Three most common infection encountered, which cause abnormal discharge per vagina with or without itching are Trichomoniasis, Candida infections and Bacterial vaginosis.
Trichomoniasis of vagina
Trichomonas vaginalis (TV) is a flagellated protozoon which is predominantly sexually transmitted. It is able to attach to squamous epithelium and can infect the vagina and urethra. Trichomonas may be acquired perinatally in babies born to infected mothers.
Infected women may, unusually, be asymptomatic. Commonly the major complaints are of vaginal discharge which is offensive and of local irritation. Men usually present as the asymptomatic sexual partners of infected women, although they may complain of urethral discharge, irritation or urinary frequency.
Examination often reveals a frothy yellowish vaginal discharge and erythematous (reddish) vaginal walls. The cervix may have multiple small haemorrhagic areas which lead to the description 'strawberry cervix'.
Trichomonas infection in pregnancy has been asso ciated with preterm delivery and low birth-weight babies.
Diagnosis of Trichomoniasis
Phase-contrast, dark -ground microscopy of a drop of vaginal discharge shows TV swimming with a charac teristic motion in 40-80% of female patients. Similar preparations from the male urethra will only be positive in about 30% of cases. Many polymorphonuclear leucocytes are also seen. Culture techniques are good and confirm the diagnosis. Trichomonas is sometimes observed on cervical cytology with a 60-80% accuracy in diagnosis. New, highly sensitive and specific tests based on polymerase chain reactions are in development.
Treatment of Trichomoniasis
Metronidazole is the treatment of choice, either 2 g orally as a single dose or 400 mg twice -daily for 7 days. There is some evidence of metronidazole resistance and nimorazole may be effective in these cases. Topical therapy with intravaginal tinidazole can be effective, but if extravaginal infection exists this may not be eradicated and vaginal infection reoccurs. Male partners should be treated, especially as they are likely to be asymptomatic and more difficult to detect.
Candidiasis of vagina
Vulvovaginal infection with Candida albicans is extremely common. The organism is also responsible for balanitis( infection in the glans penis) in men. Candida can be isolated from the vagina in a high proportion of women of childbearing age, many of whom will have no symptoms.
The role of Candida as pathogen or commensal is difficult to disentangle and it may be changes in host environment which allow the organism to produce pathological effects. Predisposing factors include pregnancy, diabetes, and the use of broad -spectrum antibiotics and corticosteroids. Immuno suppression can result in more florid infection.
Symptoms of Candidiasis
In women, pruritus vulvae (itching in the vulva or, private parts) is the dominant symptom. Vaginal discharge is present in varying degree. Many women have only one or occasional isolated episodes. Recurrent candidiasis (four or more symptomatic episodes annually) occurs in up to 5% of healthy women of reproductive age. Examination reveals erythema (redness) and swelling of the vulva with broken skin in severe cases. The vagina may contain adherent curdy discharge.
Men may have a florid balanoposthitis (infection of the glans penis). More commonly, self limiting burning penile irritation immediately after sexual intercourse with an infected partner is described . Diabetes must be excluded in men with balanoposthitis.
Diagnosis of candidiasis
Microscopic examination of a smear from the vaginal wall reveals the presence of spores and mycelia. Culture of swabs should be undertaken but may be positive in women with no symptoms. Trichomonas and bacterial vaginosis must be considered in women with itch and discharge.
Treatment of candidiasis
Topical. Pessari es or creams containing one of the imidazole antifungals such as clotrimazole 500 mg single dose used intravaginally are usually effective. Nystatin is also useful.
Oral. The triazole drugs such as fluconazole 150 mg as a single dose or itraconazole 200 mg twice in 1 day are used systemically where topical therapy has failed or is inappropriate. Recurrent candidiasis may be treated with fluconazole 100 mg weekly for 6 months, or clotrimazole pessary 500 mg weekly for 6 months.
The evidence for sexual transmission of Candida is slight and there is no evidence that treatment of male partners reduces recurrences in women.
Bacterial vaginosis
Bacterial vaginosis (Bacterial Vaginosis) is a disorder characterized by an offensive vaginal discharge. The cause and methodology are unclear but a mixed flora of Gardnerella vaginalis, anaerobes including Bacteroides, Mobiluncus spp. and Mycoplasma hominis, replaces the normal lactobacilli of the vagina. Amines and their breakdown products from the abnormal vaginal flora are thought to be responsible for the characteristic odour associated with the condition. As vaginal inflammation is not part of the syndrome the term vaginosis is used rather than vaginitis. The condition has been shown to more common in black women than in white. It is not regarded as a sexually transmitted disease.
Symptoms of Bacterial Vaginosis
Vaginal discharge and odour are the most common complaint s although a proportion of women are asymptomatic. A homogeneous, greyish white, adherent discharge is present in the vagina, the pH of which is raised (greater than 5).
Associated complications are ill defined but may include chorioamnionitis and an increased incidence of premature labour in pregnant women.
