocele
The feeling that the bowel isn’t completely emptied after passing a motion
Faecal incontinence (sometimes).

Rectovaginal septum explained

The pelvic organs are supported by the pelvic floor muscles. Structures including ligaments and connective tissue help to keep the pelvic organs tethered in place. In women, the front wall of the rectum is situated behind the rear wall of the vagina.
The front wall of the rectum and rear wall of the vagina, and the thin layer of tissue between them, are together called the rectovaginal septum (or wall). This wall can become weak or stretched by pressure such as childbirth or straining while going to the toilet and by ageing. A weak or thinned rectovaginal septum allows the front wall of the rectum to bulge into the vagina.

A range of causes

Some of the events that may weaken or thin the rectovaginal septum and cause a rectocele include:

Vaginal (normal) childbirth
Giving birth to multiple babies
A long and difficult labour
Assisted delivery during childbirth, including the use of forceps
Tearing during childbirth, particularly if the tear extended from the vagina to the anus
Episiotomy (a surgical cut made to enlarge the vaginal opening during childbirth to avoid injury to mother and baby), particularly if the cut extends to the anus
Hysterectomy
Pelvic surgery
Chronic constipation
Straining to pass bowel motions
Advancing age, as older women are more prone to rectocele.

Diagnosis methods

Rectocele is diagnosed using a number of tests including:

Pelvic examination
Special x-ray (proctogram or defaecagram).

Treatment options

Generally speaking, a rectocele with no obvious symptoms doesn’t need medical treatment, but it is wise to pay attention to diet and other lifestyle factors that contribute to constipation. Treatment options may include:

High fibre diet
Fibre supplements
At least six to eight glasses of water per day
Stool softeners (don’t use laxatives)
Instruction on how to help yourself to pass a bowel motion; for example, you may be advised to gently press a finger against the rear wall of the vagina while toileting
Don’t strain on the toilet
Hormone replacement therapy for postmenopausal women
Pelvic floor (‘Kegel’) exercises
The insertion of a pessary, which is a ring-like device worn high in the vagina that helps to support the pelvic organs.

Surgery

Surgery may be needed if the rectocele doesn’t respond to other treatments and is causing symptoms. Unfortunately, the rectocele will recur after operation in about 10 per cent of cases. Depending on individual factors, such as the severity of the rectocele and the presence of other prolapsed structures, the operation can be performed in a number of ways, including:

Through the vagina
Through the anus
Through the area between the vagina and anus (perineum)
Through the abdomen
In some cases, a combination of surgical techniques may be necessary.

Things to remember

Some of the causes of a rectocele include vaginal childbirth, hysterectomy, pelvic surgery and chronic constipation.
A rectocele may occur by itself or present alongside other pelvic abnormalities, such as a prolapsed bladder (cystocele).
Surgery may be needed if the rectocele doesn’t respond to simpler treatments.

CYSTOCELE

2009-12-01T05:14:00.002+07:00

A cystocele is when the bladder bulges into the vagina.

Risk factors include vaginal childbirth, regularly straining on the toilet to pass bowel motions, obesity, smoking and chronic lung diseases with coughing.

Postmenopausal women are more susceptible to cystocele. This is because the sex hormone, oestrogen, helps to keep the muscles of the vagina and bladder – the pelvic floor muscles – in good tone. Once oestrogen levels drop, these muscles become thinner, weaker and less elastic. The vaginal skin stretches, which may allow the bladder to bulge into the vagina.

A cystocele can occur by itself or it may happen along with other abnormalities such as a rectocele (when the rectum protrudes into the vagina) or a uterine prolapse (when the uterus and cervix drop down to the vaginal entrance).

Treatment options include pelvic floor exercises, oestrogen therapy, inserting a pessary into the vagina to hold up the pelvic organs, and surgery. Other names for cystocele include prolapse of the bladder and ‘fallen’ bladder.

Symptoms

The symptoms of cystocele depend on individual factors, such as the severity of the condition, but can include:

Stress incontinence – urine leaks when coughing, sneezing, laughing, standing up, running or walking
Inability to completely empty the bladder after going to the toilet
Recurring urinary tract infections (UTIs)
Urination problems, such as straining to get urine flow started or an unusually slow flow of urine that tends to stop and start
A sensation of fullness or pressure inside the vagina
A bulging mass felt on the front wall of the vagina
In severe cases, the vagina and the bladder protrude out of the vaginal entrance.

Grades of severity

A cystocele is graded on its degree of severity:

GRADE 1 – the bladder protrudes a little way into the vagina.
GRADE 2 – the bladder protrudes so far into the vagina that it is close to the vaginal opening.
GRADE 3 – the bladder protrudes out of the vagina.

A range of causes

The vagina and bladder are held apart by tissue known as the pubocervical fascia. Thinning, weakening or tearing of the pubocervical fascia, and poor tone of the supporting muscles and ligaments, allow the bladder to drop against the vaginal wall. Some of the events that may cause or contribute to the development of a cystocele include:

Vaginal childbirth
Repeated heavy lifting
Habitually straining to pass bowel motions
The drop in oestrogen levels that occurs at menopause.

Diagnosis

Cystocele is diagnosed using a number of tests including:

MEDICAL HISTORY – to check for possible risk factors.
PHYSICAL EXAMINATION– cases of grade 2 or 3 cystocele can be easily diagnosed by vaginal examination.
VOIDING CYSTOURETHROGRAM – a rarely used special x-ray that is taken while the patient is urinating. This test reveals whether the flow of urine is affected by the cystocele and if there is significant urine left in the bladder after passing urine (residual urine).
OTHER TESTS– such as a bladder or pelvic ultrasound, a urodynamics investigation or x-rays to exclude other possible causes of urinary problems.

Treatment

Treatment for cystocele depends on the severity of the condition, but can include:

MILD CASES – when there are no symptoms, treatment may be unnecessary. Regular monitoring is needed to make sure the cystocele doesn’t worsen. The doctor may advise a few lifestyle changes to prevent the condition getting worse, including doing pelvic floor exercises to strengthen the pelvic floor muscles.
MODERATE CASES – a pessary is a small ring-like device that’s inserted high in the vagina. This is used temporarily in younger women and helps to keep the bladder in place. Health risks of long-term pessary use include infection and ulceration. This is more likely to be used in elderly women who are considered unfit for surgery due to chronic medical conditions.
SEVERE CASES where symptoms impair quality of life. There are many different surgical techniques now available.

Pelvic floor physiotherapy

Pelvic floor exercises help to increase the strength of the pelvic floor muscles. They may reduce the symptoms felt as the result of a moderate to large cystocele. These exercises may also reduce symptoms of stress incontinence, which is often associated with a cystocele. It is important to learn to do the exercises correctly to gain the most benefit. There are specially trained physiotherapists or other health professionals available to help teach the correct techniques.

Surgery

Surgery for cystocele repair is usually done under general anaesthesia but also may be done under spinal or epidural anaesthesia. There are now many different types of surgery available depending on the symptoms a woman has. Traditionally, the vaginal wall is cut, the bladder is pushed away from the vagina and the excess vaginal tissue is removed. The bladder is supported by sutures into the pubocervical fascia and then the vagina is closed.
Mesh, graft or tape may be used to hold the bladder and urethra in place. Some procedures may be performed laparoscopically. Other procedures performed during the operation depend on individual factors: for example, a vagina overstretched by childbirth may be tightened.
A urinary catheter may be worn for between one and six days following surgery depending on the type of operation performed. Full recovery takes around four to six weeks.

Self-care suggestions

Your doctor may advise that you make a few lifestyle changes to prevent the cystocele from worsening or recurring after surgery. These suggestions may include:

Don’t lift heavy objects.
Increase the amount of fibre in your diet to prevent constipation and straining.
Drink between six and eight glasses of water each day. Not drinking enough water makes stools hard, dry and difficult to pass.
Exercise daily to help keep you regular.
Use stool softeners, which may help in the short term.
Avoid straining on the toilet for either bowels or bladder; use the hissing or sighing technique.
Perform pelvic floor exercises daily to strengthen the muscles supporting the pelvic organs. You may need instruction from your doctor or other health care professional, such as a pelvic floor rehabilitation physiotherapist.
Always squeeze up your pelvic floor muscles before you lift, cough, laugh or sneeze.
If you are postmenopausal, your doctor may recommend hormone therapy, usually in the form of local oestrogen preparations such as a cream or a vaginal tablet, to help tone the muscles supporting the vagina and bladder.
Seek medical advice for any condition that causes coughing and sneezing such as asthma, chest infections and hay fever.
Keep yourself within a healthy weight range.
Avoid sit-ups. Learn how to strengthen your deep abdominal muscles, but avoid straining.

Point to remember

A cystocele is when the bladder bulges out into an overstretched vagina.
Risk factors include vaginal childbirth and regularly straining on the toilet to pass bowel motions.
Severe cases of cystocele need surgical repair.

PROLAPSE OF THE UTERUS

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Prolapse of the uterus

The uterus (womb) is an organ of the female reproductive system.

It is shaped like an upside down pear and is located inside the pelvis.

The uterus, bladder and bowel are supported by a tight hammock of muscles slung between the tailbone (coccyx) and the pubic bone. These muscles are known as the PELVIC FLOOR, or the LEVATOR ANI MUSCLES.

Ligaments and connective tissue also anchor the uterus in place. If these tissues are weakened or damaged, the uterus can slip down into the vagina.

Common causes of uterine prolapse include CHILDBIRTH – OBESITY – CHRONIC CONSTIPATION and POSTMENOPAUSE .

Other names for uterine prolapse include PUDENDAL HERNIA and PELVIC FLOOR HERNIA

Treatment options include special muscle strengthening exercises. Surgery may be needed in severe cases.

Symptoms

The symptoms of uterine prolapse include:

A sensation of heaviness in the vagina
A distinct lump or bulge in the vagina
Tissue protruding out of the vagina
Persistent aching in the lower back
Trouble passing urine
Frequent urinary tract infections
Greater than normal amounts of vaginal discharge
Painful sexual intercourse.

Degrees of prolapse

Uterine prolapse is categorised by the degree of tissue protruding into the vagina. In most cases, other pelvic organs (such as the bladder or bowel) are also prolapsed into the vagina, and the ovaries sit lower than normal inside the pelvis. The three categories of uterine prolapse are:

FIRST DEGREE (mild) - the neck of the uterus (cervix) protrudes into the lowest third of the vagina.
SECOND DEGREE (moderate) - the cervix protrudes to the opening of the vagina.
THIRD DEGREE (severe) - the whole uterus protrudes out of the vagina.

A range of causes

The pelvic floor and associated supporting ligaments can be weakened or damaged in many ways including:

Pregnancy, especially in the case of multiple babies such as twins or triplets.
Vaginal childbirth, especially if the baby was large or delivered quickly, or if there was a prolonged pushing phase.
Obesity.
Chronic constipation and associated straining to pass motions.
Low levels of the sex hormone oestrogen after menopause.
Constant coughing associated with conditions such as chronic bronchitis or asthma.
Fibroids.
In rare cases, pelvic tumour.

Pelvic floor exercises

In mild to moderate cases, special exercises of the pelvic floor can correct uterine prolapse. Familiarising yourself with the muscles of each orifice gives you a better chance of performing the exercises correctly. To identify the muscles of your vagina, insert one or two fingers and squeeze them. For your urethra, halt the flow of urine in midstream, but do not do this on a regular basis. Finally, familiarise yourself with the muscles of your anus by pretending to stop yourself from breaking wind. Consult with your doctor, physiotherapist or health care professional to ensure correct performance. Basically, the pelvic floor exercises include:

As a warm-up, direct your attention to your pelvic floor. Gradually squeeze all three sphincters and increase the tension until you have contracted the muscles as hard as you can. Release slowly and gently.
Squeeze slowly and hold for five to 10 seconds. Release slowly. Repeat 10 times. Relax for 10 seconds in between each one.
Perform quick, short strong squeezes. Repeat 10 times.
Remember to squeeze your muscles whenever you sneeze or cough.

VAGINAL PESSARY
A device shaped like a doughnut may be inserted into the vagina and positioned to prop the cervix and uterus. Side effects include irritating discharge and an increased risk of ulceration. Vaginal pessaries are considered a short term solution, and pelvic floor exercises and perhaps surgery will still be needed in the longer term.

VAGINAL SURGERY
In moderate to severe cases, the prolapse may have to be surgically repaired. In laparoscopic surgery, slender instruments are inserted through the navel. The uterus is pulled back into its proper place and reattached to supporting ligaments using permanent stitches. Over time, scar tissue grows over these stitches and further strengthens the repair. The operation may be performed abdominally in some circumstances. In around nine out of 10 cases, corrective surgery is successful.

Prevention techniques

Some women are at increased risk of uterine prolapse. Simple preventive measures include:

PREGNANCY - pelvic floor exercises throughout the duration of pregnancy.
VAGINALCHILDBIRTH - a well-timed episiotomy (an intentional and controlled cut of the skin between the vagina and anus) to prevent tearing and trauma to the pelvic floor muscles caused by the baby’s emerging head, and post-partum pelvic floor exercises.
POSTMENOPAUSE - oestrogen creams to boost flagging hormone levels, and pelvic floor exercises.
OBESITY - loss of excess body fat with dietary modifications and regular exercise, and pelvic floor exercises.
OTHER CONDITION - treat underlying disorders (such as asthma, chronic bronchitis or chronic constipation) in consultation with your doctor.
CHRONIC CONSTIPATION - drink plenty of fluid, eat lots of fruit, vegetables and fibre, and relax your tummy muscles to avoid straining when using your bowels.

Point to remember

Uterine prolapse occurs when weakened or damaged muscles and ligaments allow the uterus to slip into the vagina.
Common causes include pregnancy, childbirth, hormonal changes after menopause, obesity and chronic constipation.
Treatment options include pelvic floor exercises and vaginal surgery.

PELVIC FLOOR

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PELVIC FLOOR ~ pelvic diaphragm

The pelvic floor muscles are tightly slung between the tailbone (coccyx) and the pubic bone, and support the bowel, bladder, uterus and vagina.

Muscular bands (sphincters) encircle the urethra, vagina and anus as they pass through the pelvic floor.

When the pelvic floor muscles are contracted, the internal organs are lifted and the sphincters tighten the openings of the vagina, anus and urethra. Relaxing the pelvic floor allows passage of urine and faeces.
If the muscles are weakened, the internal organs are no longer fully supported and you may not be able to control your urine. Common causes of a weakened pelvic floor include childbirth, obesity and the associated straining of chronic constipation. Pelvic floor exercises are designed to improve muscle tone and prevent the need for corrective surgery.

Symptoms

The symptoms of a weakened pelvic floor include:

Leaking small amounts of urine when coughing, sneezing, laughing or running
Failing to reach the toilet in time
Uncontrollably breaking wind from either the anus or vagina when bending over or lifting
Reduced sensation in the vagina
Backache
Tampons that dislodge or fall out
A distinct swelling at the vaginal opening
A sensation of heaviness in the vagina.

Common causes

The pelvic floor can be weakened in many ways, including:

The weight of the uterus during pregnancy
Vaginal childbirth, which overstretches the muscles
The pressure of obesity
Chronic constipation and associated straining to pass motions
Constant coughing
Some forms of surgery that require cutting the muscles
Lower levels of oestrogen after menopause.

Complications of a weakened pelvic floor

LOSS OF BLADDER CONTROL a common symptom of a weakened pelvic floor ( URINE INCONTINENCE ) . Some people experience BOWEL INCONTINENCE , which means they can’t always control the passage of wind or faeces ( INCONTINECE ALVI ).

Weak pelvic floor muscles can also cause SEXUAL DIFFICULTIES such as reduced vaginal sensation.

In severe cases, the internal organs supported by the pelvic floor, including the bladder and uterus, can slide down into the vagina. This is called a PROLAPSE. A distinct bulge in the vagina and deep, persistent vaginal aching are common symptoms.

Familiarising yourself with the pelvic floor

Pelvic floor exercises are designed to strengthen the muscles. Each sphincter (vaginal, urethral, anal) should be exercised, so you need to familiarise yourself with these muscles in order to contract them at will. If the pelvic floor is especially weak, it may be difficult to detect any muscular contractions at first.
Suggestions on identifying your sphincters include:

VAGINAL - one or two fingers into your vagina and try to squeeze them.
URETHRAL - you urinating, try stopping the flow in midstream. This should only be done to identify the sphincters. Do not do it on a regular basis.
ANAL – pretend you are trying to stop yourself from breaking wind and squeeze tightly.

The exercises

You can perform these exercises lying down, sitting or standing. Ideally, aim for five or six sessions every day while you are learning the exercises. After you have a good understanding of how to do the exercises, three sessions each day is enough.

Before you start, direct your attention to your pelvic floor muscles. Try to relax your abdominal muscles. Don’t bear down or hold your breath. Gradually squeeze all three sphincters and increase the tension until you have contracted the muscles as hard as you can. Release gently and slowly. Then perform the exercises, which include:

Squeeze slowly and hold as strongly as you can for 5 to 10 seconds while breathing normally. Release slowly. Repeat 10 times. Relax for 5 to 10 seconds between each one.
Perform quick, short, strong squeezes. Repeat 10 times.
Remember to squeeze the muscles whenever you clear your throat or cough.

Professional help

It is important to perform these exercises correctly. You can consult with your doctor, physiotherapist or continence advisor to ensure proper performance. It may take weeks or months before you notice a substantial improvement. In severe cases, pelvic floor exercises aren’t enough to solve the problem and surgery may be needed. Be guided by your health care professional.

Other considerations

You can further improve the strength of your pelvic floor in many ways, including:

Lose excess body fat
Cure constipation by including more fruit, vegetables, fibre and water in your daily diet
Seek medical attention for a chronic cough.

Key To Remember

The pelvic floor muscles support the bladder, uterus and bowel.
The pelvic floor can be weakened by pregnancy, childbirth, obesity and the straining of chronic constipation.
Pelvic floor exercises are designed to improve muscle strength.

HYSTERECTOMY – SURGICAL PROCEDURES

2009-11-30T23:37:00.002+07:00

Hysterectomy - surgical procedures

Hysterectomy is the surgical removal of a woman's uterus. It may also involve the removal of the fallopian tubes and ovaries. Once a hysterectomy is performed, a woman can no longer have children or menstrual periods.

Hysterectomy is used to treat a number of conditions, such as excessive menstrual bleeding and cancer. In Australia, around 30,000 women undergo this operation every year.

Conditions that may require hysterectomy

A hysterectomy may be performed to correct various gynaecological problems including:

Heavy, irregular or abnormal menstrual bleeding
Fibroids
Endometriosis
Uterine prolapse
Cancer of the uterus, ovary or cervix
Pelvic inflammatory disease.

Medical issues to consider

Apart from cancer, many of the gynaecological conditions assisted by hysterectomy may also be successfully treated using other methods. If, after discussion of all options with your doctor, you choose to have a hysterectomy, there are several things that your doctor should discuss with you before the operation. These include:

Your medical history (as some pre-existing conditions may influence decisions on surgery and anaesthetics).
The pros and cons of abdominal surgery versus vaginal surgery.
Your support options after surgery.
Your feelings about the surgery.

You will have a range of tests, including a complete blood count test to check for problems such as anaemia.

Operation procedure

You will have an intravenous drip inserted into a vein in your hand or arm, and will be given a general anaesthetic. The operation may be performed via a lower abdominal incision (cut) or through the vagina.