Diagnosis of Bacterial Vaginosis
In general it is accepted that three of the following should be present for the diagnosis to be made:
#characteristic vaginal discharge
# the amine test: raised vaginal pH using narrow-range indicator paper (> 4.7)
# a fishy odour on mixing a drop of discharge with 10% potassium hydroxide
# the presence of clue cells on microscopic examination of the vaginal fluid.
Clue cells are squamous epithelial cells from the vagina which have bacteria adherent to their surface, giving a granular appearance to the cell. A Gram stain gives a typical reaction of partial stain uptake.
Treatment of Bacterial Vaginosis
Metronidazole given orally in doses of 400 mg twice daily for 5-7 days is usually recommended. A single dose of 2 g metronidazole is less effective. Topical 2% clindamycin cream 5 g intravaginally once daily for 7 days is effective.
Recurrence is high, with some studies giving a rate of 80% within 9 months of completing metronidazole therapy. There is debate over the treatment of asymptomatic women who fulfil the diagnostic criteria for Bacterial Vaginosis.The diagnosis should be fully discussed and treatment offered if the woman wishes. Until the relevance of Bacterial Vaginosis to other pelvic infections is elucidated, the treatment of asymptomatic women with Bacterial Vaginosis is not to be recommended. There is no convincing evidence that simultaneous treatment of the male partner influences the rate of recurrence of Bacterial Vaginosis, and routine treatment of male partners is not indicated.
Tuesday, March 31, 2009
Lack of libido and erectile dysfunction (Impotence)
Lack of libido is a loss of sexual desire leading to erectile dysfunction. Erectile dysfunction (ED) may be psychological, neurogenic, vascular, endocrine or related to drugs and often includes contributions from several causes.
ED is a common symptom in hypogonadism, but most patients with ED have normal hormones and many have no definable organic cause. The endocrine causes are those of hypogonadism and can be excluded by normal testosterone, gonadotrophin and prolactin levels, and the presence of nocturnal emissions and frequent satisfactory morning erections makes endocrine disease unlikely.
Vascular disease is a common aetiology, especially in smokers, and is often associated with vascular problems elsewhere.
Autonomic neuropathy,most commonly from diabetes mellitus, is a common partial, if not total, identifiable cause .
Many drugs can also produce ED .
The patient is assessed for any physical disease, related symptoms, stress and psychological factors, together with drug and alcohol abuse.
Psychogenic impotence is frequently a diagnosis of exclusion, though complex tests of penile vasculature and function are available in some centers.
Causes of Erectile Dysfunction:
Physiological
Neonatal
Pubertal
Old age
Hyperthyroidism
Liver disease
Oestrogen-producing tumours (testis, adrenal)
Human Chorionic Gonadotrophin producing tumours (testis, lung)
Starvation/ re feeding
Carcinoma of breast
Drugs
Oestrogen Producing
Oestrogens
Digoxin
Cannabis
Diamorphine
Anti-androgens
Spironolactone
Cimetidine
Cyproterone
Treatment of Erectile Dysfunction:
Offending drugs should be stopped. Phosphodiesterase type-5 inhibitors (sildenafil or Viagra, tadalafil, vardenafil) which increase penile blood flow are usually first choice for therapy. Other treatments include apomorphine, intracavernosal injections of alprostadil, papaverine or phentolamine, vacuum expanders and penile implants.
If no organic disease is found, or if there is clear evidence of psychological problems, the couple should receive psychosexual counselling.
ED is a common symptom in hypogonadism, but most patients with ED have normal hormones and many have no definable organic cause. The endocrine causes are those of hypogonadism and can be excluded by normal testosterone, gonadotrophin and prolactin levels, and the presence of nocturnal emissions and frequent satisfactory morning erections makes endocrine disease unlikely.
Vascular disease is a common aetiology, especially in smokers, and is often associated with vascular problems elsewhere.
Autonomic neuropathy,most commonly from diabetes mellitus, is a common partial, if not total, identifiable cause .
Many drugs can also produce ED .
The patient is assessed for any physical disease, related symptoms, stress and psychological factors, together with drug and alcohol abuse.
Psychogenic impotence is frequently a diagnosis of exclusion, though complex tests of penile vasculature and function are available in some centers.
Causes of Erectile Dysfunction:
Physiological
Neonatal
Pubertal
Old age
Hyperthyroidism
Liver disease
Oestrogen-producing tumours (testis, adrenal)
Human Chorionic Gonadotrophin producing tumours (testis, lung)
Starvation/ re feeding
Carcinoma of breast
Drugs
Oestrogen Producing
Oestrogens
Digoxin
Cannabis
Diamorphine
Anti-androgens
Spironolactone
Cimetidine
Cyproterone
Treatment of Erectile Dysfunction:
Offending drugs should be stopped. Phosphodiesterase type-5 inhibitors (sildenafil or Viagra, tadalafil, vardenafil) which increase penile blood flow are usually first choice for therapy. Other treatments include apomorphine, intracavernosal injections of alprostadil, papaverine or phentolamine, vacuum expanders and penile implants.
If no organic disease is found, or if there is clear evidence of psychological problems, the couple should receive psychosexual counselling.
Monday, March 30, 2009
Irritable bowel syndrome (IBS) – Symptoms, Diagnosis and Treatment
IBS is the commonest Functional Gastro Intestinal Disorder. Female sufferers outnumber male counterpart. Reasons for this include the fact that anxiety and depression scores are higher in women than in men and the gut may be more sensitive to various stimuli in women. It is likely that men and women perceive internal events in the abdomen differently and that women may be more focused on these events. Food and eating are of more special psychological significance for women, as evidenced by a much higher incidence of eating disorders in women. The whole pelvic region carries a more specific significance for women, being associated not only with defecation, urination and sexuality but additionally with menstruation, pregnancy and childbirth.
IBS - a multisystem disorder
IBS patients suffer from a number of non-intestinal symptoms as stated below. The non-intestinal symptoms of IBS can be more intrusive than the classical features of IBS. IBS coexists with chronic fatigue syndrome, fibromyalgia and temporomandibular (Jaw joint) joint dysfunction
Gynaecological symptoms
Painful periods (dysmenorrhoea)
Pain following sexual intercourse (dyspareunia)
Premenstrual tension
Urinary symptoms
Frequency
Urgency
Passing urine at night (nocturia)
Incomplete emptying of bladder
Other symptoms
Back pain
Headaches
Bad breath, unpleasant taste in the mouth
Poor sleeping
Fatigue
Infectious diarrhoea precedes the onset of IBS symptoms in 7-30% of patients. Whether this is a factor for all patients or just a small subgroup remains controversial. Risk factors in these patients have been shown to include female gender, severity and duration of diarrhoea, pre-existing life events and high hypochondriacal anxiety and neurotic scores at the time of the initial illness.
Symptoms of anxiety and depression are more common in IBS patients and stress or life events often precedes the onset of chronic bowel symptoms.
Factors which are known to trigger IBS
Gastrointestinal infection
Antibiotic therapy
Pelvic surgery
Psychological stress
Psychological trauma
Sexual, physical, verbal abuse
Mood disturbances
Anxiety, depression
Eating disorders
Food intolerance
Diagnostic criteria (Rome II 1999)
These criteria state that, in the preceding 12 months there should be at least 12 weeks (consecutive) of abdominal discomfort or pain that has two of three of the following features:
Relieved with defecation; and/or onset associated with a change in frequency of stool; and/ or onset associated with a change in form(appearance) of stool.
The following symptoms cumulatively support the diagnosis of IBS:
#abnormal stool frequency ('abnormal' may be defined as > 3/day and <>
#abnormal stool form (lumpy/hard or loose/watery stool)
#abnormal stool passage (straining, urgency, or feeling of incomplete evacuation)
#passage of mucus
#bloating or feeling of abdominal distension.
These symptoms can be used to sub classify patients into diarrhoea- and constipation-predominant forms of IBS. In practice a third subgroup of alternating IBS exists, in which constipation and diarrhoea alternate. The three forms have equal frequency. Many patients with constipation have abdominal discomfort or pain with bloating or distension so there is considerable overlap with constipation-predominant IBS. The decision as to whether to investigate and if so what choice of investigations is required should be based on clinical judgement. Pointers to the need for thorough investigation are the presence of the above symptoms in association with rectal bleeding, nocturnal pain, fever and weight loss. Treatment Current strategies for treatment of IBS are based on the biopsychosocial conceptualization of IBS with targeting of central and end-organ therapies. End organ and central approaches to treatment should not be mutually exclusive and can be used in sequence and in combinations. Hydroxytryptamine (HT3)-receptor antagonists for diarrhea predominant IBS, HT4-receptor agonists for constipation predominant IBS as well as kappa opioid agonists for use in patients in whom visceral hyperalgesia plays a predominant role in the pathogenesis of their symptoms may become available.
These are the plan of management of IBS
Explore dietary triggers - Refer to dietician
High-fibre diet ± fibre supplements for constipation - Refer to dietician ± prescribe ispaghula husk
Anti-diarrhoeal drugs for bowel frequency – Loperamide, Codeine phosphate, Co-phenotrope
Smooth muscle relaxants for pain - Mebeverine hydrochloride, Dicycloverine hydrochloride, Peppermint oil
Central treatment consists of - Physiological explanation of symptoms, Psychotherapy, Hypnotherapy, Cognitive behavioural therapy and Antidepressant drug therapy
IBS - a multisystem disorder
IBS patients suffer from a number of non-intestinal symptoms as stated below. The non-intestinal symptoms of IBS can be more intrusive than the classical features of IBS. IBS coexists with chronic fatigue syndrome, fibromyalgia and temporomandibular (Jaw joint) joint dysfunction
Gynaecological symptoms
Painful periods (dysmenorrhoea)
Pain following sexual intercourse (dyspareunia)
Premenstrual tension
Urinary symptoms
Frequency
Urgency
Passing urine at night (nocturia)
Incomplete emptying of bladder
Other symptoms
Back pain
Headaches
Bad breath, unpleasant taste in the mouth
Poor sleeping
Fatigue
Infectious diarrhoea precedes the onset of IBS symptoms in 7-30% of patients. Whether this is a factor for all patients or just a small subgroup remains controversial. Risk factors in these patients have been shown to include female gender, severity and duration of diarrhoea, pre-existing life events and high hypochondriacal anxiety and neurotic scores at the time of the initial illness.