Abdominal hysterectomy

For an abdominal hysterectomy, a cut is usually made horizontally along your pubic hairline (and your pubic hair will be shaved around the incision). For most women, this results in a small scar. Some patients may need a vertical incision in the lower abdomen.

Vaginal hysterectomy

A vaginal hysterectomy is performed through an incision (cut) at the top of the vagina. This may or may not involve the use of a laparoscope. A laparoscope is a slender instrument used in 'keyhole' surgery. During a laparoscopic assisted vaginal hysterectomy, surgery is performed via three or four small incisions in the abdomen. It is completed through the vagina.
Vaginal hysterectomy is a preferred option for many women as it avoids the need for a long abdominal cut. An abdominal procedure is generally recommended when large fibroids or cancer is present.

Types of hysterectomy

There are four variations of hysterectomy, including:

TOTAL HYSTERECTOMY - the entire uterus and cervix is removed, but the ovaries are retained.
SUBTOTAL (partial)HYSTERECTOMY- the uterus is removed, but the cervix may be retained. While removal of the cervix is generally advised because it is a potential cancer site in the body, some women consider that it serves a purpose during penetrative sex. If the cervix is kept, regular Pap smears are necessary.
HYSTERECTOMY and BILATERAL SALPHYNGOOPHARECTOMY - the uterus, fallopian tubes and ovaries are removed. This operation is performed if cancer of the ovaries or the uterus has been diagnosed. It may also be performed for severe infection or endometriosis.
RADICAL HYSTERECTOMY - the most extensive version of the operation. It involves the removal of the uterus, fallopian tubes, ovaries, upper part of the vagina, and associated pelvic ligaments and lymph nodes. This may be performed if cancer of the cervix, ovaries or uterus is present.

Immediately after the operation

After the operation, you can expect:

There will be some soreness around the operation site - your doctor will prescribe pain-killing medication for you.
You may experience 'wind' pain for a few days.
Depending on the procedure and your condition, the intravenous tube in your arm will be removed sometime during the first few days.
The catheter (drainage tube) in your bladder is usually removed within 24 hours of surgery, unless the bladder was traumatised during the procedure.
As soon as possible, you will be encouraged to get out of bed and go for short walks around the ward.
Depending on the type of surgery, you can expect a hospital stay of between two and seven days.
Recovery is generally faster after vaginal surgery than abdominal surgery.

Following surgery, it is important to start pelvic floor and abdominal exercises as soon as possible. These exercises strengthen the muscles in the pelvis and help maintain normal bladder function and vaginal muscle tone. Your doctor or physiotherapist will let you know how soon you can start these particular exercises.

Side effects and possible complications

Some of the side effects and possible complications of hysterectomy include:

Nausea and vomiting.
Infection.
Internal haemorrhage.
Build-up of blood beneath the stitches.
Internal scar tissue.
Allergic reaction to the anaesthetic.
Blood clots.
Vaginal vault prolapse.
Feelings of grief and loss.
Injury to the bowel, bladder or ureters (tubes that carry urine from the kidneys to the bladder) - this is rare.
Fistula (abnormal hole between internal structures, such as the bowel and vagina). This is also rare.

Taking care of yourself at home

Be guided by your doctor, but general suggestions for the six week post-operative period include:

REST - try to rest as much as possible for at least two weeks. You should avoid driving during this time.
EXERCISE- continue with the exercises you were shown in hospital. After two weeks of rest, you should aim to go for a 10 minute walk each day, unless advised otherwise by your doctor.
STANDING - avoid standing for more than a few minutes at a time in the early post-operative period. You can increase standing time as recovery progresses.
LIFTING- avoid heavy lifting and stretching.
CONSTIPATION - to avoid constipation, drink plenty of fluids and eat fresh fruits and vegetables. You may wish to take stool softeners for the first few days.
MEDICATION - if you have been prescribed antibiotics, make sure you take the full course, even if you feel well.
SEX - it is advised that you avoid penetrative sex until after the post-operative check (at about six weeks) to ensure the vagina is fully healed. If vaginal dryness is a problem, it may be helpful to use a water based lubricant.

Long term outlook

After hysterectomy, you will no longer need contraception or have menstrual periods. If your ovaries were removed, you will experience sudden menopause. You may want to discuss short term hormone replacement therapy (HRT) or other options with your doctor. Hysterectomy can be effective for gynaecological complaints like fibroids and endometriosis, but some conditions (such as cancer) may recur. You will need to have regular check-ups to make sure you are cancer free. You may need to have a regular vault smear. This test is similar to a Pap smear but it takes cells from the vaginal walls instead of the cervix.

Other forms of treatment

Many of the various gynaecological conditions cured by hysterectomy can often be successfully treated using other methods, including:

FIBROID- options include surgery to remove the fibroids (myomectomy), drugs to temporarily block the action of sex hormones and shrink the growths, or else the fibroids can be frozen, cauterised or removed by laser (myolysis).
HEAVY BLEEDING - options include taking the contraceptive pill to regulate the periods, other hormonal drug therapies, surgical removal of the endometrium, or the insertion of an intrauterine device (IUD) that releases small amounts of synthesised sex hormone into the uterus.
UTERINE PROLAPSE- options include pelvic floor exercises, the insertion of a ring-shaped pessary into the vagina to prop up the uterus, or surgical repair.
ENDOMETRIOSIS - options include hormonal drugs, surgical removal of the endometrium, or the insertion of an intrauterine device (IUD) that releases small amounts of synthesised sex hormone into the uterus.

Things to remember

Hysterectomy is the surgical removal of the uterus.
A hysterectomy may be performed to correct various gynaecological problems including abnormal menstrual bleeding, fibroids, endometriosis, and cancer of the uterus, ovary or cervix.
The operation may be performed via an abdominal incision or through the vagina.
Apart from cancer, many of the various gynaecological conditions cured by hysterectomy can often be successfully treated using other methods

HYSTERECTOMY

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Hysterectomy is the surgical removal of the womb (uterus), with or without the removal of the ovaries.

The uterus is a muscular organ of the female body, shaped like an inverted pear.

The lining of the uterus, the endometrium, thickens during ovulation in preparation for receiving a fertilised ovum. If the ovum is unfertilised, the lining comes away. This is known as menstruation. If the ovum is fertilised, the developing baby is nurtured inside the uterus throughout the nine months of pregnancy.

Once a hysterectomy is performed, a woman can no longer have children or menstrual periods. Hysterectomy is used to treat a number of conditions, such as excessive menstrual bleeding.

There are concerns that more hysterectomies are performed than are necessary.

Reasons for hysterectomy

The conditions that may be treated by hysterectomy include:

FIBROIDS , which are non-malignant growths inside the muscular walls of the uterus.
Heavy or irregular menstrual periods or MENORRHAGIA
Severe period pain, or DYSMENORRHOEA.
CANCER of the cervix, uterus or ovaries.
ENDOMETRIOSIS , a condition characterised by the migration of cells from the lining the uterus to other areas of the body.
PROLAPSE, which means the uterus falls into the vagina because of loose ligaments or damage to the pelvic floor muscles.
PELVIC INFLAMATORY DISEASE , caused by bacterial infection.

Degrees of hysterectomy

There are three basic types of hysterectomy:

TOTAL HYSTERECTOMY - removal of the uterus and cervix. The ovaries and tubes remain.
SUBTOTAL HYSTERECTOMY - removal of the body of the uterus. The cervix, ovaries and the tubes remain.
TOTAL HYSTERECTOMYY and BILATERAL SALPHYNGO OOPHORECTOMY - removal of the uterus, cervix, ovaries and tubes.

Different surgical procedures

The type of procedure used influences the length of hospital stay and recovery time. Hysterectomy procedures include:

VAGINAL - the uterus is removed through an incision in the top-end of the vagina. There are no cuts to the abdomen.
VAGINAL and LAPAROSCOPY - an instrument called a laparoscope is inserted through small abdominal incisions to assist in the vaginal removal of the uterus. During laparoscopic-assisted vaginal hysterectomy, surgery is performed through three to four small incisions in the abdomen and completed through the vagina.
ABDOMINAL - the uterus is removed through a lower abdominal incision. With a total abdominal hysterectomy, surgery is performed through a long abdominal cut similar to that which is conducted for a caesarian section.

Possible complications

Possible complications of hysterectomy include:

Difficulties with urination
Decreased sexual desire
Constant pelvic pain
Psychological distress
Complications of any operation or anaesthetic.

Women of childbearing age

Once a hysterectomy of any kind is performed, pregnancy is no longer possible.

If the ovaries of a premenopausal woman are removed, then ovulation will also cease. This means there will be a drop in production of the sex hormones oestrogen and progesterone, which can cause vaginal dryness, hot flushes, sweating and other associated symptoms of natural menopause.

Women who undergo bilateral oophorectomy, or removal of both ovaries, are usually treated with hormone replacement therapy (HRT) - also known as hormone therapy (HT) - to maintain their hormone levels.

The other roles of the uterus and ovaries

Once the childbearing years are finished, hysterectomy may seem a logical treatment option. This is because pregnancy is often considered to be the only function of the uterus, which may explain Australian's high hysterectomy rate. However, the uterus has a number of other important functions, including:

SEXUALLITY- the uterus rhythmically contracts during orgasm, contributing to sensations of pleasure.
HORMONE PRODUCTION - some researchers believe the uterus contributes to the maintenance of the female hormonal system. The ovaries also play a major role in maintaining the female hormonal system. Their removal results in instant menopausal symptoms and therefore, unless diseased, they should not be removed during hysterectomy.
SELF IMAGE - the uterus is of considerable psychological importance, whether or not it is menstruating and capable of bearing a child.

Other treatments

The conditions that prompt a hysterectomy can often be treated by other means. It is recommended that women consider hysterectomy as a procedure of last resort, when all other treatment options have failed. Other options include:

DRUG TREATMENT - medications may be given to reduce or stop heavy bleeding. This is generally used in the short term to provide symptom relief and to allow women time to explore and consider other treatment options.
ENDOMETRIAL ABLATION - this involves the removal or stripping of the lining of the uterus, which is shed each month as a period. This procedure requires admission to hospital as a day patient. An anaesthetic is used. Endometrial ablation can successfully reduce or stop heavy bleeding in 85 per cent of cases. It is not recommended for women who wish to become pregnant.
CONSERVATIVE TREATMENT OF FIBROID - the size, number and position of the fibroids will determine the treatment options offered. Fibroids can be 'shrunk' using medication or by surgery, which burns them away. They can also be starved of a blood supply required for growth, or they can be individually removed through surgery, leaving the uterus intact. Sometimes a combination of these treatments may be advised.
SURGICAL REMOVAL OF ENDOMETRIOSIS - this involves cutting or burning out tissue deposits and adhesions from such areas as the ovaries, bladder, bowel, uterus, pelvic walls and ligaments which support the uterus. Hormone therapy may be used before or after surgery.
REMOVAL OF ADENOMYOSIS - localised disease can be excised (cut out) or diathermied (burnt off), leaving the uterus intact. This procedure is recommended for those women who wish to become pregnant. It has a 50 per cent success rate - that is, adenomyosis recurs in approximately one half of cases.

Things to remember

Hysterectomy is the surgical removal of the womb (uterus), with or without the removal of the ovaries.
Hysterectomy is used to treat a variety of conditions, including heavy or painful periods, fibroids and prolapse.
It is recommended that women consider hysterectomy as a procedure of last resort, when all other treatment options have failed.

MYOMECTOMY

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A myomectomy is an operation performed to remove benign tumours called fibroids from the muscular wall of the uterus.

Fibroids often cause pain and excessive menstrual bleeding. They can also interfere with your ability to become pregnant. They may degenerate or become infected, and therefore your doctor may feel they should be surgically removed.

A hysterectomy may be suggested if you are over childbearing age.
Uterine fibroids
Fibroids are categorised by their locations, which include:

INTRAMURAL- in the uterine wall. Intramural fibroids are the most common variety.
SUBMUCOSAL - in the uterine lining (endometrium). This type tends to cause excessive menstrual bleeding and period pain.
SUBSEROSAL- on the exterior wall of the uterus. They sometimes appear like long stalks.

Medical issues to consider

Your doctor may order an ULTRASOUND SCAN to try to pinpoint the fibroids prior to surgery.

Some BLOOD TESTS may be ordered to see if you are anaemic (symptoms can include excessive tiredness, breathlessness on exertion, pale skin and poor resistance to infection).

A URINE TEST will tell if you have an infection in your urinary system.

The ANAESTHETIST VISITS anaesthetist visits you prior to your operation to see if you are suitable to have a general anaesthetic. (If you are not suitable, you may have the operation performed under a spinal or epidural anaesthetic.) For a general anaesthetic, you are usually given a pre-medication injection to dry up your internal secretions and make you feel drowsy.

Some surgeons request you have an ENEMA and a portion of your pubic hair shaved prior to surgery.

Operation procedure

In most cases, the surgeon performs a DILATATION and CURETTAGE (D&C) to check for irregularities in the inner surface of the uterus. The kind of myomectomy performed depends on the type, size, number and location of the fibroids, but can include:

ABDOMINAL MYOMECTOMY - the uterus is accessed via one large incision through the abdomen. Usually, a horizontal cut just on the bikini line is performed; in some cases, the incision may need to be made vertically in the midline of your abdomen. The uterus is cut, sometimes with a laser (which closes off blood vessels and reduces bleeding). The fibroids are then removed and the uterus, abdominal wall and skin are closed with sutures. This type of myomectomy is preferred for multiple or deeply rooted fibroids. The drawback of abdominal myomectomy is that it takes longer to recover.
LAPAROSCOPIC MYOMECTOMY - subserosal fibroids can often be removed via laparoscopic (‘keyhole’) myomectomy. The surgeon makes a number of small incisions, which allow different instruments access to the uterus. Among these instruments is the laparoscope, which contains fibre-optic camera heads or surgical heads (or both). The fibroids are removed, and the small wounds sutured (sewn) closed. Recovery time for the patient is comparatively fast.

HYSTEROSCOPIC MYOMECTOMY - the fibroids are removed via the dilated cervix, so no abdominal incisions are needed. The instrument is called a resectoscope, which is a hysteroscope fitted with a wire loop. The instrument is inserted through the cervix, and the wire loop slung over the fibroid. Electrical energy passes through the loop, which cuts the fibroid loose. The fibroid can then be removed through the vagina.

Immediately after the operation

After the operation, you can expect:

Your temperature, pulse, respiration and blood pressure is observed and noted.
Any vaginal discharge is noted.
An intravenous fluid line may still be running into your arm to replace fluids in your body. Antibiotics may be included to combat infection.
You may have some tubes at the wound site to drain off excess fluid if necessary.
If you need pain relief, tell your nurse.
You may have a catheter to drain off urine for the next day or so.
You are given a normal diet, once your doctor feels it is safe to do so. Tell your nurses as soon as you pass wind or a bowel motion, as this shows that your digestive system is getting back to normal.
Perform your breathing, coughing and leg exercises hourly when you are awake.
You are assisted out of bed and taken for a walk the day following surgery.
You may be in hospital for five to seven days following surgery.

Possible complications

Possible complications of myomectomy include:

Haemorrhage
Injury to the uterus
Damage to the nearby organs of the urinary system
Formation of scar tissue (adhesions) within the uterus
Infection
Blood clots
Eventual re-growth of fibroids.

Taking care of yourself at home

Be guided by your doctor, but general suggestions include:

TRY TO REST as much as possible for two weeks.
Avoid standing for more than a few minutes at a time.
Continue to TAKE YOUR MEDICATION , and follow strictly the instructions on taking your antibiotics.
After two weeks, AIM TO WALK for about 10 minutes every day, unless advised otherwise by your doctor.
Depending on the type of surgery, you can RETURN TO WORK rk within two to six weeks (abdominal myomectomy takes the longest recovery time).
If you have any excessive vaginal bleeding, or signs of infection at your wound site (such as redness, increasing pain, swelling, or an increased or offensive discharge from your wound), see your doctor immediately.

Long term outlook

You will still have your uterus and all reproductive organs following myomectomy.

Once healed, there should be no effects on your sexual activity, and you should still be able to conceive. Depending on the depth of the scar in your uterus, you may require an elective caesarean section at 38 weeks to safely give birth.

If you are seeking myomectomy as a remedy to excessive menstrual bleeding, it is important to know that the operation is unsuccessful in around 20 per cent of cases - your heavy menstrual flow may be due to factors other than fibroids. See your doctor for further information and advice.

Other forms of treatment

Other possible forms of treatment for fibroids may include:

MONITORING - if the fibroids are asymptomatic, a ‘wait and see’ approach is often adopted.
DRUGS - such as hormones, used in combination, to shrink the fibroids prior to surgery.
HYSTERECTOMY- the surgical removal of some or all of the uterus. Pregnancy is no longer possible after a hysterectomy.

FIBROID

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UTERINE MYOMA

Fibroids, or myomas, are growths or benign tumours that form inside the uterus (womb). Around four in 10 women over the age of 40 will have fibroids.

No one knows why fibroids develop, but it is suspected that the sex hormones – oestrogen and progesterone – play significant roles. This is because fibroids rarely grow in prepubescent girls and postmenopausal women.

Pre-existing fibroids stop growing, and may even shrink, once a woman passes the menopause.

Fibroids often cause no problems, but may occasionally be associated with infertility, miscarriage and premature labour. Other possible problems include heavy, lengthy and painful periods. Treatment depends on the size, number and location of the fibroids, but may include drugs, procedures performed under local anaesthetic and surgery. Fibroids rarely turn cancerous.

Symptoms

Most women with fibroids have no symptoms. When present, symptoms may include:

Heavy periods
Lengthy periods
Period pain
Spotting between periods
Painful intercourse
A sensation of heaviness or pressure in the back, bowel and bladder
Frequent urination
A lump or swelling in the lower abdomen.

Different types

Fibroids are categorised by their location, which includes:

INTRAMURAL – growing in the uterine wall. Intramural fibroids are the most common variety.
SUBMUCOSAL– growing in the uterine lining (endometrium). This type tends to cause excessive menstrual bleeding and period pain.
SUBSEROSAL – growing on the exterior wall of the uterus. These sometimes appear like long stalks.

Common complications

Fibroids can cause a variety of complications, including:

ANEMIA – excessive menstrual blood loss can cause anaemia, a disorder characterised by the body’s inability to carry sufficient oxygen in the blood. Symptoms of anaemia include breathlessness, fatigue and paleness.
URINATION PROBLEMS– large fibroids can bulge the uterus against the bladder, causing a sensation of fullness or discomfort and the need to urinate often.
INFERTILITY – the presence of fibroids can interfere with implantation of the fertilised egg in a number of ways. For example, the egg may try to burrow into a fibroid, or fibroids close to the uterine cavity may ‘prop open’ the uterus, making successful implantation difficult.
MISCARRIAGE and PREMATURE DELIVERY – fibroids can reduce blood flow to the placenta or may compete for space with the developing baby.

Diagnosis

Uterine fibroid (right lateral wall)
Nine (9) weeks and 4 days gestation

Fibroids can be detected using an ULTRASOUND , where sound waves create a two-dimensional picture.

The inside of the uterus can be examined with a HYSTEROSCOPE , which is a thin tube passed through the cervix (neck of the womb). A small camera may be placed at the tip of the hysteroscope, so that the interior of the uterus can be viewed on a monitor.

Treatment

Treatment depends on the location, size and number of the fibroids, but may include:

MONITORING – if the fibroids are causing no symptoms and are not large, a ‘wait and see’ approach is usually adopted.
DRUGS– such as hormones, used in combination to shrink the fibroids prior to surgery.
ARTERIAL EMBOLISATION – under local anaesthetic, a fine tube is passed via an artery in the arm or leg into the main artery supplying the fibroid with blood. The whole process is monitored by x-ray. Fine particles (like sand) are then injected into the artery to block the blood supply to the fibroid. The fibroid slowly dies and symptoms should settle over a few months.
HYSTEROSCOPY – the fibroids are removed via the cervix, using a hysteroscope.
LAPAROSCOPY – or ‘keyhole surgery’, where a thin tube is inserted through the abdomen to remove the fibroids.
OPEN SURGERY– larger fibroids need to be removed via an abdominal incision. This procedure weakens the uterine wall and makes Caesarean sections for subsequent pregnancies more likely.
HYSTERECTOMY – the surgical removal of some, or all, of the uterus. Pregnancy is no longer possible after a hysterectomy.

GONORRHOEA INFECTION

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Gonorrhoea

Gonorrhoea is caused by bacteria known as Neisseria gonorrhoeae.

It usually affects the genital area, although the throat or anus (back passage) may also be involved.

Gonorrhoea affects both men and women and is easily transmitted during vaginal intercourse. It can also be transmitted during anal or oral sex.

Gonorrhoea may not cause symptoms in women

A lack of specific signs and symptoms means gonorrhoea may go undetected for longer in women. Often there are no symptoms. Sometimes, gonorrhoea causes:

An unusual discharge from the vagina
Pain while urinating or passing water.

Untreated gonorrhoea can lead to infertility in women
If left untreated, gonorrhoea can lead to pelvic inflammatory disease (PID), which can cause infertility. Symptoms of PID include:

Lower abdominal pain and tenderness
Deep pain during sexual intercourse
Heavy and painful periods
Fever.

Women who have had PID need to be especially careful about gonorrhoea, because the risk of infertility increases with each bout of inflammation.

A check for gonorrhoea may be recommended

Because gonorrhoea may not cause symptoms until PID has already developed, sexually active women who have recently had a change of sexual partner or feel they may be at risk of a sexually transmissible infection (STI) should have a test for gonorrhoea (and for chlamydia infection).

Men may experience a burning sensation while urinating

Gonorrhoea commonly infects the inside of the penis (the urethra). Symptoms may include:

A burning sensation while urinating or passing water
A white or yellow pus-like discharge from the penis
Swelling and pain in the testicles, which can occur if the gonorrhoea infection goes untreated.

In a small percentage of men there are no symptoms at all.

Oral and anal gonorrhoea

In both men and women:

ANAL GONORRHOEA Anal gonorrhoea often occurs without signs or symptoms
THROAT GONORRHOEA may cause a sore throat, however, it usually occurs without symptoms.

Gonorrhoea is treated with antibiotics
Gonorrhoea is treated with antibiotics. Some strains of gonorrhoea are now resistant to penicillin and some other antibiotics. Tell your doctor if you have been travelling overseas because many of the new resistant strains have originated from outside Australia.

Prevention through the proper use of condoms and dams is best

The best protection against gonorrhoea is to always use barrier protection such as condoms, female condoms and dams (a thin piece of latex placed over the anal or vulval area during oral sex). Condoms and dams can be used for oral-vaginal sex and oral-anal sex to help prevent the spread of infection.

Condoms for men can be bought from supermarkets, chemists and other outlets. Female condoms and dams are available through Family Planning Victoria and may be available from selected shops. Latex free condoms are also available from some outlets. Male condoms and lubricant are available free from the Melbourne Sexual Health Centre, along with female condoms and dams on request.

When using a condom for men you should:

Open the packet carefully so that you don’t tear the condom.
Pinch the tip of the condom before carefully rolling it down the entire shaft of the erect penis.
Do not use spit, Vaseline, baby oil or other oil-based lubricants.
Use water-based lubricants, such as KY, Muko or Wet Stuff.
Withdraw the penis before the erection is lost, so that the condom does not fall off. Hold the base of the condom to prevent spills.
Store condoms in a cool, dry place and check the expiry date.

SALPINGITIS

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Salpingitis

The fallopian tubes extend from the uterus, one on each side, and both open near an ovary. During ovulation, the released egg (ovum) enters a fallopian tube and is swept along by tiny hairs towards the uterus.

Salpingitis is inflammation of the fallopian tubes. Almost all cases are caused by bacterial infection, including sexually transmitted diseases such as gonorrhoea and chlamydia. The inflammation prompts extra fluid secretion or even pus to collect inside the fallopian tube. Infection of one tube normally leads to infection of the other, since the bacteria migrates via the nearby lymph vessels.

Salpingitis is one of the most common causes of female infertility. Without prompt treatment, the infection may permanently damage the fallopian tube so that the eggs released each menstrual cycle can't meet up with sperm. Treatment options include antibiotics. Salpingitis is sometimes called pelvic inflammatory disease (PID). This umbrella term includes other infections of the female reproductive system, including the uterus and ovaries.

Symptoms

In milder cases, salpingitis may have no symptoms. This means the fallopian tubes may become damaged without the woman even realising she has an infection. The symptoms of salpingitis may include:

Abnormal vaginal discharge, such as unusual colour or smell
Spotting between periods
Dysmenorrhoea (painful periods)
Pain during ovulation
Uncomfortable or painful sexual intercourse
Fever
Abdominal pain on both sides
Lower back pain
Frequent urination
Nausea and vomiting
The symptoms usually appear after the menstrual period.

Acute and chronic salpingitis

Salpingitis is usually categorised as either acute or chronic. In acute salpingitis, the fallopian tubes become red and swollen, and secrete extra fluid so that the inner walls of the tubes often stick together. The tubes may also stick to nearby structures such as the intestines. Sometimes, a fallopian tube may fill and bloat with pus. In rare cases, the tube ruptures and causes a dangerous infection of the abdominal cavity (peritonitis). Chronic salpingitis usually follows an acute attack. The infection is milder, longer lasting and may not produce many noticeable symptoms.

Most cases are caused by bacteria

In nine out of 10 cases of salpingitis, bacteria are the cause. Some of the most common bacteria responsible for salpingitis include:

Chlamydia
Gonococcus (which causes gonorrhoea)
Mycoplasma
Staphylococcus
Streptococcus.

Access to the reproductive system

The bacteria must gain access to the woman's reproductive system for infection to take place. The bacteria can be introduced in a number of ways, including:

Sexual intercourse
Insertion of an IUD (intra-uterine device)
Miscarriage
Abortion
Childbirth
Appendicitis.

Lifestyle risk factors

Lifestyle factors that significantly increase a woman's risk of contracting salpingitis include:

Engaging in sexual intercourse without a condom
Prior infection with a sexually transmitted disease.

Complications of salpingitis

Without treatment, salpingitis can cause a range of complications, including:

FURTHER INFECTION - the infection may spread to nearby structures, such as the ovaries or uterus.
INFECTION OF SEX PARTNERS - the woman's partner or partners may contract the bacteria and become infected too.
TUBO-OVARIAN ABSCESS - about 15 per cent of women with salpingitis develop an abscess, which requires hospitalisation.
ECTOPIC PREGNANCY - a blocked fallopian tube prevents the fertilised egg from entering the uterus. The embryo then starts growing inside the confined space of the fallopian tube. The risk of ectopic pregnancy for a woman with prior salpingitis or other form of pelvic inflammatory disease (PID) is around one in 20.
INFERTILITY - the fallopian tube may become deformed or scarred to such an extent that the egg and sperm are unable to meet. After one bout of salpingitis or other PID, a woman's risk of infertility is about 15 per cent. This rises to 50 per cent after three bouts.

Diagnosis methods

Diagnosing salpingitis involves a number of tests, including:

GENERAL EXAMINATION - to check for localised tenderness and enlarged lymph glands.
PELVIC EXAMINATION - to check for tenderness and discharge.
BLOOD TESTS - to check the white blood cell count and other factors that indicate infection.
MUCUS SWAB - a smear is taken to be cultured and examined in a laboratory so that the type of bacteria can be identified.
LAPAROSCOPY - in some cases, the fallopian tubes may need to be viewed by a slender instrument inserted through abdominal incisions.

Treatment options

Treatment depends on the severity of the condition, but may include:

ANTIBIOTICS - to kill the infection, which is successful in around 85 per cent of cases.
HOSPITALISATION - including intravenous administration of antibiotics.
SURGERY- if the condition resists drug treatment.

PELVIC INFLAMATORY DISEASE

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Pelvic Inflammatory Disease – PID

Pelvic inflammatory disease (PID) occurs when an infection spreads from the vagina to the cervix, endometrium (lining of the uterus) and fallopian tubes. The infection is usually sexually transmitted. It can also occur after a ruptured (burst) appendix or a bowel infection.
Some surgical procedures, such as abortion or insertion of an intrauterine device (IUD), can lead to PID.

The infection usually occurs in three stages - the cervix is infected first, followed by the endometrium and then the fallopian tubes.

The silent epidemic

PID is often called the ‘silent epidemic’ because it is common among sexually active women but does not always cause symptoms. About 10,000 women in Australia are treated for PID in hospital each year. About 10 to 30 times that number are treated as outpatients. Women aged 20 to 29 have the highest reported incidence of PID.

Signs and symptoms that can occur

Signs and symptoms of PID that may occur include:

Lower abdominal pain or tenderness
Menstrual disturbances
Burning pain when urinating (dysuria)
A change in smell, colour or amount of vaginal discharge
Deep pain during sexual intercourse
Fever.

Female infertility can be a devastating consequence

Scarring and blockage of the fallopian tubes is the most frequent long term complication of PID. Infertility occurs because the fertilised egg cannot pass through the tube to the uterus:

One episode of PID doubles the risk of tubal infertility.
The risk of fallopian tube blockage rises to 75 per cent after three or more episodes of PID.
The risk of ectopic pregnancy (where the foetus develops outside the uterus) after one episode of PID is increased seven fold.

Chlamydia and gonorrhoea are the most common causes of PID

Chlamydia is responsible for 50 per cent of PID cases while gonorrhoea is the cause in 25 per cent of cases. The risk of fallopian tube blockage is slightly higher for PID caused by gonorrhoea. Both are bacterial infections and are sexually transmitted diseases (STDs). Non-specific urethritis, the most common STD among men, is most often caused by chlamydia.

Diagnosing PID

Your doctor will test for possible causes like chlamydia and gonorrhoea. In some cases, laparoscopy is required to correctly diagnose PID. Laparoscopy involves inserting an endoscope (which is like a surgical video camera) into the abdomen to view the reproductive organs.

Without treatment, chronic pain may develop

Chronic pain and, sometimes, severe disability can occur if PID is not treated. This is usually due to extensive scarring. Treatment involves:

ANTIBIOTICS that are active against a broad range of organisms - amoxycillin (a type of penicillin) and doxycycline are usually prescribed.
TESTING and TREATING male partners and treating them, if necessary - symptoms may be mild or non-existent in men.
AVOIDING GENITAL SEXUAL XONTACT until the treatment is complete and a negative test result is obtained.
SURGERY to remove scar tissue.

Women with severe episodes of PID must be HOSPITALISED for treatment.

Protecting yourself from PID

To help prevent the transmission of the bacteria that can cause PID:

Use condoms during vaginal or anal intercourse.
Use condoms if you have an intrauterine device (IUD) inserted.

The string attached to the IUD can act as a wick for an infection from the vagina into the cervix and beyond. Women who use IUDs are 1.5 times more likely to develop PID. This may not apply to the new progesterone IUD (Mirena).

Use of the oral contraceptive pill may help

Sexually active women who are on the pill appear to have only one-third the risk of PID compared to women not on the pill. However, this data was collected in the 1970s and it is not known if the lower-dose pills more commonly used now have the same protective effect, although it is likely that they do.

ENDOMETRIOSIS – Treatment Options

2009-11-30T03:18:00.002+07:00

The tissue that lines the interior of the uterus is called the endometrium.

Endometriosis is the growth of endometrial tissue (from the lining of the uterus) in places outside of the uterus, such as the ovaries, fallopian tubes and bowel.

Endometriosis can cause numerous symptoms, including painful periods and pain with sex, fertility problems, pelvic and ovulation pain, pain in the lower back and thighs, and bowel and bladder symptoms.
Treatment options include :

SURGERY
HORMONE TRATMENT and
COMPLEMENTARY THERAPIES

Diagnosis can be difficult

Diagnosing endometriosis can be difficult, especially in the early stages of disease. The only way to diagnose the disease is to look inside the pelvic cavity, using a special instrument called a laparoscope. Diagnosis may be delayed if the woman assumes her degree of pain is normal and so doesn’t see her doctor. A diagnosis may also be delayed if the doctor is not familiar with the range of symptoms associated with endometriosis. If you have bad period pain, you should see your doctor.

Treatment options

The treatment options for endometriosis include:

Observation with no medical intervention
Hormone treatment
Surgery
Combined treatment
Complementary therapies.

Observation with no medical intervention

In mild cases of endometriosis, it may be possible to simply monitor the condition with regular visits to your doctor or gynaecologist. Antiprostaglandin medications (non-steroidal anti-inflammatory drugs such as ibuprofen and mefenamic acid) can help to control any associated pain.
If symptoms progress, talk over the medical options with your health care provider before making a final decision. Remember that a mild condition can become moderate to severe. Removal of adhesions through surgery is the most effective treatment to lessen the chances of recurrence.

Hormone treatment

Each month, a woman’s uterine lining is prompted by the hormone oestrogen to thicken in preparation for possible pregnancy. During menstruation, the hormone progesterone causes the plump uterine lining to shed. The misplaced endometrial cells in other areas of the body also respond to oestrogen and progesterone. Hormone therapy can sometimes be an effective way to manage the symptoms of endometriosis.
Options for hormone therapy include:

GESTRINONE – is a synthetic hormone that causes the endometriosis to become inactive and waste away. Side effects of gestrinone include weight gain, acne, depression, mood swings, hot flushes and loss of libido (sex drive).
DYDROGESTERONE– a synthesised version of the hormone progesterone, which helps to dry up the stray endometrial cells. Ovulation may still occur. Side effects of dydrogesterone can include depression, tender breasts, weight gain, fatigue, nausea, headaches and dizziness.
MEDROXYPROGESTERON ACETATE– another synthesised version of the hormone progesterone. Most women taking medroxyprogesterone acetate will stop ovulating and menstruating. Other side effects include weight gain, bloating, irregular vaginal bleeding, depression, sweating, headaches, acne, nausea, fatigue and tender breasts.
GnRH AGONIST– gonadotrophin-releasing hormones help to govern the menstrual cycle. GnRH agonists are drugs that stop the ovaries from producing as much oestrogen by reducing the hormones produced by the pituitary gland (follicle stimulating hormone and luteinising hormone). Without oestrogen, the misplaced endometrial cells are unable to grow. Side effects of GnRH agonists include menopausal symptoms such as thinning of the bones, hot flushes, dry vagina, headaches, depression, loss of libido and night sweats. These symptoms can be relieved, while still maintaining the benefit of the treatment, by adding back oestrogen and progesterone.
The oral CONTRACEPTIVE PILL– the pill is frequently used to achieve long-term suppression of endometriosis. It can be used to stop the disease progressing in women with mild disease or to stop the disease from recurring following surgical or hormonal treatment.
DANAZOLE– this mild form of the male hormone testosterone reduces the amount of oestrogen produced by the ovaries to around the same level as occurs during menopause. Without oestrogen, the stray endometrial cells can’t grow and, therefore, shrink and disappear during the treatment. Danazol is now rarely used to treat endometriosis due to its serious side effects, which can include weight gain, bloating, fluid retention, acne, smaller breasts, increase in muscle mass, increased facial and body hair, muscle cramps, mood swings, voice deepening and clitoral enlargement. Danazol can also cause gastrointestinal upsets, depression and liver disease.

Surgery

The different types of surgery include:

LAPAROSCOPIC SURGERY– a slender tube is inserted into the abdominal cavity via a small incision (also known as ‘keyhole’ surgery). Endometrial implants, cysts and adhesions are then removed by cutting out (excision), burning (cauterisation) or vapourising (ablation) them. Cutting out is the most effective of these methods. You should seek an expert in advanced laparoscopic surgery to conduct your procedure. Some doctors can perform surgery, including the removal of the ovaries or removal of endometriosis from the bowel, laparoscopically.
LAPAROTOMY (open surgery) – a surgical incision into the abdominal cavity to cut out or burn tissue or remove cysts (with the advent of laparoscopic surgery, this procedure is now rarely necessary).
BOWEL RESECTION – may be necessary if the bowel has developed endometriosis adhesions.
HYSTERECTOMY – the uterus is removed, along with endometrial implants, cysts and adhesions. In some cases, the fallopian tubes and ovaries will also be removed. Unfortunately, hysterectomy does not always cure endometriosis.

Combined treatment

In some cases, a woman will benefit from undergoing hormone therapy as well as surgery. Hormone therapy may be offered before or after the surgery, depending on the circumstances.

Complementary therapies

Some women find complementary therapies to be helpful. Always tell your doctor about the kinds of complementary therapies you are using or considering. Options include:

Acupuncture
Chinese medicine
Herbal therapy
Homeopathy.

Pregnancy is not a cure

Some people believe that endometriosis can be cured by pregnancy. This isn’t the case. The symptoms may improve for some women, but worsen in others. For those women who experience an end to all symptoms during pregnancy, the relief may only be short lived. Unfortunately, for some women, the endometriosis will recur.

ENDOMETRIOSIS – causes and risk factors

2009-11-30T03:01:00.002+07:00

The tissue that lines the inside of the uterus is called the endometrium. Endometriosis is the growth of endometrial tissue in places outside the uterus, such as the ovaries, uterus, bowel and lining of the pelvic cavity.

The causes of endometriosis remain unknown, but researchers have uncovered a number of possible causes and risk factors.

Endometriosis can cause numerous symptoms, including :

Painful periods (DYSMENORRHOEA)
Pain with sex (DYSPAREUNIA) ,
Fertility problems,
Pelvic and ovulation pain,
Pain in the lower back and thighs, and
Bowel and bladder symptoms.

Usually, endometriosis causes pain around the time of the period, but some women experience almost constant pain. If you have bad period pain, you should see your doctor.

Stray endometrial cells respond to hormones

The endometrium responds to the sex hormones oestrogen and progesterone. In women with endometriosis, the stray endometrial cells in the pelvic cavity also respond to these hormones.
During ovulation, oestrogen prompts the uterine lining – and the misplaced endometrial cells – to thicken. However, the misplaced endometrial cells cannot leave the body via menstruation; they simply bleed a little, causing inflammation and pain, and then heal. Over time, this may create scar tissue. Affected organs, such as the ovaries and bowel, may stick together. This can cause chronic pain and bowel symptoms. Sometimes, it can cause fertility problems if the scar tissue (adhesions) stops the released egg from getting to the fallopian tube.

Genetic susceptibility

Studies indicate that some women are genetically predisposed to developing endometriosis. According to researchers from the University of Queensland, endometriosis runs in families, which means the genetic susceptibility is inherited.
Australian researchers have found that women who have a sister with the disease are 2.3 times more likely to have the disease than women in the general community. The increased likelihood of developing the disease is not just confined to the daughters and sisters of women with the disease but also affects their cousins.
Possible causes
Some of the theories on what causes endometriosis include:

Retrograde menstruation
Immune system malfunction
Genetic factors.