Symptoms of anxiety and depression are more common in IBS patients and stress or life events often precedes the onset of chronic bowel symptoms.
Factors which are known to trigger IBS
Gastrointestinal infection
Antibiotic therapy
Pelvic surgery
Psychological stress
Psychological trauma
Sexual, physical, verbal abuse
Mood disturbances
Anxiety, depression
Eating disorders
Food intolerance
Diagnostic criteria (Rome II 1999)
These criteria state that, in the preceding 12 months there should be at least 12 weeks (consecutive) of abdominal discomfort or pain that has two of three of the following features:
Relieved with defecation; and/or onset associated with a change in frequency of stool; and/ or onset associated with a change in form(appearance) of stool.
The following symptoms cumulatively support the diagnosis of IBS:
#abnormal stool frequency ('abnormal' may be defined as > 3/day and <>
#abnormal stool form (lumpy/hard or loose/watery stool)
#abnormal stool passage (straining, urgency, or feeling of incomplete evacuation)
#passage of mucus
#bloating or feeling of abdominal distension.
These symptoms can be used to sub classify patients into diarrhoea- and constipation-predominant forms of IBS. In practice a third subgroup of alternating IBS exists, in which constipation and diarrhoea alternate. The three forms have equal frequency. Many patients with constipation have abdominal discomfort or pain with bloating or distension so there is considerable overlap with constipation-predominant IBS. The decision as to whether to investigate and if so what choice of investigations is required should be based on clinical judgement. Pointers to the need for thorough investigation are the presence of the above symptoms in association with rectal bleeding, nocturnal pain, fever and weight loss. Treatment Current strategies for treatment of IBS are based on the biopsychosocial conceptualization of IBS with targeting of central and end-organ therapies. End organ and central approaches to treatment should not be mutually exclusive and can be used in sequence and in combinations. Hydroxytryptamine (HT3)-receptor antagonists for diarrhea predominant IBS, HT4-receptor agonists for constipation predominant IBS as well as kappa opioid agonists for use in patients in whom visceral hyperalgesia plays a predominant role in the pathogenesis of their symptoms may become available.
These are the plan of management of IBS
Explore dietary triggers - Refer to dietician
High-fibre diet ± fibre supplements for constipation - Refer to dietician ± prescribe ispaghula husk
Anti-diarrhoeal drugs for bowel frequency – Loperamide, Codeine phosphate, Co-phenotrope
Smooth muscle relaxants for pain - Mebeverine hydrochloride, Dicycloverine hydrochloride, Peppermint oil
Central treatment consists of - Physiological explanation of symptoms, Psychotherapy, Hypnotherapy, Cognitive behavioural therapy and Antidepressant drug therapy
Psychological (Functional) Dyspepsia
This is the second most common functional gastrointestinal disorder (after irritable bowel syndrome). Patients can present with a spectrum of symptoms including upper abdominal pain/discomfort, fullness, early satiety, bloating and nausea.
These patients have no structural abnormality as an explanation for their symptoms.
Types of functional dyspepsia
Two subgroups based on the predominant (or most troublesome) single symptoms are suggested:
Ulcer-like dyspepsia with pain centered in the upper abdomen as the predominant (most troublesome) symptom.
Dysmotility-like dyspepsia with non painful sensation (discomfort) centered in the upper abdomen being the prominent symptom. Upper abdominal fullness, early satiety, bloating and nausea may also be associated with the discomfort.
There is considerable overlap between these two groups.
Diagnosis of Functional dyspepsia
Many young patients (< 50) require no investigation. Older patients or those with alarm symptoms require endoscopy . Gastroscopy often shows gastritis but whether this is the cause of the symptoms is doubtful.
Treatment of Functional dyspepsia
The range of therapies prescribed for functional dyspepsia reflects the uncertain pathogenesis and the lack of satisfactory treatment options. Management is further Confounded by high placebo response rates (20-60%). A proportion of patients will respond satisfactorily to reassurance, explanations and lifestyle changes, but anti secretory or prokinetic agents are used for patients with ulcer-like and dysmotility-like dyspepsia respectively. Reducing intake of fat, coffee, alcohol and cigarette smoking may help. H. pylori eradication therapy is often used in functional dyspepsia empirically with varied success. Most gastroenterologists usually try such therapy if only for its possible long-term benefit.
Psychological ailments are major reason for such type of dyspeptic episodes. If all organic causes are excluded visiting a reputed psychologist near you may be of great help.
These patients have no structural abnormality as an explanation for their symptoms.
Types of functional dyspepsia
Two subgroups based on the predominant (or most troublesome) single symptoms are suggested:
Ulcer-like dyspepsia with pain centered in the upper abdomen as the predominant (most troublesome) symptom.
Dysmotility-like dyspepsia with non painful sensation (discomfort) centered in the upper abdomen being the prominent symptom. Upper abdominal fullness, early satiety, bloating and nausea may also be associated with the discomfort.
There is considerable overlap between these two groups.