Retrograde menstruation

Retrograde menstruation is also known as ‘backward menstruation’. The lining of the uterus is shed during the period. In almost all women, some of the menstrual fluid flows backwards into the fallopian tubes instead of leaving the body through the vagina.
Since the fallopian tubes are open-ended (they are not joined to the ovaries, but open nearby), menstrual fluid can drip into the pelvic cavity. It is suspected that, in women who experience endometriosis, the endometrial tissue contained in the menstrual fluid sticks to whatever structures it lands on (such as the ovaries) and starts to grow.

Immune system malfunction

Retrograde menstruation occurs in almost all women, but only 3–10 per cent of menstruating women develop endometriosis. One theory suggests that the immune systems of some women allow endometriosis to develop by failing to control or stop the growth of endometrial tissue outside the uterus.

The genetic factor

It seems that genetic susceptibility plays a significant role in the development of endometriosis – but how? Some researchers suspect that some families carry faulty genes that allow abnormal cells to survive and grow in the pelvic cavity.

Risk factors

Apart from genetic susceptibility, some of the suspected risk factors include:

MENSTRUAL CYCLE FACTORS– some evidence suggests that women with endometriosis are more likely to have started their periods at an early age. Other factors related to the menstrual cycle that may predispose a woman to endometriosis include heavy or painful periods, short menstrual cycles (less than 27 days) and long periods (more than one week).
ALLERGIES – such as food, eczema and hay fever.
OBESITY
EXPOSURE TO TOXINS – persistent environmental pollutants, such as dioxins, are suspected of contributing to the development of endometriosis. Animal experiments have indicated such an effect, but at levels of exposure higher than those currently seen in humans.

Reducing your endometriosis risk

Factors that may help reduce your risk of endometriosis include:

AEROBIC EXCERCISE of five hours per week – studies show a 50 per cent reduction in the risk of recurrence
CHILDBEARING – reduces the risk of recurrence by about 50 per cent.
The CONTRACEPTIVE PILL – this prevents ovulation, during which there is a surge of oestrogen production and spill into the pelvis.

ENDOMETRIOSIS

2009-11-30T02:48:00.002+07:00

Endometriosis is a condition in which endometrium, the tissue that normally lines the womb (uterus), grows in locations outside the uterus.

Endometriosis may cause adhesions (fibrous scar tissue) on the uterus.

The uterus can become stuck to the ovaries, fallopian tubes and bowel.
The pain of endometriosis can be so bad that it stops you from going to work or school. Usually, it causes pain around the time of your period but for some women the pain is almost constant. If you need treatment, you may need emotional as well as physical support.

Symptoms

The symptoms of endometriosis include:

Painful periods
Pain with sex
Pelvic pain
Ovulation pain
Pain in the lower back and thighs
Bowel symptoms
Bladder symptoms
Reduced fertility
Nausea and lethargy
Pre-menstrual tension (PMT).

Many women think that painful periods are normal. If you have bad period pain, you should see your doctor.

Diagnosis

Tests that are used to help diagnose endometriosis include:

LAPAROSCOPY– surgical procedure performed under general anaesthetic, where a medical instrument with a video camera attached is used to examine your pelvic organs.
ULTRASOUND – a vaginal or abdominal instrument that uses sound waves to create a video image of your pelvic organs.
COLONOSCOPY– a medical instrument with a video camera attached that is used to examine your bowel. This is done if it is thought that the endometriosis could also be affecting your bowel. You would be sedated for the procedure.

Endometriosis may not show up during an internal pelvic examination. Your doctor may need to refer you to a gynaecologist if you have endometriosis.

Treatment

Endometriosis can be treated medically (with drugs or medicine) or with surgery. Sometimes both medicine and surgery are used. Some women also benefit from natural therapies.
Drug therapy
Medications that are used to help treat endometriosis include:

Anti-inflammatory medications
Pain killers (Mersyndol is often used)
Hormonal treatments, which suppress ovulation and menstruation and may have side effects. There are different categories of these such as GnRH agonists (Zoladex, Synarel), androgenic steroids (Danocrine, Azol, Dimetriose), progestogens (Provera, Duphaston, Primolut) and the oral contraceptive pill.

Surgery

Surgical methods used to treat endometriosis include:

LAPAROSCOPIC SURGERY– performed to diagnose and treat endometriosis. Laser surgery may be used to remove the adhesions. This is done to reduce pain and improve the chances of you becoming pregnant.
LAPAROTOMY – to cut out or burn tissue or remove cysts.
BOWEL RESECTION – may be necessary if the bowel has developed endometriosis adhesions.
HYSTERECTOMY(removal of the uterus) – may be an option if endometriosis is significantly impacting on your quality of life and other treatments have not worked.

If your ovaries are removed during a hysterectomy, you will need to discuss hormone replacement with your doctor.

Complementary therapies

There are many different forms of complementary therapies that can be used to treat endometriosis. Most therapies may be used in conjunction with Western medicine or instead of surgery and drug therapy.

Examples of different therapies include:

Herbal medicine
Homeopathy
Traditional Chinese medicine
Nutritional therapies
Massage
Yoga.

ADENOMYOSIS

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Adenomyosis

Known as "Endometriosis of the uterus," Adenomyosis is benign and does not cause cancer. Most commonly, the disease affects the back wall (posterior side) of the uterus. The endometrial cells penetrate deep into the uterine muscle (myometrium). When this occurs, the uterus is enlarged usually more than twice the normal size and very hard. The disease may be localized with well-defined borders or diffuse, meaning having no limits or borders. When this localized disease is found it is called adenomyoma. These adenomyomas can be located at different depths of the uterine muscle and can penetrate into the uterine cavity, becoming submucosal tumors

How common is Adenomyosis?

This disease can only be diagnosed with 100% certainty by doing a biopsy of the uterine muscle. Depending on the various reported studies published, it has been noted to occur in 8-62% of women who have had hysterectomies. 12% of women with Adenomyosis have also had Endometriosis in other sites such as the pelvic wall, ovaries, fallopian tubes etc. The highest incidence is seen in women in their mid to upper forties, and though this disease may cause infertility, it often appears in women who have already had children.

What are the symptoms of Adenomyosis?

As with Endometriosis, patients with Adenomyosis may not show any symptoms (asymptommatic). However, women most commonly experience excessive, heavy or prolonged menstrual bleeding and painful periods (dysmenorrhea). The amount of bleeding and cramps is usually associated with the degree of disease involvement and depth of penetration into the uterine walls. Extensive involvement of the uterine muscle can also interfere with the normal contractility of the muscle which then leads to excessive bleeding.

How is Adenomyosis diagnosed?

An exact diagnosis is often difficult to establish pre-operatively because abnormal patterns of bleeding (dysfunctional bleeding) and fibroid tumors can result in similar symptom patterns. Sometimes during a D&C procedure to remove intra-uterine polyps or small fibroid tumors, tissue is removed enabling a pathologist to make the diagnosis.

Pelvic Exam Findings

Pelvic exam findings can reveal a normal, or only slightly enlarged uterus to a very firm tender uterus enlarged to twice the normal size.

MRI- Magnetic Resonance Imaging

At times, this can distinguish adenomyomas from fibroid tumors, but again, experienced physicians and radiologists possessing extensive training are required.

MRI provides better diagnostic capability due to the increased spatial and contrast resolution, and to not being limited by the presence of bowel gas or calcified uterine fibroids (as is ultrasound). In particular, MR is better able to differentiate adenomyosis from multiple small uterine fibroids. The uterus will have a thickened junctional zone with diminished signal on both T1 and T2 weighted sequences due to susceptibility effects of iron deposition due to chronic microhemorrhage. A thickness of the junctional zone greater than 10 to 12 mm (depending on who you read) is diagnostic of adenomyosis (<8 mm is normal). Interspersed within the thickened, hypointense signal of the junctional zone, one will often see foci of hyperintensity (brightness) on the T2 weighted scans representing small cystically dilatated glands or more acute sites of microhemorrhage.

MR can be used to classify adenomyosis based on the depth of penetration of the ectopic endometrium into the myometrium.

Transvaginal Ultrasound

Extensive recent work has been completed with this test, but the amount of false positive results is still high.

Tissue Diagnosis

Tissue diagnosis in some form remains the only definitive method for diagnosing Adenomyosis. If the diagnosis is suspected pre-operatively, then a laparoscopy and a long needle biopsy can be performed, whereby a needle is inserted into the back of the uterus to collect a tissue sample for pathological testing. It may also be diagnosed when fibroid tumors are removed .

Can Adenomyosis be treated without surgery?

Some studies have shown that there is a relationship between Adenomyosis and hormone imbalance, most commonly an excess of estrogen. Progesterone therapy, either in the natural or synthetic form has been known to help, but shows very little long term benefits. A medication called Danazol may be helpful in treating the pain and decreasing the size of the uterus but long term positive results are poor. Although gonadotropin-releasing hormone agonists such as Lupron have been found to reduce uterine symptoms of adenomyosis during treatment, the symptoms return quickly after the medicine wears off.

How can Female Alternative Surgery help Adenomyosis?

Most commonly, hysterectomy has been the mainstay of treatment. Traditional medicine states that since most women with Adenomyosis are beyond child-bearing age, the uterus is no longer relevant. At the Institute, we want to give women every opportunity to retain their female organs even if fertility is not a concern. Our surgical approach is first to make a diagnosis. For women who still wish to conceive, we try to remove the Adenomyosis using laser technology (CO2 Yag and Argon) which preserves the endometrial cavity but treats the remaining deep uterine muscle disease. In the case of women who are not concerned with fertility but want to preserve their organs, our approach is to remove as much of the affected tissue and, if necessary, decrease the size of the endometrial cavity. We treat the remaining uterine muscle with a deep tissue laser technique. Post surgical results have shown that pain almost always disappears and menstrual flow and volume decrease.

HUMAN FERTILIZATION

2009-11-29T06:13:00.003+07:00

The acrosome reaction for a sea urchin, a similar process. Note that the picture shows several stages of one and the same spermatozoon - only one penetrates the ovum

Human fertilization is the union of a human egg and sperm, usually occurring in the ampulla of the uterine tube. It is also the initiation of prenatal development. Scientists discovered the dynamics of human fertilization in the nineteenth century.^[1]

Fertilization (also known as conception, fecundation and syngamy), is the fusion of gametes to produce a new organism. The process involves a sperm fusing with an ovum, which eventually leads to the development of an embryo.

It is when first of all the acrosome at the head tip produces enzymes, which cuts through the outer jelly coat of the egg. After that has happened, the sperm plasma fuses with the egg’s plasma membrane. Finally, the Head disconnects with the body, and the egg can now travel down the Fallopian tube to reach the womb, where the baby grows.

Fertilization may or may not involve sexual intercourse. In vitro fertilisation (IVF) is a process by which egg cells are fertilized by sperm outside the womb, in vitro. Sperm is propelled through the female reproductive tract by flagellation and may get through the jelly coat through a process called sperm activation. The oocyte and sperm fuse once the sperm is through the corona radiata and the zona pellucida; two layers covering and protecting the oocyte from fertilization by more than one sperm.

Corona radiata

Human ovum examined fresh in the liquor folliculi. The zona pellucida is seen as a thick clear girdle surrounded by the cells of the corona radiata.
The egg itself shows a central granular deutoplasmic area and a peripheral clear layer, and encloses the germinal vesicle, in which is seen the germinal spot.

The egg binds the sperm through the corona radiata, a layer of follicle cells on the outside of the secondary oocyte. Fertilization is when the nuclei of a sperm and an egg fuse. The successful fusion of gametes form a new organism.

Acrosome reaction

The acrosome reaction must occur to mobilise enzymes within the head of the spermatozoon to degrade the zona pellucida.

Zona pellucida

The sperm then reaches the zona pellucida, which is an extra-cellular matrix of glycoproteins. A special complementary molecule on the surface of the sperm head then binds to a ZP2 glycoprotein in the zona pellucida. This binding triggers the acrosome to burst, releasing enzymes that help the sperm get through the zona pellucida.

Some sperm cells consume their acrosome prematurely on the surface of the egg cell, facilitating for other surrounding sperm cells, having on average 50% genome similarity, to penetrate the egg cell.^[2] It may be regarded as a mechanism of kin selection.

Recent studies have shown that the egg is not passive during this process.^[3][4]

Cortical reaction

Once the sperm cells find their way past the zona pellucida, the cortical reaction occurs: cortical granules inside the secondary oocyte fuse with the plasma membrane of the cell, causing enzymes inside these granules to be expelled by exocytosis to the zona pellucida. This in turn causes the glyco-proteins in the zona pellucida to cross-link with each other, making the whole matrix hard and impermeable to sperm. This prevents fertilization of an egg by more than one sperm.

Fusion

After the sperm enters the cytoplasm of the oocyte, the cortical reaction takes place, preventing other sperm from fertilizing the same egg. The oocyte now undergoes its second meiotic division producing the haploid ovum and releasing a polar body. The sperm nucleus then fuses with the ovum, enabling fusion of their genetic material.

Cell membranes

The cell membranes of the secondary oocyte and sperm fuse together.

Transformations

Both the oocyte and the sperm go through transformations, as a reaction to the fusion of cell membranes, preparing for the fusion of their genetic material.

The oocyte now completes its second meiotic division. This results in a mature ovum. The nucleus of the oocyte is called a pronucleus in this process, to distinguish it from the nuclei that are the result of fertilization.

The sperm's tail and mitochondria degenerate with the formation of the male pronucleus. This is why all mitochondria in humans are of maternal origin.

Replication

The pronuclei migrate toward the center of the oocyte, rapidly replicating their DNA as they do so to prepare the new human for its first mitotic division.

Mitosis

The male and female pronuclei don't fuse, although their genetic material do so. Instead, their membranes dissolve, leaving no barriers between the male and female chromosomes. During this dissolution, a mitotic spindle forms around them to catch the chromosomes before they get lost in the egg cytoplasm. By subsequently performing a mitosis (which includes pulling of chromatids towards centrioles in anaphase) the cell gathers genetic material from the male and female together. Thus, the first mitosis of the union of sperm and oocyte is the actual fusion of their chromosomes.

Each of the two daughter cells resulting from that mitosis have one replica of each chromatid that was replicated in the previous stage. Thus, they are genetically identical.

In other words, the sperm and oocyte don't fuse into one cell, but into two identical cells.

Footnotes

^ Garrison, Fielding. An Introduction to the History of Medicine, pages 566-567 (Saunders 1921).
^ Sleek, Fast and Focused: The Cells That Make Dad Dad New York Times 2007/06/12
^ Suzanne Wymelenberg, Science and Babies, National Academy Press, page 17
^ Richard E. Jones and Kristin H. Lopez, Human Reproductive Biology, Third Edition, Elsevier, 2006, page 238

EARLY PREGNANCY SYMPTOMS

2009-11-29T00:45:00.002+07:00

Introduction

Most women equate a missed menstrual period with the possibility of being pregnant, but other symptoms and signs are experienced by most women in the early stages of pregnancy. It's important to remember that not all women will experience all of these symptoms or have the symptoms to the same degree. Even the same woman can have different types of symptoms in a subsequent pregnancy than she had in previous pregnancies. The following are the most common pregnancy symptoms in the first trimester.

Missed period

A missed menstrual period is most often the first sign of pregnancy. Sometimes a woman who is pregnant may still experience some bleeding or spotting around the time of the expected period, typically 6 to 12 days after conception. When it occurs, this so-called "implantation bleeding" is generally not as heavy or long as a regular menstrual period. This small amount of bleeding that occurs at the time of the expected menstrual period happens when the fertilized egg attaches to the uterine wall and is referred to as implantation bleeding.

Any bleeding during pregnancy is typically lighter than that observed during the regular menstrual period. However, if a woman does not have regular menstrual cycles, she may notice some of the other symptoms of early pregnancy before it is apparent that the menstrual period has been missed. A missed menstrual period also does not confirm that a woman is pregnant even if she has regular cycles, since both emotional and physical conditions may cause absent or delayed periods.

Breast swelling, tenderness, and pain

Feelings of breast swelling, tenderness, or pain are also commonly associated with early pregnancy. These symptoms are sometimes similar to the sensations in the breasts in the days before an expected menstrual period. Women may also describe a feeling of heaviness or fullness in the breasts. These symptoms can begin in some women as early as one to two weeks after conception.

Nausea and vomiting

Nausea and vomiting are also common in early pregnancy. Traditionally referred to as "morning sickness," the nausea and vomiting associated with early pregnancy can occur at any time of the day or night. Its typical onset is anywhere between the 2nd and 8th weeks of pregnancy. Most women who have morning sickness develop nausea and vomiting about one month after conception, but it may develop sooner in some women. Sometimes women report an increased in sensitivity to certain odors or smells that can sometimes cause nausea and/or vomiting.

Elevations in progesteron that occur early in pregnancy are thought to slow the emptying of the stomach and may be related to the development of nausea. Accompanying the characteristic "morning sickness" may be cravings for, or aversions to, specific foods or even smells. It is not unusual for a pregnant woman to change her dietary preferences, often having no desire to eat previous "favorite" foods. In most women, nausea and vomiting begin to subside by the second trimester of pregnancy.

Food cravings

Many women report cravings for certain foods during the early stages of pregnancy. These cravings can persist throughout the entire pregnancy.

Fatigue and tiredness

Fatigue and tiredness are symptoms experienced by many women in the early stages of pregnancy. Some women report feeling fatigued even in the weeks immediately prior to conception. The cause of this fatigue has not been fully determined, but it is believed to be related to rising levels of the hormone progesterone. Of course, fatigue is a very nonspecific symptom that can be related to many causes other than pregnancy.

Abdominal bloating

Some women may experience feelings of abdominal enlargement or bloating, but there is usually only a small amount of weight gain in the first trimester of pregnancy. In this early stage of pregnancy a weight gain of about one pound per month is typical. Sometimes women also experience mild abdominal cramping during the early weeks of pregnancy, which may be similar to the cramping that occurs prior to or during the menstrual period.

Frequent urination

A woman in the early stages of pregnancy may feel she has to urinate frequently, especially at nighttime, and she may leak urine with a cough, sneeze, or laugh. The increased desire to urinate may have both physical and hormonal causes. Once the embryo has implanted in the uterus, it begins to produce the hormone known as human chorionic gonadotrophin (hCG), which is believed to stimulate frequent urination. Another cause of frequent urination that develops later is the pressure exerted by the growing uterus on the bladder.

Elevated basal body temperature

A persistently elevated basal body temperature (the oral temperature measured first thing in the morning, before arising from bed) is another characteristic sign of early pregnancy. An elevation in the basal body temperature occurs shortly after ovulation and persists until the next menstrual period occurs. Persistence of the elevated basal body temperature beyond the time of the expected menstrual period is another sign of early pregnancy.

Changes in nipple color

Women may notice a deepening of the color of the area surrounding the nipple, called the areola and/or a dark line going down from the middle of the central abdomen area to the pubic area (known as the linea nigra). Some degree of darkening of the areola persists after pregnancy in many women, but the linea nigra typically disappears in the months following delivery of the baby.

Melasma (darkening of the skin)

Some women may develop a so-called "mask of pregnancy" in the first trimester, referring to a darkening of the skin on the forehead, bridge of the nose, upper lip, or cheeks. The darkened skin is typically present on both sides of the face. Doctors refer to this condition as melasma or chloasma, and it is more common in darker-skinned women than those with lighter skin. Melasma can also occur in some conditions other than pregnancy. Women who have a family history of melasma are at greater risk of developing this sign of pregnancy.

Mood swings and stress

Mood swings and stress are common symptoms reported by many women in the early stages of pregnancy. Many women in the early stages of pregnancy describe feelings of heightened emotions or even crying spells. The rapid changes in hormone levels are believed to cause these changes in mood. Pregnant women may also notice more rapid and drastic changes in their moods.

Headaches

Some women report suffering from headaches early on in their pregnancy, which may be related to corresponding changes in hormone levels.

MENOPAUSE and SEXUAL ISSUES

2009-11-27T22:12:00.002+07:00

Menopause occurs when a woman stops ovulating and her monthly period (menstruation) ceases. It is a natural event that marks the end of the reproductive years.

The production of sex hormones, in particular oestrogen, falls significantly around menopause. Testosterone levels in women slowly decline from about 30 years of age. A woman in her forties has, on average, half the testosterone circulating in her bloodstream as a woman in her twenties.

The reduction of these hormones may directly affect libido or sex drive and sexual function for some women. It may also cause physical and psychological changes that will affect sexual function.

Other important issues that may influence the menopausal woman’s sexual desire and activity include contraception, physical changes (such as a dry, painful vagina), body image, relationship issues, illness and external stresses.

Contraception

Pregnancy is possible, though rare, before and even after your last period. It is generally advised that menopausal women should use contraception until at least one year after their natural periods have ceased. This is because a pregnancy late in a woman’s reproductive life increases the risk of birth defects for the child and health problems for the mother.

Hormone replacement therapy (HRT) is not a form of contraception. HRT is prescribed by a doctor to help manage the symptoms of a woman’s menopause. However, HRT does not contain sufficient hormones to suppress ovulation, so pregnancy can still occur.

There are many different options for contraception, which need to be discussed with your doctor.

Women who are sexually active should also continue to use condoms to protect against sexually transmissible infections (STIs). When using a condom, choose a water-based lubricant to avoid condom breakage.

Physical changes

Both during and after menopause, a woman may notice certain physical changes that affect her sexuality in positive and negative ways. These changes may include:

Vaginal changes –as oestrogen levels fall, the walls of the vagina become thinner and drier. This loss of lubrication can make having sex uncomfortable.
Slowed sexual response – getting aroused and reaching orgasm may take longer and be less intense.
Infections – the post-menopausal vagina and bladder are more susceptible to bacterial infections.
Menopause symptoms – such as hot flushes, night sweats, insomnia and unusual skin sensations like prickling or itching.
Touch avoidance – some women can’t bear to be touched. Their skin feels more sensitive and they may recoil from closeness, particularly sexual intimacy. The physical discomfort of menopause symptoms may reduce a woman’s interest in sex or make her tired. Even the close proximity of her partner may be distressing because of the combined body heat.
Absent periods – a woman who was troubled by heavy or painful periods may feel relieved and positive about her change of life. This can lead to a renewed interest in sex.
No fear of pregnancy – many women who were trying to avoid pregnancy during their reproductive years may find the menopause begins a time of renewed sexual interest. Without the fear of possible pregnancy, sex becomes relaxed, fun and more frequent.

Body image

Some of the issues that may contribute to a menopausal woman’s body image include:

Social attitudes – Western culture tends to value youth, thinness and beauty, while older women are rarely portrayed as sexual or desirable. These ingrained social attitudes may prompt some women who are approaching the menopause to feel less attractive. Other women may erroneously believe that sex is only for the young, and this attitude can cause sexual interest and activity to wane.
Weight gain – an increase in body fat, especially around the abdomen, can occur during menopause because of hormonal changes. The age-related decrease in muscle tissue and the associated slowing of the metabolism also contribute.
Changes to body hair – some women experience abnormal hair growth after menopause, particularly on the face. Others may experience thinning of scalp and pubic hair.

Other issues

Other issues that may impact on a woman’s sexuality during and after menopause include:

Ill-health – since disorders such as cardiovascular disease and osteoporosis are more prevalent in older women.
Some medications – such as some antidepressants or antihypertensives, which may affect sexual function and libido.
Ill-health or sexual difficulties of a partner – such as erectile problems.
Loss of a partner – through death, divorce or separation.
Depression
Children leaving or staying at home – children leaving home allows more sexual freedom for the older couple; children staying at home may restrict independence; the ‘revolving door’, with children coming and going, can also have an impact.

Enhance your sex life

Suggestions to maintain or improve your sex life after the menopause include:

Talk openly with your partner about sex and the impacts – both positive and negative – of menopause.
Physical changes may slow your reaction times. Plan for slow, lingering sessions of lovemaking.
Try widening your sexual horizons and include sexual activities that don’t involve vaginal penetration such as oral sex, sexual aids and mutual masturbation.
Regular masturbation helps to improve blood flow and muscle tone.
Wash your vulva with warm water and sorbolene rather than soap, which can further dry and irritate the tissues.
If vaginal dryness persists, consider using water-based vaginal lubricants, available from pharmacists and supermarkets.
Vaginal preparations of oestrogen creams, tablets and pessaries or hormone replacement therapy can help manage vaginal dryness. Consult with your doctor.
Exercise regularly and eat a healthy diet to maintain an appropriate weight for your height.
Oestrogen plus testosterone therapy may affect sexuality positively.
Seek advice from a professional if you need help with any sexual issues.
Relationship or sexual counselling may help resolve issues with partners.

CYTOLYTIC VAGINOSIS

2009-11-27T21:57:00.003+07:00

What is cytolytic vaginosis?

Cytolytic vaginosis is an occasional cause of vaginal discharge.

What is the cause of cytolytic vaginosis?

The normal vagina of an adult woman is colonised by lactobacilli. These bacteria produce lactic acid, which maintains an acid pH, and hydrogen peroxide, which is an antiseptic agent. The lactobacilli protect the vagina from pathogenic infections and are considered important for vaginal health.

Cytolytic vaginosis arises because of an overgrowth of the lactobacilli. They can irritate the cells that make up the vaginal lining, causing them to break up. The damaged or fragmented cells are then shed with the normal vaginal secretions.

What are the symptoms?

Many women with cytolytic vaginosis are unaware of it. It may be reported after a vaginal swab or cervical smear. However, they may have the following symptoms:

Abundant whitish vaginal discharge, which may be thin and watery or thick and curd-like
Vaginal and/or vulval itching (pruritus vulvae)
Burning (vulvodynia), especially on passing urine (dysuria)
Discomfort during sexual intercourse (dyspareunia)

The symptoms are similar to those of vaginal thrush. Like thrush, they may get worse in the second half of the menstrual cycle. However, high vaginal swabs do not culture the yeast that causes thrush, Candida albicans, and antifungal creams and tablets are not effective. The vaginal pH is acidic (3.3 to 5.5).

How is the diagnosis made?

Cytolytic vaginosis should be considered in women with vaginal symptoms that have not settled down or have recurred after treatment for thrush.

A vaginal swab should be taken. The laboratory may report numerous lactobacilli and epithelial cells. There should be no sign of candida or other infective organisms.

What is the treatment for cytolytic vaginosis?

In most women, no specific treatment is required. Antifungal medications should be discontinued.

In those with symptoms, the following measures may be helpful:

Pads instead of tampons for menstruation.
Baking soda (sodium bicarbonate) sitz baths or douches to increase vaginal pH and thus discourage the growth of lactobacilli. Use 2-4 tablespoons of baking soda in 5cm of water in a warm bath several times in a week, then once or twice per week to prevent recurrences.

MENOPAUSE- hormone replacement therapy

2009-11-27T21:53:00.002+07:00

Many women, although not all, experience uncomfortable symptoms during and after menopause, including hot flushes, night sweats and vaginal dryness. These symptoms, and the associated physical changes, can be managed in various ways including education and lifestyle changes like diet and exercise.

Hormone replacement therapy (HRT) is also available if required. This is also known as hormone therapy (HT). While HRT reduces the risk of some debilitating diseases, it also increases the risk of others.

Menopause occurs when a woman stops ovulating, the ovaries no longer produce oestrogen (one of the female sex hormones) and her monthly period (menstruation) ceases. It is a natural event that marks the end of the reproductive years, just as the first menstrual period during puberty marked the start.

Menopause symptoms can be reduced by HRT

The following menopause-related symptoms may be reduced by HRT:

Hot flushes
Night sweats
Vaginal dryness
Thinning of vaginal walls
Vaginal and bladder infections
Mild urinary incontinence
Insomnia
Cognitive changes, such as memory loss
Reduced sex drive
Mood disturbance
Abnormal sensations, such as ‘prickling’ or ‘crawling’ under the skin
Palpitations
Hair loss or abnormal growth
Dry and itching eyes
Tooth loss
Gingivitis (gum problems).

Side effects of HRT

HRT needs to be individually tailored. Some women experience side effects during the early stages of treatment, which may include:

Breakthrough bleeding
Breast tenderness
Bloating – around one in 10,000 women aged 50 experience bloating and this increases with age
Blood clots – the risk increases with age. Younger women on oral HRT face a one in 5,000 to one in 10,000 risk of blood clots. Older women, aged 50 to 60 years, face a one in 500 to one in 1,000 risk of blood clots when on oral HRT.

HRT does not cause weight gain

An increase in body fat, especially around the abdomen, can occur during menopause because of our own hormonal changes, although exactly why this happens is not clear. The age-related decrease in muscle tissue and the slowing down of the metabolism can also contribute to weight gain.

Various studies prove that weight gain is not linked to HRT. If a woman is prone to weight gain during her middle years, she will do so regardless of whether or not she uses HRT. Some women may experience symptoms at the start of treatment, including bloating and breast fullness, which may be misinterpreted as weight gain. These symptoms usually disappear once the therapy doses are modified to suit the individual.

Contraception is still needed

HRT is not a form of contraception. The treatment does not contain sufficient hormones to suppress ovulation, so pregnancy is still possible in women who are ovulating occasionally in the perimenopause. It is generally advised that menopausal women should continue to use contraception until their natural periods have ceased for at least one year.

Long-term use of HRT to prevent disease

HRT reduces the risk of various chronic conditions that can affect postmenopausal woman, including:

Osteoporosis – thinning of the bones to the point where they break easily. HRT prevents further bone loss, which preserves bone integrity and reduces the risk of fractures, but is not recommended as a first-line treatment.
Bowel cancer – the risk of colorectal cancers is slightly reduced with HRT.

HRT- related health risks

While HRT reduces the risk of some debilitating diseases, it also increases the risk of others. These small risks must be balanced against the benefits for the individual. Three areas of concern are:

Breast cancer – current research suggests that women over 50 years of age, who use oestrogen and progestogen replacement for less than five years, have little or no increased risk of breast cancer. Women who use HRT with progestogen for more than five years appear to have a slightly increased risk. Women on oestrogen alone appear to have no increased risk up to 15 years of usage. There is no evidence to suggest that a woman with a family history of breast cancer will have an added increased risk of developing the disease if she uses HRT. The risk with combined oestrogen and progestogen is greater than with oestrogen alone or with newer HRT agents, including Tibolone, but research in this area is ongoing.
Cardiovascular disease – current research suggests that women over 60 have a small increased risk of developing both heart disease and strokes on combined oral HRT. Although this risk is small (7 heart attacks and 8 strokes per 10,000 treatment years – that is, 1,000 women treated for 10 years), it needs to be considered when starting HRT, as the risk occurs early in treatment and persists with time. Oestrogen used on its own increases the risk of stroke (12 per 1,000 women per year). Women who commence HRT around the time of menopause may not have the same increased risk as women aged 60 or more. The risk with other forms of hormone therapy such as Tibolone is unknown. The results of ongoing research are awaited with interest.
Thrombosis – these are blood clots that form inside veins. Some women on HRT are more likely to get thrombosis than women who are not on HRT. This risk seems to be highest in the first one to two years of therapy and in women who have a high risk of blood clots anyway. This especially applies to women who have a genetic predisposition to developing thrombosis. More research is needed to clarify if oestrogen applied through the skin as patches, implants or gels has the same effect. Limited research to date would suggest the increased risk of clots is mainly related to oestrogen and progestogen in tablet form.
Endometrial cancer – this is cancer of the lining of the uterus. Long-term use (for 10 years or more) of oestrogen alone increases the risk of this cancer, but this risk is neutralised with the addition of progestogen to the treatment.

Long-term use is not recommended

It is currently believed that, overall, the risks of long-term HRT use outweigh the benefits. HRT should not be recommended for disease prevention. However, the jury is still out on the use of oestrogen alone, other HRT preparations (including Tibolone) and other forms of HRT (including patches). We await the results of further trials before recommendations in these areas can be made.
However, in women with long-term severe symptoms, HRT may be the only effective therapy. Seek specialist advice from a menopause clinic or specialist physician. Regular check-ups are recommended.

HRT and prior history of breast cancer

To date, there is conflicting specific evidence that HRT will increase the risk of breast cancer recurring in a woman with a prior history of the disease. However, oestrogen and progestins may stimulate some types of cells in the breast and increase the risk of breast cancer in women without a history of breast cancer. It is advisable for woman with a prior history of breast cancer to avoid HRT.

Phytoestrogens and prior history of breast cancer

There is no evidence that phytoestrogens increase the risk of breast cancer recurring but, under certain circumstances, some breast cells may be stimulated. Other forms of management for menopausal symptoms may be advised, such as oestrogen vaginal creams or low doses of antidepressants, which may reduce hot flushes. Be advised by your doctor.

Alternative therapies

Alternative therapies for the management of menopausal symptoms remain controversial. Many of these therapies have not been subjected to clinical trials, so their effectiveness is based on the experiences reported by some women. To date, no alternative therapy has been clinically proven to reduce a menopausal woman’s risk of osteoporosis, and preliminary studies would suggest there is no benefit for the bones. Some of the more popular alternative therapies include:

Soy products
Phytoestrogens
Herbal medicines.

VULVOVAGINAL CANDIDIASIS

2009-11-27T07:50:00.002+07:00

Vulvovaginal Candidiasis

Vulvovaginal candidiasis is the name often given to Candida albicans infection of the vagina associated with a dermatitis of the vulva (an itchy rash). ‘Vaginal thrush’, and ‘monilia’ are also names for Candida albicans infection.

What causes vaginal discharge?

Most women notice from time to time that they have a discharge from the vagina. This is a normal process which keeps the mucous lining of the vagina moist. The discharge is usually clear but may dry on underclothes leaving a faint yellowish mark. This type of discharge does not require any medication even when quite profuse, as is often the case in pregnancy.

Vaginal discharge may also be due to microorganisms:

Vulvovaginal candidiasis (discussed here).
Trichomoniasis (due to a small parasite,Trichomonas vaginalis). This causes a fishy or offensive odour and yellow, green or frothy discharge.
Bacterial vaginosis (due to an imbalance of the amounts of bacteria which live in the vagina). This causes a thin, white/grey discharge and offensive odour.
Cytolytic vaginosis (due to an overgrowth of lactobacilli).

Excessive vaginal discharge may also be due to injury, foreign bodies and other causes of vaginitis.

What is the cause of vulvovaginal candidiasis?

About 20% of non-pregnant women aged 15 to 55 harbour Candida albicans in the vagina. Most have no symptoms and it is harmless to them. Overgrowth of Candida albicans causes a heavy white curd-like vaginal discharge, a burning sensation in the vagina and vulva and/or an itchy rash on the vulva and surrounding skin.

Candidal vulvovaginitis on a wet smear. Addition of potassium hydroxide here has made the hyphae more apparent. Arrows indicate budding yeast. (Courtesy of Pharmacia and Upjohn.)

Gram's stain of Candida organisms in vaginal secretions. Spores and hyphae (staining red/purple) as well as normal bacterial flora are seen. Arrows show buds and hyphae. (Courtesy of CDC.)

Oestrogen causes the lining of the vagina to mature and to contain glycogen, a substrate on which Candida albicans thrives. Lack of oestrogen in younger and older women makes vulvovaginal candidiasis much less common.

Overgrowth of Candida albicans occurs most commonly with:

Pregnancy
Higher dose combined oral contraceptive pill and oestrogen-based hormone replacement therapy
A course of broad spectrum antibiotics such as tetracycline or amoxiclav
Diabetes mellitus
Iron deficiency anaemia
Immunological deficiency e.g., HIV infection
On top of another skin condition, often psoriasis, lichen planus or lichen sclerosus.
Other illness

What are the symptoms?

Symptoms of vulvovaginal candidiasis, i.e., an overgrowth of Candida albicans, include:

Itching, soreness and/or burning discomfort in the vagina and vulva
Heavy white curd-like vaginal discharge
Bright red rash affecting inner and outer parts of the vulva, sometimes spreading widely in the groin to include pubic areas, inguinal areas and thighs.

These may last just a few hours or persist for days, weeks, or rarely, months.

Symptoms may sometimes be aggravated by sexual intercourse.

How is the diagnosis made?

The doctor diagnoses the condition by inspecting the affected area and recognising typical clinical appearance. The pH of the discharge tends to be less than 4.5 the diagnosis is often confirmed by a vaginal swab. In recurrent cases the swab should be repeated after treatment to see whether Candida albicans is still present.

It is best to avoid treatment for four weeks prior to a swab to improve the chance of positive culture.

Swab results can be misleading because the Candida albicans can be present without causing symptoms, and it can only be cultured if a certain amount is present. Swabs from outside the vagina can be negative, even when the yeast is present inside the vagina and there is a typical rash on the vulva. This is because the vaginal discharge has caused an irritant dermatitis, rather than the rash being directly due to infection.

Some women with recurring vulvovaginal symptoms appear to be hypersensitive to the organism (cyclic vulvovaginitis). In these cases it may be difficult for the laboratory to detect the yeast as a vigorous dermatitis has eradicated it.

In other cases, a different species of yeast i.e. a non-albicans candida is found. This is not likely to cause significant vulvovaginitis. Antifungal agents may not clear non-albicans candida from the vagina but luckily, it tends to disappear in time by itself.

Similar symptoms may occur from cytolytic vaginosis.

Treatment

Appropriate treatment for Candida albicans infection can be obtained without prescription from a chemist. If the treatment is ineffective or symptoms recur, see your doctor for examination and advice.

There are a variety of effective treatments for candidiasis. Topical antifungal pessaries or vaginal tablets are usually recommended – in mild cases a single treatment is all that is necessary. A cream formulation may be preferred. Oral antifungal medicines may be used if Candida albicans infection is severe or recurrent.

The creams can be used safely in pregnancy, but the tablets are best avoided.

Not all genital rashes are due to candida, so if treatment is unsuccessful it may because you have another reason for itching (pruritus vulvae) or burning (vulvodynia).

Recurrent Candidiasis

Occasionally Candida albicans infection persists despite adequate conventional therapy. In some women this may be a sign of iron deficiency, diabetes mellitus or an immune problem, and appropriate tests should be done.

It is now thought that women who experience recurrent vulvovaginal Candida albicans do so because of persistent infection, rather than re-infection. The aim of treatment in this situation is therefore to avoid the overgrowth of candida that leads to symptoms, rather than necessarily being able to achieve complete eradication or cure.

There is some evidence that the following measures can be helpful:

Cotton or moisture-wicking underwear and loose fitting clothing – avoid nylon pantyhose.
Soaking in a salt bath. Avoid soap – use a non-soap cleanser or aqueous cream for washing.
Apply hydrocortisone cream to reduce itching and treat secondary dermatitis affecting the vulva.
Treat with an antifungal cream before each menstrual period and before antibiotic therapy to prevent relapse.
A prolonged course of a topical antifungal agent is occasionally warranted (but these may themselves cause dermatitis or result in proliferation of non-albicans candida).
Oral antifungal medication (itraconazole or fluconazole) may be taken regularly and intermittently (e.g. once a month). The dose and frequency is quite variable, depending on the severity of symptoms. Oral antifungal agents may be unsuitable in pregnancy. They require a prescription.
Boric acid (boron) 600mg as a suppository at night may help to acidify the vagina and reduce the presence of yeasts (albicans and non-albicans candida).