Diagnosis of Functional dyspepsia
Many young patients (< 50) require no investigation. Older patients or those with alarm symptoms require endoscopy . Gastroscopy often shows gastritis but whether this is the cause of the symptoms is doubtful.
Treatment of Functional dyspepsia
The range of therapies prescribed for functional dyspepsia reflects the uncertain pathogenesis and the lack of satisfactory treatment options. Management is further Confounded by high placebo response rates (20-60%). A proportion of patients will respond satisfactorily to reassurance, explanations and lifestyle changes, but anti secretory or prokinetic agents are used for patients with ulcer-like and dysmotility-like dyspepsia respectively. Reducing intake of fat, coffee, alcohol and cigarette smoking may help. H. pylori eradication therapy is often used in functional dyspepsia empirically with varied success. Most gastroenterologists usually try such therapy if only for its possible long-term benefit.
Psychological ailments are major reason for such type of dyspeptic episodes. If all organic causes are excluded visiting a reputed psychologist near you may be of great help.
Causes Of Itchy Bottom
Pruritus ani, or an itchy bottom, is common. Perianal excoriation results from scratching. Usually the condition results from seepage from haemorrhoids or overactivity of sweat glands. Treatment consists of salt baths, keeping the area dry with powder; the use of all creams should be avoided. Secondary causes include threadworm (Enterobius vermicularis) infestation, fungal infections ( e.g. candidiasis) and perianal eczema, which should be treated appropriately.
Haemorrhoids (Piles) can cause itching in the anus:
Haemorrhoids (primary, internal, second degree, prolapsing, third degree prolapsed) usually cause rectal bleeding, discomfort and pruritus ani. Patients may notice red blood on their toilet paper and blood on the outside of their stools. They are the most common cause of rectal bleeding. Diagnosis is made by inspection, rectal examination and proctoscopy. If symptoms are minor no treatment is required; depending on severity of symptoms, treatment is with injection of sclerosant, rubber band ligation or surgery.
Haemorrhoids (Piles) can cause itching in the anus:
Haemorrhoids (primary, internal, second degree, prolapsing, third degree prolapsed) usually cause rectal bleeding, discomfort and pruritus ani. Patients may notice red blood on their toilet paper and blood on the outside of their stools. They are the most common cause of rectal bleeding. Diagnosis is made by inspection, rectal examination and proctoscopy. If symptoms are minor no treatment is required; depending on severity of symptoms, treatment is with injection of sclerosant, rubber band ligation or surgery.
Causes and treatment of ulcers in the mouth (Oral cavity)
Recurrent ulceration (Apthous Ulcer) in the oral cavity (Mouth)
Recurrent aphthous ulceration of unknown aetiology (reason) is a common oral mucosa disorder affecting 20% of the population. It consists of recurrent bouts of one or more rounded, shallow, painful ulcers recurring at intervals of days to a few months.
Minor aphthous ulcers are the most common. They are less than 10 mm diameter, have a grey/white centre with a thin erythematous (red colored) halo and heal within 14 days without scarring.
Major aphthous ulcers are larger (more than 20 mm diameter), often persist for weeks or months and heal with scarring.
Most patients with recurrent ulcers are otherwise well. Various nutritional deficiencies of iron, folic acid or vitamin B12 (with or without gastrointestinal disorders) are occasionally found.
There are no specific, effective therapies. Corticosteroids may lessen the duration and severity of the attacks. Chlorhexidine gluconate mouthwash, dapsone, colchicine, systemic steroids and azathioprine have all been used with variable effect.
Ulceration associated with other diseases
Oral ulceration is seen in gastrointestinal disorders, such as Crohn's disease, ulcerative colitis and coeliac disease in approximately 10-20% of cases. Other diseases associated with oral ulceration include lupus erythematosus (systemic and discoid), Behcet's disease, neutropenia and immunodeficiency disorders (HIV). In Reiter's disease, ulceration occurs in approximately 25-30% of patients.
Ulceration associated with dermatological disorders / Skin Diseases
Oral cavity is also a part of our skin so many skin disorders also produce lesion in the oral cavity as well. These include erythema multiforme major, toxic epidermal necrolysis, lichen planus, pemphigus vulgaris, bullous pemphigoid , epidermolysis bullosa and dermatitis herpetiformis.
Ulceration associated with viral infection
Herpes simplex virus. Primary herpes simplex (usually type I but rarely type II) presents with fever and widespread confluent painful ulcers. After resolution, the virus remains latent and recurs as herpes labialis (ulcers in the angle of the mouth) also commonly known as cold sores.
Other viruses. Herpes zoster and cytomegalovirus are among many viruses that can produce mouth ulceration, usually during the acute infective phase.
Ulceration associated with bacterial infection
Syphilis and tuberculosis can rarely cause oral ulcerations and are seen mainly in developing countries.
Ulceration associated with drugs
Certain drugs can cause oral lichenoid eruptions. They include antimalarials, methyldopa, tolbutamide, penicillamine and gold salts.
Traumatic Ulcers
Traumatic ulcers may be due to ill-fitting dentures, tooth brushing or lacerations by sharp teeth.
Neoplastic lesions (squamous cell carcinoma)
The majority of such ulcers develop on the floor of the mouth or lateral borders of the tongue. Early tumours may be painless, but advanced tumours are easily recognizable as indurated aphthous ulcers with raised and rolled edges.
Causative agents include tobacco, heavy alcohol consumption and the areca nut.
Intra-oral lesions which undergo malignant transformation include leucoplakia, lichen planus, submucous fibrosis and erythroplaki a (a red patch). The previous male predominance has declined. Treatment is by surgical excision and/or radiotherapy.
Recurrent aphthous ulceration of unknown aetiology (reason) is a common oral mucosa disorder affecting 20% of the population. It consists of recurrent bouts of one or more rounded, shallow, painful ulcers recurring at intervals of days to a few months.
Minor aphthous ulcers are the most common. They are less than 10 mm diameter, have a grey/white centre with a thin erythematous (red colored) halo and heal within 14 days without scarring.
Major aphthous ulcers are larger (more than 20 mm diameter), often persist for weeks or months and heal with scarring.
Most patients with recurrent ulcers are otherwise well. Various nutritional deficiencies of iron, folic acid or vitamin B12 (with or without gastrointestinal disorders) are occasionally found.
There are no specific, effective therapies. Corticosteroids may lessen the duration and severity of the attacks. Chlorhexidine gluconate mouthwash, dapsone, colchicine, systemic steroids and azathioprine have all been used with variable effect.
Ulceration associated with other diseases
Oral ulceration is seen in gastrointestinal disorders, such as Crohn's disease, ulcerative colitis and coeliac disease in approximately 10-20% of cases. Other diseases associated with oral ulceration include lupus erythematosus (systemic and discoid), Behcet's disease, neutropenia and immunodeficiency disorders (HIV). In Reiter's disease, ulceration occurs in approximately 25-30% of patients.
Ulceration associated with dermatological disorders / Skin Diseases
Oral cavity is also a part of our skin so many skin disorders also produce lesion in the oral cavity as well. These include erythema multiforme major, toxic epidermal necrolysis, lichen planus, pemphigus vulgaris, bullous pemphigoid , epidermolysis bullosa and dermatitis herpetiformis.
Ulceration associated with viral infection
Herpes simplex virus. Primary herpes simplex (usually type I but rarely type II) presents with fever and widespread confluent painful ulcers. After resolution, the virus remains latent and recurs as herpes labialis (ulcers in the angle of the mouth) also commonly known as cold sores.
Other viruses. Herpes zoster and cytomegalovirus are among many viruses that can produce mouth ulceration, usually during the acute infective phase.
Ulceration associated with bacterial infection
Syphilis and tuberculosis can rarely cause oral ulcerations and are seen mainly in developing countries.
Ulceration associated with drugs
Certain drugs can cause oral lichenoid eruptions. They include antimalarials, methyldopa, tolbutamide, penicillamine and gold salts.
Traumatic Ulcers
Traumatic ulcers may be due to ill-fitting dentures, tooth brushing or lacerations by sharp teeth.
Neoplastic lesions (squamous cell carcinoma)
The majority of such ulcers develop on the floor of the mouth or lateral borders of the tongue. Early tumours may be painless, but advanced tumours are easily recognizable as indurated aphthous ulcers with raised and rolled edges.
Causative agents include tobacco, heavy alcohol consumption and the areca nut.
Intra-oral lesions which undergo malignant transformation include leucoplakia, lichen planus, submucous fibrosis and erythroplaki a (a red patch). The previous male predominance has declined. Treatment is by surgical excision and/or radiotherapy.
Sunday, March 29, 2009
Migraine - Symptoms, Diagnosis and Treatment
Migraine is recurrent headache associated with visual and gastrointestinal disturbance. The borderline between migraine and tension headaches is vague. Over 12% of any population world-wide report these symptoms.
Mechanisms of migraine
Precise mechanisms of migraine remain unknown. Genetic factors play some part . The headache of migraine, often throbbing, is due to vasodilatation or oedema of blood vessels, with stimulation of nearby nerve endings. Release of vasoactive substances such as nitric oxide has a role . Serum 5 – hydroxytryptamine (5HT) rises with initial symptoms and falls during the headache. Cerebral features, such as tingling limbs, aphasia and weakness, are caused by focal depression of cortical function.
Some patients recognize precipitating factors:
#Week-end migraine (a time of relaxation)
#Chocolate (high in phenylethylamine)
#Cheese (high in tyramine)
#Noise and irritating lights
#With premenstrual symptoms.
Migraine is common around puberty and at the menopause and sometimes increases in severity or frequency with hormonal contraceptives, in pregnancy and with the onset of hypertension. There is no reason to suppose that the development of migraine is suggestive of any serious intracranial lesion. However, since migraine is so common, an intracranial mass and migraine sometimes occur together by coincidence. Migraine sometimes follows a blow to the head - often minor.
Symptoms of Migraine
Migraine attacks vary from intermittent headaches indistinguishable from tension headaches to discrete episodes that mimic thromboembolic cerebral ischaemia.
Distinction between variants is somewhat artificial.