TRICHOMONIASIS

2009-11-27T07:21:00.002+07:00

What is trichomoniasis?

Trichomoniasis, sometimes referred to as "trich", is a common cause of vaginitis. It is caused by the single-celled protozoan parasite Trichomonas vaginalis. Trichomoniasis is primarily an infection of the urogenital tract; the most common site of infection is the urethra and the vagina in women.

Trichomoniasis is a common sexually transmitted disease (STD) that affects both women and men, although symptoms are more common in women.

How common is trichomoniasis?

Trichomoniasis is the most common curable STD in young, sexually active women. An estimated 7.4 million new cases occur each year in women and men.

How do people get trichomoniasis?

Trichomoniasis is caused by the single-celled protozoan parasite, Trichomonas vaginalis. The vagina is the most common site of infection in women, and the urethra (urine canal) is the most common site of infection in men.

The parasite is sexually transmitted through penis-to-vagina intercourse or vulva-to-vulva (the genital area outside the vagina) contact with an infected partner. Women can acquire the disease from infected men or women, but men usually contract it only from infected women.

What are the signs and symptoms of trichomoniasis?

Most men with trichomoniasis do not have signs or symptoms; however, some men may temporarily have an irritation inside the penis, mild discharge, or slight burning after urination or ejaculation.

Some women have signs or symptoms of infection which include a frothy, yellow-green vaginal discharge with a strong odor. The infection also may cause discomfort during intercourse and urination, as well as irritation and itching of the female genital area. In rare cases, lower abdominal pain can occur. Symptoms usually appear in women within 5 to 28 days of exposure.

What are the complications of trichomoniasis?

The genital inflammation caused by trichomoniasis can increase a woman’s susceptibility to HIV infection if she is exposed to the virus. Having trichomoniasis may increase the chance that an HIV-infected woman passes HIV to her sex partner(s).

How does trichomoniasis affect a pregnant woman and her baby?

Pregnant women with trichomoniasis may have babies who are born early or with low birth weight (low birth weight is less than 5.5 pounds)

How is trichomoniasis diagnosed?

For both men and women, a health care provider must perform a physical examination and laboratory test to diagnose trichomoniasis. The parasite is harder to detect in men than in women. In women, a pelvic examination can reveal small red ulcerations (sores) on the vaginal wall or cervix.

What is the treatment for trichomoniasis?

Trichomoniasis can usually be cured with prescription drugs, either metronidazole or tinidazole, given by mouth in a single dose. The symptoms of trichomoniasis in infected men may disappear within a few weeks without treatment. However, an infected man, even a man who has never had symptoms or whose symptoms have stopped, can continue to infect or re-infect a female partner until he has been treated. Therefore, both partners should be treated at the same time to eliminate the parasite. Persons being treated for trichomoniasis should avoid sex until they and their sex partners complete treatment and have no symptoms. Metronidazole can be used by pregnant women.

Having trichomoniasis once does not protect a person from getting it again. Following successful treatment, people can still be susceptible to re-infection.

How can trichomoniasis be prevented?

The surest way to avoid transmission of sexually transmitted diseases is to abstain from sexual contact, or to be in a long-term mutually monogamous relationship with a partner who has been tested and is known to be uninfected.

Latex male condoms, when used consistently and correctly, can reduce the risk of transmission of trichomoniasis.

Any genital symptom such as discharge or burning during urination or an unusual sore or rash should be a signal to stop having sex and to consult a health care provider immediately.

A person diagnosed with trichomoniasis (or any other STD) should receive treatment and should notify all recent sex partners so that they can see a health care provider and be treated. This reduces the risk that the sex partners will develop complications from trichomoniasis and reduces the risk that the person with trichomoniasis will become re-infected.

Sex should be stopped until the person with trichomoniasis and all of his or her recent partners complete treatment for trichomoniasis and have no symptoms.

BACTERIAL VAGINOSIS

2009-11-27T06:39:00.002+07:00

What is Bacterial Vaginosis?

Bacterial vaginosis is vaginal condition that can produce vaginal discharge and results from an overgrowth of normal bacteria in the vagina. In the past, the condition was called Gardnerella vaginitis, after the bacteria that were thought to cause the condition. However, the newer name, bacterial vaginosis, reflects the fact that there are a number of species of bacteria that naturally live in the vaginal area and may grow to excess. The Gardnerella organism is not the sole culprit causing the symptoms. When these multiple species of bacteria become imbalanced, a woman can have a vaginal discharge with a foul odor.

Bacterial vaginosis is not dangerous, but it can cause disturbing symptoms. Any woman with an unusual discharge should be evaluated so that more serious infections such as chlamydia and gonorrhea, can be excluded.

What are the symptoms of Bacterial Vaginosis?

The symptoms of bacterial vaginosis are vaginal discharge and odor. Usually, there are no other symptoms. The amount of vaginal discharge that is considered normal varies from woman to woman. Therefore, any degree of vaginal discharge that is abnormal for a particular woman should be evaluated.

Many women with bacterial vaginosis actually have no symptoms at all. Others experience an unpleasant fishy odor with vaginal discharge. The discharge is usually thin and grayish white. The discharge is often more noticeable after sexual intercourse.

What causes Bacterial Vaginosis?

Researchers have had difficulty determining exactly what causes bacterial vaginosis. At present, it seems to be that a combination of multiple bacteria must be present together for the problem to develop. Bacterial vaginosis typically features a reduction in the number of the normal hydrogen peroxide-producing lactobacilli in the vagina. Simultaneously, there is an increase in concentration of other types of bacteria, especially anaerobic bacteria (bacteria that grow in the absence of oxygen). As a result, the diagnosis and treatment are not as simple as identifying and eradicating a single type of bacteria. Why the bacteria combine to cause the infection is unknown.

Certain factors have been identified that increase the chances of developing bacterial vaginosis. These include multiple or new sexual partners, vaginal douching, and cigarette smoking. However, the role of sexual activity in the development of the condition is not fully understood, and bacterial vaginosis can still develop in women who have not had sexual intercourse.

How is Bacterial Vaginosis diagnosed?

When a woman reports an unusual vaginal discharge, the doctor will ask her a series of routine questions to help distinguish mild from more serious conditions. Additional issues that might indicate the presence of a more serious condition include fever, pelvic pain, new or multiple sexual partners (especially with unprotected intercourse), and a history of sexually-transmitted infections.

In addition to these questions, the doctor will perform a pelvic exam. During the exam, the doctor notes the appearance of the vaginal lining and cervix. The doctor will also perform a manual exam of the ovaries and uterus. The cervix is examined for tenderness, which might indicate a more serious infection. The doctor may collect samples to check for chlamydia or gonorrhea infection.

Examining the vaginal discharge under the microscope can help distinguish bacterial vaginosis from yeast vaginitis (candidiasis) and trichomonas (a type of sexually transmitted infection). A sign of bacterial vaginosis under the microscope is an unusual vaginal cell called a clue cell. Clue cells are believed to be the most reliable diagnostic sign of bacterial vaginosis. In addition to clue cells, women with bacterial vaginosis have fewer of the normal vaginal bacteria, called lactobacilli. A vaginal pH greater than 4.5 is also suggestive of bacterial vaginosis.

Finally, the doctor may perform a "whiff test" with potassium hydroxide (KOH) liquid. When a drop of KOH testing liquid used in the "whiff test" contacts a drop of the discharge from a woman with bacterial vaginosis, a certain fishy odor can result.

What is the treatment for Bacterial Vaginosis?

Treatment for bacterial vaginosis consists of antibiotics. A few antibiotics are routinely used. Metronidazole (Flagyl) taken by either oral (pill) form or by vaginal metronidazole gel (Metrogel) is an effective treatment. Also available is the vaginal clindamycin cream (Cleocin). The oral metronidazole can cause some minor but unpleasant side effects, but is believed to be the most effective treatment. The gels do not typically cause side effects, although yeast vaginitis can occur as a side effect of the medication.

Tinidazole is an antibiotic that appears to have fewer side effects than metronidazole and is also effective in treating bacterial vaginosis.

Recurrence of bacterial vaginosis is possible even after successful treatment. More than half of those treated experience recurrent symptoms within 12 months. It is unclear why so many recurrent infections develop. With recurrent symptoms, a second course of antibiotics is generally prescribed.

What are complications of Bacterial Vaginosis?

Bacterial vaginosis can resolve completely without complications after treatment. No special follow-up is necessary if the symptoms disappear.

In pregnancy, bacterial vaginosis can cause premature labor, premature birth, infection of the amniotic fluid, and infection of the uterus after delivery. However, treatment of asymptomatic (not producing symptoms) bacterial vaginosis in pregnancy has not been shown to decrease the incidence of premature births in most studies. For these reasons, screening and treatment for bacterial vaginosis during pregnancy is controversial, and research is still being conducted to determine its utility and value. Currently the routine screening of all pregnant women is not recommended. However, screening and treatment of bacterial vaginosis is sometimes recommended for women with a history of a preterm birth.

Bacterial Vaginosis At A Glance

Bacterial vaginosis is an abnormal vaginal condition that is characterized by vaginal discharge and results from an overgrowth of normal bacteria in the vagina.
Bacterial vaginosis is not dangerous, but it can cause disturbing symptoms.
Symptoms of bacterial vaginosis are vaginal discharge and odor, although 50% to 75% of women with the condition experience no symptoms.
In diagnosing bacterial vaginosis, it is important to exclude other serious infections, such as gonorrhea and chlamydia.
Treatment options for bacterial vaginosis include oral antibiotics ( metronidazole , tinidazole , clindamycin ) oral and topical vaginal gels.
Serious complications of bacterial vaginosis can occur during pregnancy, and recurrence is possible even after successful treatment.

MENOPAUSE

2009-11-11T04:59:00.004+07:00

Definition

Menopause is the permanent end of menstruation and fertility, defined as occurring 12 months after your last menstrual period.

Menopause is a natural biological process, not a medical illness. Even so, the physical and emotional symptoms of menopause can disrupt your sleep, sap your energy and — at least indirectly — trigger feelings of sadness and loss.

Hormonal changes cause the physical symptoms of menopause, but mistaken beliefs about the menopausal transition are partly to blame for the emotional ones. First, menopause doesn't mean the end is near — you've still got as much as half your life to go. Second, menopause will not snuff out your femininity and sexuality. In fact, you may be one of the many women who find it liberating to stop worrying about pregnancy and periods.

Most important, even though menopause is not an illness, you shouldn't hesitate to get treatment if you're having severe symptoms. Many treatments are available, from lifestyle adjustments to hormone therapy.

Symptoms

Technically, you don't actually "hit" menopause until it's been one year since your final menstrual period. Menopause, that happens about age 51, on average.

The signs and symptoms of menopause, however, often appear long before the one-year of your final period. They include:

Irregular periods
Decreased fertility
Vaginal dryness
Hot flashes
Sleep disturbances
Mood swings
Increased abdominal fat
Thinning hair
Loss of breast fullness

When to see a doctor
It's important to see your doctor during the years leading up to menopause (perimenopause) and the years after menopause (postmenopause) for preventive health care as well as care of medical conditions that may occur with aging.

If you've skipped a period but aren't sure you've started menopause, you may want to see your doctor to determine whether you're pregnant. He or she may take a medical history, do a pelvic examination and, if appropriate, order a pregnancy test.

Always seek medical advice if you have bleeding from your vagina after menopause.

Causes

Causes of menopause include:

Natural decline of reproductive hormones. As you approach your late 30s, your ovaries start making less estrogen and progesterone, the hormones that regulate menstruation. During this time, fewer potential eggs are ripening in your ovaries each month, and ovulation is less predictable. Also, the post-ovulation surge in progesterone — the hormone that prepares your body for pregnancy — becomes less dramatic. Your fertility declines, partially due to these hormonal effects.

These changes become more pronounced in your 40s. Your menstrual periods may become longer or shorter, heavier or lighter, and more or less frequent, until eventually, your ovaries stop producing eggs, and you have no more periods. It's possible, but very unusual, to menstruate every month right up to your last period. More likely, you'll experience some irregularity in your periods.

Hysterectomy. A hysterectomy that removes your uterus, but not your ovaries, usually doesn't cause menopause. Although you no longer have periods, your ovaries still release eggs and produce estrogen and progesterone. But an operation that removes both your uterus and your ovaries (total hysterectomy and bilateral oophorectomy) does cause menopause, without any transitional phase. Your periods stop immediately, and you're likely to have hot flashes and other menopausal signs and symptoms.

Chemotherapy and radiation therapy. These cancer therapies can induce menopause, causing symptoms such as hot flashes during the course of treatment or within three to six months.

Primary ovarian insufficiency. Approximately 1 percent of women experience menopause before age 40. Menopause may result from primary ovarian insufficiency — when your ovaries fail to produce normal levels of reproductive hormones — stemming from genetic factors or autoimmune disease, but often no cause for primary ovarian insufficiency can be found.

Stages of menopause
Because the menopausal transition occurs over months and years, menopause is commonly divided into these stages:

Perimenopause. This is the time you begin experiencing menopausal signs and symptoms, even though you still menstruate. Your hormone levels rise and fall unevenly, and you may have hot flashes and other symptoms. Perimenopause may last four to five years or longer. During this time, it's still possible to get pregnant, but it's quite unlikely.

Postmenopause. Once 12 months have passed since your last period, you've reached menopause. Your ovaries produce much less estrogen and no progesterone, and they don't release eggs. The years that follow are called postmenopause.

Complications

Several chronic medical conditions can develop after menopause:

Cardiovascular disease. When your estrogen levels decline, your risk of cardiovascular disease increases. Heart disease is the leading cause of death in women as well as in men. Yet you can do a great deal to reduce your risk of heart disease. These risk-reduction steps include stopping smoking, reducing high blood pressure, getting regular aerobic exercise, and eating a diet low in saturated fats and plentiful in whole grains, fruits and vegetables.
Osteoporosis. During the first few years after menopause, you may lose bone density at a rapid rate, increasing your risk of osteoporosis. Osteoporosis causes bones to become brittle and weak, leading to an increased risk of fractures. Postmenopausal women are especially susceptible to fractures of the hip, wrist and spine. That's why it's important during this time to get adequate calcium and vitamin D — about 1,200 to 1,500 milligrams of calcium and 800 international units of vitamin D daily. It's also important to exercise regularly. Strength training and weight-bearing activities, such as walking and jogging, are especially beneficial in keeping your bones strong.
Urinary incontinence. As the tissues of your vagina and urethra lose their elasticity, you may experience a frequent, sudden, strong urge to urinate, followed by an involuntary loss of urine (urge incontinence), or the loss of urine with coughing, laughing or lifting (stress incontinence).
Weight gain. Many women gain weight during the menopausal transition. You may need to eat less — perhaps as many as 200 to 400 fewer calories a day — and exercise more, just to maintain your current weight.

Preparing for your appointment

Your first appointment will likely be with either your primary care provider or a gynecologist.

Because appointments can be brief, and it can be difficult to remember everything you want to discuss, it's a good idea to prepare in advance of your appointment.

What you can do

Keep track of symptoms you're experiencing. For instance, write down how many hot flashes you experience in a day or week and note how severe they are.
Make a list of any medications and vitamin supplements you take. Write down doses and how often you take them.
Have a family member or close friend accompany you, if possible. You may be given a lot of information at your visit, and it can be difficult to remember everything.
Take a notebook or notepad with you. Use it to write down important information during your visit.
Prepare a list of questions to ask your doctor. List your most important questions first, in case time runs out.

Some basic questions to ask include:

What kind of tests might I need?
What treatments are available to minimize my symptoms?
Is there anything I can do to relieve my symptoms?
What steps can I take to maintain my health?
Do you have any printed material or brochures I can take with me? What Web sites do you recommend?

Make sure that you understand everything that your doctor tells you. Don't hesitate to ask your doctor to repeat information or to ask follow-up questions for clarification.

What to expect from your doctor
Some potential questions your doctor might ask include:

Are you still having periods?
When was your last period?
How often do you experience bothersome symptoms?
How uncomfortable do your symptoms make you?
Does anything seem to improve your symptoms?
Does anything make your symptoms worse?

Tests and diagnosis

The signs and symptoms of menopause are enough to tell most women they have begun going through the menopausal transition. If you have concerns about irregular periods or hot flashes, talk with your doctor. In some cases further evaluation may be recommended.

Under certain circumstances, your doctor may check your level of follicle-stimulating hormone (FSH) and estrogen (estradiol) with a blood test. As menopause occurs, FSH levels increase and estradiol levels decrease. Your doctor may also recommend a blood test to determine your level of thyroid-stimulating hormone (TSH ) , because hypothyroidism can cause symptoms similar to those of menopause.

Treatments and drugs

Menopause itself requires no medical treatment. Instead, treatments focus on relieving your signs and symptoms and on preventing or lessening chronic conditions that may occur with aging. Treatments include:

Hormone therapy. Estrogen therapy remains, by far, the most effective treatment option for relieving menopausal hot flashes. Depending on your personal and family medical history, your doctor may recommend estrogen in the lowest dose needed to provide symptom relief for you.
Low-dose antidepressants. Venlafaxine (Effexor), an antidepressant related to the class of drugs called selective serotonin reuptake inhibitors (SSRIs), has been shown to decrease menopausal hot flashes. Other SSRIs can be helpful, including fluoxetine (Prozac, Sarafem), paroxetine (Paxil, others), citalopram (Celexa) and sertraline (Zoloft).
Gabapentin (Neurontin). This drug is approved to treat seizures, but it also has been shown to significantly reduce hot flashes.
Clonidine (Catapres, others). Clonidine, a pill or patch typically used to treat high blood pressure, may significantly reduce the frequency of hot flashes, but unpleasant side effects are common.
Bisphosphonates. Doctors may recommend these nonhormonal medications, which include alendronate (Fosamax), risedronate (Actonel) and ibandronate (Boniva), to prevent or treat osteoporosis. These medications effectively reduce both bone loss and your risk of fractures and have replaced estrogen as the main treatment for osteoporosis in women.
Selective estrogen receptor modulators (SERMs). SERMs are a group of drugs that includes raloxifene (Evista). Raloxifene mimics estrogen's beneficial effects on bone density in postmenopausal women, without some of the risks associated with estrogen.
Vaginal estrogen. To relieve vaginal dryness, estrogen can be administered locally using a vaginal tablet, ring or cream. This treatment releases just a small amount of estrogen, which is absorbed by the vaginal tissue. It can help relieve vaginal dryness, discomfort with intercourse and some urinary symptoms.

Before deciding on any form of treatment, talk with your doctor about your options and the risks and benefits involved with each.