Migraine can be separated into phases:
# initial or, prodromal symptoms
# the main attack (headache, nausea, vomiting)
# sleep and feeling drained afterwards.
Types of Migraine
Migraine with aura (classical migraine)
Prodromal symptoms are usually visual and related to depression of visual cortical function or retinal function. Unilateral patchy scotomata (retina) (Patchy blindness), hemianopic symptoms (cortex), teichopsia (flashes) and fortification spectra (jagged lines resembling battlements) are common. Transient aphasia (Unable to speak) sometimes occurs, with tingling, numbness, vague weakness of one side and nausea. The prodrome persists for a few minutes to about an hour.
Headache then follows. This is occasionally hemicranial (i.e. splitting the head) but often begins locally and becomes generalized. Nausea increases and vomiting follows. The patient is irritable and prefers a darkened room. Superficial temporal arteries are engorged and pulsating. After several hours the migraine settles, sometimes with a diuresis. Deep sleep often ensues.
Migraine without aura (common migraine)
This is the usual variety. Prodromal visual symptoms are vague. There is recurrent headache accompanied by nausea and malaise.
Basilar migraine
Prodromal symptoms include circumoral and tongue tingling, vertigo, diplopia, transient visual disturbance (even blindness), syncope, dysarthria and ataxia. These occur alone or progress to a typical migraine.
Hemiparetic migraine
This rarity is classical migraine with hemiparetic features, i.e. resembling a stroke but with recovery within 24 hours. Exceptionally, cerebral infarction (stroke) occurs.
Ophthalmoplegic migraine
This rarity is a third nerve, or exceptionally a sixth nerve, palsy with a migraine - and difficult to diagnose without investigation to exclude other conditions.
Facioplegic migraine
This is unilateral facial weakness during a migraine.
The diseases, which should be differentiated from migraine
The sudden headache may resemble meningitis or SAH(Sub Arachnoid Haemorrhage). Hemiplegic, visual and hemi sensory symptoms must be distinguished from thromboembolic TIAs(Transient Ischaemic Attacks). In TIAs maximum deficit is present immediately and headache is unusual. Unilateral tingling or numbness may resemble sensory epilepsy (partial seizures). In epilepsy, distinct march (progression) of symptoms is usual.
Treatment of Migraine
#reassurance and relief of anxiety
#avoidance of dietary factors - rarely helpful.
Patients taking hormonal contraceptives may benefit from a brand change, or trying without. Premenstrual migraine may respond to diuretics. Depot oestrogens are sometimes used. Severe hemiplegic symptoms are an indication for stopping hormonal contraceptives.
During an attack. After ruling out any serious cause for a sudden headache, paracetamol or other simple analgesics should be given, with an antiemetic such as metoclopramide if necessary. Repeated use of analgesics leads to further headaches.
Triptans (5-HT, agonists) are also helpful. In some 30% of cases, where there is
recurrent severe migraine, sumatriptan, zolmitriptan, naratriptan and rizatriptan are of value either by prompt self-administered subcutaneous injection, or orally by wafer or inhaler. Triptans should be avoided when there is vascular disease, and not overused.
Prophylaxis of Migraine attack
It is difficult to discern placebo effects of prophylactic drugs. The following are used when attacks are frequent:
#pizotifen (antihistamine and 5-HT antagonist) 0.5 mg at night for several days, increasing to 1.5 mg (common side-effects: weight gain and drowsiness)
#propranolol 10 mg three times daily, increasing to 40-80 mgthree times daily
#amitriptyline: 10 mg(or more) at night.
#Sodium valproate, methysergide, SSRIs, verapamil, topiramate, nifedipine and naproxen are also used.
Mechanisms of migraine
Precise mechanisms of migraine remain unknown. Genetic factors play some part . The headache of migraine, often throbbing, is due to vasodilatation or oedema of blood vessels, with stimulation of nearby nerve endings. Release of vasoactive substances such as nitric oxide has a role . Serum 5 – hydroxytryptamine (5HT) rises with initial symptoms and falls during the headache. Cerebral features, such as tingling limbs, aphasia and weakness, are caused by focal depression of cortical function.
Some patients recognize precipitating factors:
#Week-end migraine (a time of relaxation)
#Chocolate (high in phenylethylamine)
#Cheese (high in tyramine)
#Noise and irritating lights
#With premenstrual symptoms.
Migraine is common around puberty and at the menopause and sometimes increases in severity or frequency with hormonal contraceptives, in pregnancy and with the onset of hypertension. There is no reason to suppose that the development of migraine is suggestive of any serious intracranial lesion. However, since migraine is so common, an intracranial mass and migraine sometimes occur together by coincidence. Migraine sometimes follows a blow to the head - often minor.
Symptoms of Migraine
Migraine attacks vary from intermittent headaches indistinguishable from tension headaches to discrete episodes that mimic thromboembolic cerebral ischaemia.
Distinction between variants is somewhat artificial.