Lifestyle and home remedies

Fortunately, many of the signs and symptoms associated with menopause are temporary. Take these steps to help reduce or prevent their effects:

Cool hot flashes. Get regular exercise, dress in layers and try to pinpoint what triggers your hot flashes. For many women, triggers may include hot beverages, spicy foods, alcohol, hot weather and even a warm room.
Decrease vaginal discomfort. Use over-the-counter water-based vaginal lubricants (Astroglide, K-Y) or moisturizers (Replens, Vagisil). Staying sexually active also helps.
Optimize your sleep. Avoid caffeine and plan to exercise during the day, although not right before bedtime. Relaxation techniques, such as deep breathing, guided imagery and progressive muscle relaxation, can be very helpful. You can find a number of books and tapes on different relaxation exercises. If hot flashes disturb your sleep, you may need to find a way to manage them before you can get adequate rest.
Strengthen your pelvic floor. Pelvic floor muscle exercises, called Kegel exercises, can improve some forms of urinary incontinence.
Eat well. Eat a balanced diet that includes a variety of fruits, vegetables and whole grains and that limits saturated fats, oils and sugars. Aim for 1,200 to 1,500 milligrams of calcium and 800 international units of vitamin D a day. Ask your doctor about supplements to help you meet these requirements, if necessary.
Don't smoke. Smoking increases your risk of heart disease, stroke, osteoporosis, cancer and a range of other health problems. It may also increase hot flashes and bring on earlier menopause. It's never too late to benefit from stopping smoking.
Exercise regularly. Get at least 30 minutes of moderate-intensity physical activity on most days to protect against cardiovascular disease, diabetes, osteoporosis and other conditions associated with aging. More vigorous exercise for longer periods may provide further benefit and is particularly important if you're trying to lose weight. Exercise can also help reduce stress.
Try yoga. Preliminary studies show that yoga — an exercise regimen that involves controlled breathing, posing and meditation — may be effective in decreasing the number of hot flashes in perimenopausal women. Yoga classes are often offered at health clubs or through community education programs. Sign up for a class to learn how to perform yoga postures and breathing correctly.
Schedule regular checkups. Talk with your doctor about how often you should have mammograms, Pap tests, lipid level (cholesterol and triglyceride) testing and other screening tests.

Alternative medicine

Many approaches have been promoted as aids in managing the symptoms of menopause, but not all of them have scientific evidence to back up the claims. Below are some complementary and alternative treatments that have been or are being studied:

Phytoestrogens. These estrogens occur naturally in certain foods. There are two main types of phytoestrogens — isoflavones and lignans. Isoflavones are found in soybeans, chickpeas and other legumes. Lignans occur in flaxseed, whole grains and some fruits and vegetables. Whether the estrogens in these foods can relieve hot flashes and other menopausal signs and symptoms remains to be seen. Most studies have found them ineffective. Isoflavones have some weak estrogen-like effects, so there's some concern about cancer risk. If you've had breast cancer, talk to your doctor before supplementing your diet with isoflavone pills.
Vitamin E. This vitamin occasionally provides relief from mild hot flashes for some women. However, scientific studies haven't proved its overall benefit in relieving hot flashes, and taking more than 400 international units of vitamin E supplements daily may not be safe.
Black cohosh. Black cohosh has been used widely in Europe for treating hot flashes and has been popular among women with menopausal symptoms in the United States. While its safety record has been good, there's no longer much reason to believe that it is effective for menopausal symptom relief.

You may have heard of — or even tried — other dietary supplements, such as dong quai, licorice, chasteberry, evening primrose oil and wild yam (natural progesterone cream). Although some might swear by these remedies, scientific evidence of their safety and effectiveness is lacking.

Be sure to consult your doctor before taking any herbal treatments or dietary supplements for signs and symptoms of menopause. Herbal products can interfere or interact with other medications you may be taking.

IN VITRO FERTILIZATION - IVF

2009-10-31T16:54:00.009+07:00

In vitro fertilisation (IVF) is the process used to conceive a child outside the body. A woman’s eggs and a man’s sperm are placed together in a plastic dish for fertilisation. Once fertilised, the resulting embryos are placed back in the woman’s uterus in the hope that a successful pregnancy will follow.

The IVF procedure
IVF is not one simple procedure, but a series of steps over several weeks. The steps involved in this procedure are outlined below.

Stimulating the ovaries
Hormones are usually given to stimulate the ovaries to produce more than the usual one egg per cycle. This is to enable the collection of several eggs.The development of the eggs is monitored by one or two blood tests and ultrasounds. The ultrasound and blood tests ensure that eggs are collected at precisely the right time.

Collecting the eggs

The ultrasound is inserted in the vagina and a very fine needle is threaded through a guide, which is attached to a probe. Only a light anaesthetic is required for this procedure. The ultrasound monitor shows where the follicles are. The needle pierces the follicle and extracts the follicular fluid, which contains the egg.

Fertilisation and embryo transfer
A couple of hours after egg collection, the man provides a sample of semen. In a standard IVF treatment, the eggs are mixed with the sperm in a culture dish. For intracytoplasmic sperm injection (ICSI) treatment, one sperm is injected directly into the cytoplasm of each egg.
If an egg is fertilised by a sperm, a zygote or pre-embryo will begin to develop. The pre-embryo remains in the incubator for one or two days, until it has divided into two or four cells. Following fertilisation, two to three embryos will be transferred to the uterus using a soft, fine catheter. This procedure (known as embryo transfer) is quite painless, similar to a smear test, and requires no anaesthetic.
For the gamete intrafallopian transfer (GIFT) program, eggs and sperm are placed directly into the fallopian tubes, allowing fertilisation to take place in the natural way. The procedure is performed using a laparoscope, and a general anaesthetic is required. This procedure is rarely used now.

Pregnacy test results
Two weeks after the transfer, a blood test is taken to determine if the woman is pregnant.

Possible risks and side effects
There is no clear evidence that infertility medicines, if properly used, increase the risk of birth defects or cancer. The increase in the hormone oestrogen can cause breast tenderness, slight nausea, dizziness and slight abdominal swelling. Occasionally, too many follicles develop and a condition called ovarian hyperstimulation syndrome (OHSS) may occur. This is an unpleasant experience, which may include marked abdominal swelling, nausea, vomiting and diarrhoea, lower abdominal pain and shortness of breath. There is also a theoretical risk (very rare) of damaging organs, or causing infection or bleeding, with the collection needle.

Things to remember

IVF is a process where fertilisation of an egg occurs outside of the body.
IVF is not one procedure but rather a series of steps taken over several weeks.
While infertility drugs have some side effects, there is no evidence that they cause cancer or birth defects.

OVULATION PAIN - MITTELSCHMERZ

2009-10-31T16:39:00.002+07:00

Ovulation is a phase of the female menstrual cycle, which involves the release of an egg (ovum) from one of the ovaries. For most women, ovulation occurs about once every month until menopause, apart from episodes of pregnancy and breastfeeding.
About one in five women experience pain and discomfort during ovulation. The duration of the pain varies from one woman to the next, but ranges from a few minutes to 48 hours. In most cases, ovulation pain doesn’t mean that anything is wrong. However, severe pain may sometimes be symptomatic of gynaecological conditions including endometriosis. See your doctor if your ovulation pain lasts longer than three days or is associated with other unusual menstrual symptoms, such as heavy bleeding. Ovulation pain is also known as mid-cycle pain and mittelschmerz (German for ‘middle pain’).

Symptoms
The symptoms of ovulation pain can include:

Pain in the lower abdomen, just inside the hip bone.
The pain typically occurs about two weeks before the menstrual period is due.
The pain is felt on the right or left side, depending on which ovary is releasing an egg.
The pain may switch from one side to the other from one cycle to the next, or remain on one side for a few cycles.
The pain sensation varies between individuals - for example, it could feel like uncomfortable pressure, twinges, sharp pains or cramps.
The duration of pain ranges anywhere from minutes to 48 hours.

Theories on possible causes
The exact cause of ovulation pain is not clear, but theories include:

Emerging follicle - hormones prompt the ovaries to produce around 20 follicles. Each follicle contains an immature egg (ovum) but only one follicle usually survives to maturity. It is supposed that ovulation pain is caused by the expanding follicle stretching the membrane of the ovary.
Ruptured follicle - when the egg is mature, it bursts from the follicle. This may cause slight bleeding. The peritoneum (abdominal lining) could be irritated by the blood or fluids from the ruptured follicle, and this may trigger the pain.

Underlying medical problems
In most cases, ovulation pain is harmless. However, severe and prolonged ovulation pain, or other pains felt in the lower abdomen, can be symptomatic of various medical conditions including:

Salpingitis - inflammation of the fallopian tubes following an infection.
Chronic pelvic inflammatory disease - inflammation following an infection.
Endometriosis - the lining of the womb (endometrium) grows in other locations, such as the bowel. Other symptoms include painful periods and painful sex.
Ovarian cyst - an abnormal pocket of fluid that develops on the ovary.
Ectopic pregnancy - a pregnancy that develops outside of the womb, most commonly in one of the fallopian tubes. Symptoms include cramping, abdominal pain and vaginal bleeding. Seek urgent medical help.
Appendicitis - inflammation of the appendix can sometimes be confused with ovulation pain. Seek urgent medical help if the pain is on the right side of your abdomen and you are experiencing nausea and vomiting.
Other gastrointestinal problems - lower abdominal pain can be symptomatic of a range of gastrointestinal problems, including perforated ulcer, gastroenteritis and inflammatory bowel disease.

Diagnosis methods
Tests that help determine whether ovulation pain is harmless or caused by infection or disease may include:

Medical history
Physical examination, including an internal pelvic examination
Blood tests
Cervical cultures
Abdominal ultrasound
Vaginal ultrasound
Exploratory surgery (laparoscopy or ‘keyhole’ surgery).

Taking care of yourself
Consult with your doctor to make sure that your ovulation pain isn’t caused by any underlying medical problem. Suggestions on taking care of benign ovulation pain yourself include:

Relax. If the pain is particularly bothersome, rest in bed whenever you can.
Use pain-killing medication.
Warmth on the lower abdomen may help. Use heat packs, hot water bottles or warm baths.
Take anti-inflammatory drugs. See your doctor or pharmacist for recommendations.
The Pill and other forms of hormonal contraceptive can prevent ovulation pain because they stop ovulation. Talk over this option with your doctor.
See your doctor if you experience ovulation pain that lasts longer than three days, or if you have other symptoms such as heavy bleeding or discharge.

Family planning
Chances of conception are high if a couple have sex in the days before, during and after ovulation. Some women rely on ovulation pain to help them plan a pregnancy. However, it is unwise to rely on ovulation pain alone if you’re trying to avoid pregnancy. Always use other methods of birth control.

Things to remember

About one in five women experience pain during ovulation that can last from a few minutes to 48 hours.
Ovulation pain is usually harmless, but can sometimes indicate various medical conditions such as endometriosis.
See your doctor if your ovulation pain lasts longer than three days or is associated with other unusual menstrual symptoms, such as heavy bleeding.

SPERM ANALYSIS

2009-10-30T05:00:00.002+07:00

Semen analysis

A semen analysis evaluates certain characteristics of a male's semen and the sperm contained in the semen. It may be done while investigating a couple's infertility or after a vasectomy to verify that the procedure was successful.

Relation to fertility

The characteristics measured by semen analysis are only some of the factors in semen quality. One source states that 30% of men with a normal semen analysis actually have abnormal sperm function.^[1] Conversely, men with poor semen analysis results may go on to father children.^[2]^[3]

Collection methods

The most common way to collect a semen sample is through masturbation, directing the sample into a clean cup.^[2]

A sample may also be collected during intercourse in a special type of condom known as a collection condom. Collection condoms are made from silicone or polyurethane, as latex is somewhat harmful to sperm.^[4] Many men prefer collection condoms to masturbation, and some religions prohibit masturbation entirely. Adherents of religions that prohibit contraception, such as Catholicism, may use collection condoms with holes pricked in them.^[5]

A third option for collecting a sample is through coitus interruptus (withdrawal). With this technique, the man removes his penis from his partner near the end of intercourse and ejaculates into a cup.

Finally, if a blockage in the vas deferens is suspected to impede fertility, semen can be taken directly from the epididymis. Such a collection is called per cutaneous epididymal sperm aspiration (PESA). Alternatively, the testicular tissue itself, instead of the sperm produced can be investigated. Then, the collecting method is called TESE.^[6]

Tested characteristics

Examples of parameters measured in a semen analysis are: sperm count, motility, morphology, volume, fructose level and pH.

1. Sperm count

Approximate pregnancy rate varies with amount of sperm used in an artificial insemination cycle. Values are for intrauterine insemination, with sperm number in total sperm count, which may be approximately twice the total motile sperm count.
Sperm count, or sperm concentration to avoid mixup, measures the concentration of sperm in a man's ejaculate, distinguished from total sperm count, which is the sperm count multiplied with volume.^[7] Anything over 20 million sperm per milliliter is considered normal.^[1]^[2] Anything less is considered oligospermia. A vasectomy is considered successful if the sample is azoospermic. Some define success with rare non-motile sperm are observed (fewer than 100,000 per millilitre).^[8] Others advocate obtaining a second semen analysis to verify the counts are not increasing (as can happen with re-canalization) and others still may perform a repeat vasectomy for this situation.
The average sperm count today is around 60 million per milliliter in the Western world, having decreased by 1-2% per year from a substantially higher number decades ago.^[9]

2. Motility

The motility of the sperm is evaluated. WebMD defines normal motility as 60% of observed sperm, or at least 8 million per millilitre, showing good forward movement.^[2] The World Health Organization has a similar value of 50% and this must be measured within 60 minutes of collection. A man can have a total number of sperm far over the limit of 20 million sperm cells per milliliter, but still have bad quality because too few of them are motile. However, if the sperm count is very high, then a motility of less than 60% might not matter, because the fraction might still be more than 8 million per millilitre. The other way around, a man can have a sperm count far less than 20 million sperm cells per millilitre and still have good motility, if more than 60% of those observed sperm cells show good forward movement.

A more specified measure is motility grade, where the motility of sperm are divided into four different grades:^[10]

Grade 4: Sperm with progressive motility. These are the strongest and swim fast in a straight line. Sometimes it is also denoted motility a.
Grade 3: (non-linear motility): These also move forward but tend to travel in a curved or crooked motion. Sometimes also denoted motility b.
Grade 2: These have non-progressive motility because they do not move forward despite the fact that they move their tails.
Grade 1: These are immotile and fail to move at all.

3. Morphology

The morphology of the sperm is also evaluated. With WHO criteria as described in the old manual of 1989, a sample is normal if 30% or more of the observed sperm have normal morphology.^[1] If morphology is evaluated using the Tygerberg strict criteria developed by Dr. Roelof Menkveld, Tygerberg Hospital, South Africa, and disseminated by Dr. Thinus Kruger from the same hospital,^[11] a sample is normal if 14% or more of the observed sperm have normal morphology.^[1]. The Tygerberg strict criteria for morpology assessment are recommended in the most recent WHO manual on semen analysis (WHO 1999). According to the above references, morphology was developed as a predictor of success in fertilizing oocytes during invitro fertilization.

4. Volume

The volume of the sample is measured. WebMD advises that volumes between 1.0 mL and 6.5 mL are normal;^[2] WHO criteria specify that any volume greater than 2.0 mL is normal. Low volume may indicate partial or complete blockage of the seminal vesicles, or that the man was born without seminal vesicles.^[1] In clinical practice, a volume of less than 2 mL in the setting of infertility and absent sperm should prompt an evaluation for obstructive azoospermia. A caveat to this is be sure it has been at least 48 hours since the last ejaculation to time of sample collection.

5. Fructose level

The level of fructose in the semen is measured. WebMD lists normal as at least 3 ^mg/_mL.^[2] WHO specifies a normal level of 13 μmol per sample. Absence of fructose may indicate a problem with the seminal vesicles.^[1]

6. pH

The pH of the sample is measured. WebMD lists a normal range of 7.1-8.0;^[2] WHO criteria specify normal as 7.2-7.8.^[1] Acidic ejaculate (lower pH value) may indicate one or both of the seminal vesicles are blocked. A basic ejaculate (higher pH value) may indicate an infection.^[1] A pH value outside of the normal range is harmful to sperm.^[2]

7. Liquefaction

The liquefaction is the process when the gel formed by proteins from the seminal vesicles is broken up and the semen becomes more liquid. It normally takes less than 20 minutes for the sample to change from a thick gel into a liquid. An abnormally long liquefaction (more than 30 minutes at 37 24°C) time may indicate an infection.

8. MOT

MOT is a measure of how many million sperm cells per ml are highly motile^[12], that is, approximately of grade 4, or sometimes also taking grade 3 into account. Thus, it is a combination of sperm count and motility.
With a straw volume of 0.5 milliliter per straw, the general guideline is that, for intracervical insemination (ICI), straws making a total of MOT40 is recommended. This is equal to 8 straws with MOT5, or 2 straws of MOT20. For intrauterine insemination (IUI), straws making a total of MOT10 is regarded sufficient.^[13] In WHO terms, it is thus recommended to use approximately 20 million grade 3+4 sperm in ICI, and 5 million ones in IUI.

Total motile spermatozoa

Total motile spermatozoa (TMS)^[14] or total motile sperm count (TMSC)^[15] is a combination of sperm count, motility and volume, measuring how many million sperm cells in an entire ejaculate are motile.

Use of approximately 20 million grade 3+4 sperm in ICI, and 5 million ones in IUI may be an approximate recommendation.

9. Others

The sample is tested for white blood cells. A high level of white blood cells (over 1 million per milliliter) may indicate an infection.^[1]

Abnormalities

Aspermia: absence of semen
Azoospermia: absence of sperm
Oligospermia: low number of sperm
Asthenozoospermia: poor sperm motility
Teratozoospermia: sperm carry more morphological defects than usual

Factors that influence results

Compared to samples obtained from masturbation, semen samples from collection condoms have higher total sperm counts, sperm motility, and percentage of sperm with normal morphology. For this reason, they are believed to give more accurate results when used for semen analysis.^[4]
How long the man has abstained prior to providing the sample for analysis affects the results. Longer periods of abstinence correlate with poorer results - one study found that men with repeated normal results produced abnormal samples if they abstained for more than 10 days. It is recommended not to abstain for more than one or two days before providing the semen sample for analysis.^[16]
If the results from a man's first sample are subfertile, they must be verified with at least two more analyses. At least 2 to 4 weeks must be allowed between each analysis.^[17] Results for a single man may have a large amount of natural variation over time, meaning a single sample may not be representative of a man's average semen characteristics.^[18] In addition, sperm physiologist Joanna Ellington believes that the stress of producing an ejaculate sample for examination, often in an unfamiliar setting and without any lubrication (most lubricants are somewhat harmful to sperm), may explain why men's first samples often show poor results while later samples show normal results.^[3]
A man may prefer to produce his sample at home rather than at the clinic. The site of semen collection does not affect the results of a semen analysis.^[19]

Measurement methods

Volume can be determined by measuring the weight of the sample container, knowing the mass of the empty container. Sperm count and morphology can be calculated by microscopy. Sperm count can also be estimated by kits that measure the amount of a sperm-associated protein, and are suitable for home use. ^[20]
Computer Assisted Semen Analysis (CASA) is a catch-all phrase for automatic or semi-automatic semen analysis techniques. Most systems are based on image analysis, but alternative methods exist such as tracking cell movement on a digitizing tablet.^[21]^[22] Computer-assisted techniques are most-often used for the assessment of sperm concentration and mobility characteristics, such as velocity and linear velocity. Although many systems can give very accurate information about motility patterns of motile sperm, immotile sperm cannot accurately be distinguished from other cells, particles or debris without addition of staining. The first CASA systems in general cannot give reliable results for sperm concentration and proportions of sperm with different grades of motility, at least not in semen samples, where there are many other particles, cells and debris. Even when it comes to motility, most systems cannot give reliable results when the concentration of motile sperm leads to significant "crossed paths" - due to difficulties to decide if there were two sperm crossing each others way, or if there were for instance four sperm moving close to each other. Nowadays, there are CASA systems, based on image analysis and using new techniques, with near perfect results, and doing full analysis in a few seconds.

CASA Systems

SQA-V - The SQA-V, also known as the 'Sperm Quality Analyzer or Spermalite, is a high performance sperm analysis instrument used to test male fertility. It combines electro-optics, computer algorithms and video microscopy to provide a precise and accurate 75 second automated semen analysis. This device is manufactured by Medical Electronic Systems ^[23], who specializes in rapid, automated semen analysis. The main reason the SQA-V is a growing instrument among the semen analysis community is due to the speed, accuracy, and precision to run a semen sample. In addition, the SQA-V semen analysis eliminates inter-operator variables from the manual method, and still provides 16 clinical parameters including: Sperm Concentration, Rapid Progressive motility, Slow Progressive motility, Non-progressive motility, Immotility, %Normal Morphology, and more.

A study was conducted by the world renowned Cleveland Clinic comparing the SQA-V to the Manual method and the CASA device, presenting results favoring the SQA-V. ^[24]

ISAS - Integrated Semen Analysis System is a CASA system based on image analysis from the company Projects i Serveis R+D S.L., also known as PROISER. PROISER was founded on 2004 by a team of CASA developers (SCA 96, SCA 98 and SCA 2002) with more than 15 years in experience of seminal analysis by computer image analysis. ISAS can be considered as the most complete and easiest-to-use system in market which, furthermore, works in different hardware and operating-system conditions, in order to adapt as much as possible to the needs of our users. Current computers and AAVT technology allows a very good matching of spermatozoon, thanks to the tail and morphology analysis made at the same time as motility analysis. Only motility and concentration analysis give to the customers more tan 17 sperm parameters, but also ISAS analyzes automatically stained morphometry, giving 15 parameters and DNA fragmentation analysis. ISAS has been developed to be used in several species, from classical species like human, boar or bull to new research species like cod or some small rodents. There are a lot of publications and works in progress with ISAS like ^[25]. A list of last publications with this CASA system can be found on publications with ISAS

Sperm Class Analyzer - The Sperm Class Analyzer, also known as 'SCA' from the company Microptic S.L., provides fast, accurate and objectively repeatable results. This would be impossible to attain using traditional (subjective) methods. This CASA system has the following modules: SCA Motility & Concentration: The system provides immediately and objectively detailed results of motility and concentration in a complete report. SCA Morphology: Following a manual or automatic image capture, a precise morphological and morphometric analysis of each spermatozoid is provided in real time. SCA DNA Fragmentation: Analysis of halo formation of the samples prepared for study of the DNA fragmentation provides detailed numerical data for each of the cells. SCA Vitality: Automatically analyze the vitality of a sperm sample. All this modules can be used with a motorized stage or link the database with any hospital system.

IVOS Sperm Analyzer - The Integrated Visual Optical System (IVOS) was developed by Hamilton Thorne, the leading manufacturer of CASA systems since 1986. The IVOS is found in hospitals, universities, IVF clinics, pharmaceutical companies, contract labs, reproductive toxicology labs, veterinary clinics and animal breeding facilities around the world. The standard IVOS software may be used to analyze sperm of multiple species, with a specific program geared toward analysis of rat sperm. The IVOS is unique in that it is the only CASA system that integrates the optical system within the unit, so that an external microscope is not needed. The light source of the IVOS produces stroboscopic illumination to provide blur free sperm images. This stroboscopic light source is especially beneficial when utilizing the IDENT fluorescent option on the IVOS as it allows the analysis of motile sperm under fluorescent illumination without adverse affect on sperm motility or velocity (this is not possible with continuous light fluorescent microscopes). Analysis using the IVOS IDENT provides highest accuracy of sperm counts in samples with a high degree of detritus, such as occurs in egg yolk extended samples or naturally in some species, such as rabbits. Samples are placed on a computer-controlled, heated stage which maintains samples at the proper analysis temperature and automatically moves to selected fields for analysis. A field of sperm are analyzed in just 0.5 second with a level of accuracy and repeatability unobtainable by visual assessment. Results calculated include count, concentration, motility, progressive motility, curvilinear velocity (VCL), straight line velocity (VSL), average path velocity (VAP), linearity (LIN), straightness (STR), amplitude of lateral head displacement (ALH) and beat cross frequency (BCF). Custom software packages are available, such as Animal Breeder, Equine Breeder and Animal Motility, which provide additional features specific to the target industries. In addition, the TOX IVOS is a complete system configured specifically for the inticacies of rat sperm analysis. Two automated morphology options, Dimesnisons Strict Morphology (developed and validated by Dr. Thinus Kruger) and Metrix user defined morphology are available. Another fluorescent option is VIADENT, which permits the analysis of motility and viability on the same live sample.

"Our results suggest that the VIADENT option of the IVOS system is capable of a rapid, accurate and objective evaluation of both viability and motility parameters using large numbers of spermatozoa. Application of this technique in the industry may prove useful in the clinical assessment of fertilizing potential of equine spermatozoa." ^[26]

CEROS Sperm Analyzer - Also from Hamilton Thorne and built upon the same analysis algorithms and software interface as the IVOS, the CEROS offers the same level of accuracy and reliability for sperm analysis. The CEROS uses an external negative phase contrast microscope for image visulaization and analysis. The system comes complete with motility analysis software, microscope, camera, computer and monitor. The CEROS is also compatible with both the Dimensions and Metrix morphology options and can be used for to analyze sperm from all species except rat. Both systems offer 4 levels of quality control as well as high-level security and audit trail for data inetgrity. A searacble list of publications featuring the Hamilton Thorne IVOS and CEROS CASA systems is found on Connotea.

References

"Understanding Semen Analysis". Stonybrook, State University of New York. 1999. http://www.uhmc.sunysb.edu/urology/male_infertility/SEMEN_ANALYSIS.html. Retrieved 2007-08-05.
Essig, Maria G.; Edited by Susan Van Houten and Tracy Landauer, Reviewed by Martin Gabica and Avery L. Seifert (2007-02-20). "Semen Analysis". Healthwise. WebMD. http://www.webmd.com/infertility-and-reproduction/guide/semen-analysis?page=1. Retrieved 2007-08-05.
Ellington, Joanna (2004). "Understanding a Sperm Analysis". INGfertility. http://www.preseed.com/FAQs/FAQ4.php. Retrieved 2008-06-28.
Dr. Joanna Ellington (January 2005). Use of a Specialized Condom to Collect Sperm Samples for Fertility Procedures. INGfertility. http://www.preseed.com/FAQs/FAQ4.php#Using_a_Sperm_Collection_Condom. Retrieved 2008-06-28.
Kippley, John; Sheila Kippley (1996). The Art of Natural Family Planning (4th addition ed.). Cincinnati, OH: The Couple to Couple League. pp. pp.306–307. ISBN 0-926412-13-2.
Fertility Center, Stockholm (translated from Swedish)
sharedjourney.com - Male Infertility Testing
Rajmil O, Fernández M, Rojas-Cruz C, Sevilla C, Musquera M, Ruiz-Castañe E (2007). "Azoospermia should not be given as the result of vasectomy" (in Spanish; Castilian). Arch. Esp. Urol. 60 (1): 55–8. PMID 17408173.
Dhar NB, Bhatt A, Jones JS (2006). "Determining the success of vasectomy". BJU Int. 97 (4): 773–6. doi:10.1111/j.1464-410X.2006.06107.x. PMID 16536771.
The sperm count has been decreasing steadily for many years in Western industrialized countries: Is there an endocrine basis for this decrease? The Internet Journal of Urology TM. ISSN: 1528-8390
Shared Journey: Semen Analysis
"Semen analysis morphology". IVF 1. 2005-10-27. http://www.ivf1.com/Semen-analysis-morphology/. Retrieved 2007-08-05.
Cryos FAQs - What does MOT mean?
Cryos FAQs - What is the recommended quantity and quality by ordering of donor semen?
Merviel P, Heraud MH, Grenier N, Lourdel E, Sanguinet P, Copin H (November 2008). "Predictive factors for pregnancy after intrauterine insemination (IUI): An analysis of 1038 cycles and a review of the literature". Fertil. Steril.. doi:10.1016/j.fertnstert.2008.09.058. PMID 18996517.
Pasqualotto EB, Daitch JA, Hendin BN, et al. (October 1999). "Relationship of total motile sperm count and percentage motile sperm to successful pregnancy rates following intrauterine insemination". J. Assist. Reprod. Genet. 16 (9): 476–82. doi:10.1023/A:1020598916080. PMID 10530401. http://www.kluweronline.com/art.pdf?issn=1058-0468&volume=16&page=476.
Ellington, Joanna (2005). "How Long to Abstain for a Sperm Test/Analysis". INGfertility. http://preseed.com/FAQs/FAQ1.php#How_Long_to_Abstain_for_a_Sperm_Test/Analysis__. Retrieved 2008-06-28. , which cites:
Levitas E, Lunenfeld E, Weiss N, et al. (June 2005). "Relationship between the duration of sexual abstinence and semen quality: analysis of 9,489 semen samples". Fertil. Steril. 83 (6): 1680–6. doi:10.1016/j.fertnstert.2004.12.045. PMID 15950636.
Jurema MW, Vieira AD, Bankowski B, et al. (September 2005). "Effect of ejaculatory abstinence period on the pregnancy rate after intrauterine insemination". Fertil. Steril. 84 (3): 678–81. doi:10.1016/j.fertnstert.2005.03.044. PMID 16169402.
Weschler, Toni (2002). Taking Charge of Your Fertility (Revised ed.). New York: HarperCollins. pp. p.189. ISBN 0-06-093764-5.
"Adequate Analysis Frequency". Kokopelli Technologies. 2007. http://www.fertilityformen.com/info_why.php#frequency. Retrieved 2007-08-11.
Shetty Licht R, Handel L, Sigman M (2007). "Site of semen collection and its effect on semen analysis parameters". Fertil Steril. 89: 395. doi:10.1016/j.fertnstert.2007.02.033. PMID 17482174.
dailyprogress.com > Charlottesville company sends out its home male sterility tests By Brian McNeill. Published: May 14, 2009
Mortimer ST (01 Jul 2000). "CASA--practical aspects". J. Androl. 21 (4): 515–24. PMID 10901437. http://www.andrologyjournal.org/cgi/reprint/21/4/515. Retrieved 2007-08-05.
Hinting A, Schoonjans F, Comhaire F (1988). "Validation of a single-step procedure for the objective assessment of sperm motility characteristics". Int. J. Androl. 11 (4): 277–87. doi:10.1111/j.1365-2605.1988.tb01001.x. PMID 3170018.
http://mes-ltd.com/overview.asp
Agarwal A, Sharma R (2007). "Automation is the key to standardized semen analysis using the automated SQA-V sperm quality analyzer". Fertility and Sterility 87 (No. 1): 156. doi:10.1016/j.fertnstert.2006.05.083. http://www.clevelandclinic.org/ReproductiveResearchCenter/docs/agradoc230.pdf.
L. Ramió, M.M. Rivera, A. Ramírez, I.I. Concha, A. Peña, T. Rigau and J.E. Rodríguez-Gil (2008). "Dynamics of motile-sperm subpopulation structure in boar ejaculates subjected to in vitro capacitation and further in vitro acrosome reaction". Theriogenology 69 (No. 4): 501. doi:10.1016/j.theriogenology.2007.10.021. http://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B6TCM-4RCNPPD-1&_user=10&_coverDate=03%2F01%2F2008&_rdoc=15&_fmt=summary&_orig=browse&_srch=doc-info(%23toc%235174%232008%23999309995%23679613%23FLA%23display%23Volume)&_cdi=5174&_sort=d&_docanchor=&_ct=17&_acct=C000050221&_version=1&_urlVersion=0&_userid=10&md5=9926ba71bee609b30a7c56f73857f511.
Wessel MT, Althouse GC. Validation of an objective approach for simultaneous assessment of viability and motility of fresh and cooled equine spermatozoa. Proceedings of the International Symposium on Equine Reproduction, Animal Reproduction Science 94 (2006) 21-22

INFERTILITY TREATMENT - MALE

2009-10-30T04:50:00.002+07:00

Approximately one in five couples have trouble conceiving a child. If a couple is unable to conceive after one year of unprotected intercourse, they are said to be subfertile. Around 40 per cent of fertility problems originate in the man, with causes including sperm abnormalities and blockages within structures of the reproductive system, such as the vas deferens. Many men have sufficient sperm to fertilise their partner's eggs in a test tube, even if they are unable to do so during sexual intercourse. In most cases, the couple can be helped with assisted reproductive technologies. For around one in 10 couples investigated for infertility, no cause is found. This is known as 'idiopathic infertility'.

Diagnosis methods
Investigating suspected infertility requires a range of tests for both the man and his partner. Some of the tests the man may undergo include:

Physical examination - including medical history.
Ultrasound scans - to check the health of reproductive organs.
Blood tests - to check sex hormone levels.
Semen analysis - a sperm sample is checked for abnormalities and antibodies.
Testicular biopsy - the fine network of tubes within the testicles is checked for the presence of sperm.

A range of reproductive technologies
Some of the reproductive technologies available to infertile men include:

Surgery
Hormone therapy
Artificial insemination
In vitro fertilisation (IVF)
Intra cytoplasmic sperm injection (ICSI).

Surgery
Fertility may be impaired by varicocele, or the bloating of veins inside the testes. This condition can be surgically treated. The tubes within the male reproductive system that transport sperm may be blocked, perhaps by injury or vasectomy. In some cases, the blockage can be surgically removed or the tubes repaired. If this doesn't work, the man may undergo another surgical procedure called percutaneous epididymal sperm aspiration (PESA). Under local anaesthetic, a slender needle is inserted into the epididymis, which is the tube at the back of the testicle that collects and stores sperm. Sperm is removed, and either used immediately for IVF or frozen.

Hormone therapy
The pituitary gland in the brain releases the hormone gonadotropin, which prompts the testicles to produce sperm. In a small number of cases, male infertility is caused by insufficient levels of gonadotropin. Taking a synthesised version of this hormone can boost sperm production.

Artificial insemination
The man's semen is collected, washed and concentrated, then introduced (via instruments) into his partner's vagina, cervix, uterus or fallopian tubes, depending on the circumstances. This option is often chosen if the husband has functional problems (such as impotence), or if his sperm can't make it through the cervix to the uterus. Some of the factors that can stall sperm at the entrance to the uterus include:

The man's seminal fluid contains antibodies that destroy his sperm
The cervical mucus contains antibodies that destroy his sperm
The cervical mucus is so acidic that sperm are unable to survive.

In vitro fertilisation (IVF)
In vitro fertilisation (IVF) is conception within a test tube (or similar). The woman undergoes ovulation induction (hormonal stimulation of her ovaries) and a number of eggs are removed. This is done through the vagina under ultrasound control. The collected eggs are then mixed with sperm previously collected from the woman's partner, and placed in a special incubator. The fertilised eggs are then implanted into the woman's uterus via a thin tube inserted through the cervix.

Intra cytoplasmic sperm injection (ICSI)
Sometimes, semen contains too few sperm to make fertilisation possible through IVF. In this case, intra cytoplasmic sperm injection (ICSI) can be used. The eggs are removed from the woman's ovaries, then individually injected with a single sperm each. When the eggs are fertilised, the embryos are transferred into the uterus.

Figure 1:
Immobilizing the sperm's tail before picking it up.

Figure 2:
Injection of sperm into the egg.

Figure 3:
Fertilized egg demonstrating the two nuclei – one from the father, one from the mother.

Pregnancy isn't always possible
Despite the sophistication of assisted reproductive technologies, pregnancy doesn't always happen. It depends on a range of factors, including the type of technology used and the reasons for the man's infertility. It should be remembered that assisted reproductive technologies can't improve the quality of sperm. Azoospermia, for example, means that the man's semen doesn't contain any sperm at all. In such cases, donor insemination may be considered. This involves artificially inseminating the partner with sperm from an anonymous donor.

Things to remember

Around 40 per cent of fertility problems originate in the man, with causes including sperm abnormalities and blockages within structures of the reproductive system, such as the vas deferens.
Some of the reproductive technologies available to infertile men include surgery to clear blockages, hormone therapy, artificial insemination, in vitro fertilisation (IVF) and intra cytoplasmic sperm injection (ICSI).

REPROSAIT 4 U

Syphilis During Pregnancy

What is syphilis?

What are the symptoms?

How can syphilis affect my pregnancy and my baby's health?

Will I be tested for syphilis during my pregnancy?

How is syphilis treated during pregnancy?

How can I avoid getting syphilis?

STDs and Pregnancy - Fact Sheet

Can Pregnant Women Become Infected With STDs

How Common Are STDs In Pregnant Women

How Do STDs Affect A Pregnant Women and Her Baby

Should Pregnant Women Be Tested For STDs ?

Can STDs Be Treated During Pregnancy ?

How Can Pregnant Women Protect Themselves Against Infection ?

URINARY TRACT INFECTIONS in PREGNANCY

What is a UTI?

Symptoms of a UTI can include:

I've always been susceptible to urinary tract infections. What will happen if I get one while I'm pregnant?

What can I do to avoid getting an infection?

GROUP B STREPTOCOCCUS INFECTION and PREGNANCY

What is Group B streptococcus?

How do I know if I carry GBS?

Now I'm pregnant, what should I know about GBS?

Is my baby at risk of developing GBS infection?

How should my labour and delivery be managed?

What are the risks of treatment?

What are the signs of GBS infection in a baby?

Why isn't there a national screening programme for GBS?

I'm carrying GBS - what now?

SWINE FLU and PREGNANCY

What is swine flu (H1N1)?

How does swine flu spread?

What are the symptoms of swine flu?

I'm pregnant. Am I more at risk of catching swine flu?

Can I be vaccinated against swine flu?

Are there other ways I can protect myself against swine flu?

Could swine flu affect my developing baby?

How long do people stay contagious?

What should I do if I or somebody in my family has symptoms of swine flu?

How can swine flu be treated?

GENITAL HERPES IN PREGNANCY

What is genital herpes?

How might genital herpes affect my pregnancy?

Will I need to have a caesarean?

Can I breastfeed if I have herpes?

What are the symptoms of a genital herpes infection?

How can I avoid catching the virus while I am pregnant?

LISTERIA and PREGNANCY

What is Listeria?

What are the risks of a pregnant woman getting listeriosis?

How will I know if I have listeriosis?

Can listeriosis harm my baby?

How is listeriosis treated?

What can I do to protect my baby from listeriosis?

Do not eat refrigerated pates or meat spreads.

Do not eat refrigerated smoked seafood unless it is contained in a cooked dish, such as a casserole.

Practice safe food handling:

Proper Temperatures for Cooking Foods:

Refrigerate or freeze food promptly.

REPIRATORY INFECTIONS DURING PREGNANCY

What if I'm exposed to a viral respiratory infection when I'm pregnant?

What should I do if I'm exposed to CHICKENPOX?

What should I do if I'm exposed to FIFTH disease?

What if I'm exposed to CYTOMEGALOVIRUS?

What if I'm exposed to RUBELLA (German measles)?

What if I'm exposed to INFLUENZA?

What about other viral infections?

HEPATITIS IN PREGNANCY

Effects of Hepatitis B Virus Infection

Blood

Semen

Vaginal fluids

Saliva

Fatigue

Loss of appetite

Nausea

Jaundice (yellowing of the skin and eyes)

Dark urine

Soreness in the liver