Migraine can be separated into phases:
# initial or, prodromal symptoms
# the main attack (headache, nausea, vomiting)
# sleep and feeling drained afterwards.
Types of Migraine
Migraine with aura (classical migraine)
Prodromal symptoms are usually visual and related to depression of visual cortical function or retinal function. Unilateral patchy scotomata (retina) (Patchy blindness), hemianopic symptoms (cortex), teichopsia (flashes) and fortification spectra (jagged lines resembling battlements) are common. Transient aphasia (Unable to speak) sometimes occurs, with tingling, numbness, vague weakness of one side and nausea. The prodrome persists for a few minutes to about an hour.
Headache then follows. This is occasionally hemicranial (i.e. splitting the head) but often begins locally and becomes generalized. Nausea increases and vomiting follows. The patient is irritable and prefers a darkened room. Superficial temporal arteries are engorged and pulsating. After several hours the migraine settles, sometimes with a diuresis. Deep sleep often ensues.
Migraine without aura (common migraine)
This is the usual variety. Prodromal visual symptoms are vague. There is recurrent headache accompanied by nausea and malaise.
Basilar migraine
Prodromal symptoms include circumoral and tongue tingling, vertigo, diplopia, transient visual disturbance (even blindness), syncope, dysarthria and ataxia. These occur alone or progress to a typical migraine.
Hemiparetic migraine
This rarity is classical migraine with hemiparetic features, i.e. resembling a stroke but with recovery within 24 hours. Exceptionally, cerebral infarction (stroke) occurs.
Ophthalmoplegic migraine
This rarity is a third nerve, or exceptionally a sixth nerve, palsy with a migraine - and difficult to diagnose without investigation to exclude other conditions.
Facioplegic migraine
This is unilateral facial weakness during a migraine.
The diseases, which should be differentiated from migraine
The sudden headache may resemble meningitis or SAH(Sub Arachnoid Haemorrhage). Hemiplegic, visual and hemi sensory symptoms must be distinguished from thromboembolic TIAs(Transient Ischaemic Attacks). In TIAs maximum deficit is present immediately and headache is unusual. Unilateral tingling or numbness may resemble sensory epilepsy (partial seizures). In epilepsy, distinct march (progression) of symptoms is usual.
Treatment of Migraine
#reassurance and relief of anxiety
#avoidance of dietary factors - rarely helpful.
Patients taking hormonal contraceptives may benefit from a brand change, or trying without. Premenstrual migraine may respond to diuretics. Depot oestrogens are sometimes used. Severe hemiplegic symptoms are an indication for stopping hormonal contraceptives.
During an attack. After ruling out any serious cause for a sudden headache, paracetamol or other simple analgesics should be given, with an antiemetic such as metoclopramide if necessary. Repeated use of analgesics leads to further headaches.
Triptans (5-HT, agonists) are also helpful. In some 30% of cases, where there is
recurrent severe migraine, sumatriptan, zolmitriptan, naratriptan and rizatriptan are of value either by prompt self-administered subcutaneous injection, or orally by wafer or inhaler. Triptans should be avoided when there is vascular disease, and not overused.
Prophylaxis of Migraine attack
It is difficult to discern placebo effects of prophylactic drugs. The following are used when attacks are frequent:
#pizotifen (antihistamine and 5-HT antagonist) 0.5 mg at night for several days, increasing to 1.5 mg (common side-effects: weight gain and drowsiness)
#propranolol 10 mg three times daily, increasing to 40-80 mgthree times daily
#amitriptyline: 10 mg(or more) at night.
#Sodium valproate, methysergide, SSRIs, verapamil, topiramate, nifedipine and naproxen are also used.
Difficulty in Swallowing (Dysphagia) Causes and Treatment
Difficulty in swallowing is a common symptom but can be the presenting feature of carcinoma of the pharynx and therefore requires investigation.
Pharyngeal pouch can cause difficulty in swallowing
A pharyngeal pouch is a herniation of mucosa through the fibres of the inferior pharyngeal constrictor muscle (cricopharyngeus) . An area of weakness known as Killian's dehiscence allows a pulsion diverticulum to form. This will collect food which may regurgitate into the mouth or even down to the lungs at night with secondary pneumonia.
Diagnosis is made radiologically and treatment is surgical, either via an external approach through the neck where the pouch is excised or more commonly endoscopically with stapling of the gaping wall.
Foreign bodies can cause difficulty on swallowing
Foreign bodies in the pharynx can be divided into three general categories: soft food bolus, coins (smooth), bones (sharp). Soft food bolus can be initially treated conservatively with muscle relaxants for 24 hours. Impacted coins should be removed at the earliest opportunity but sharp objects require emergency removal to avoid perforation of the muscle wall. If the patient perceives the foreign body to be to one side, then it should be above cricopharyngeus, the constrictor muscle and an ENT examination will locate it; common areas are the tonsillar fossae, base of tongue, posterior pharyngeal wall and valleculae. Radiology will identify coins, and it can be a clinical decision to see whether a coin will pass down to the stomach, in which case no further treatment is required as it will exit naturally.
Fish can be divided into those with a bony skeleton (teleosts) and those with a cartilaginous skeleton (elasmobranchs), and therefore radiology may only be useful in some cases. Radiology can also identify air in the cervical oesophagus indicating a radiolucent foreign body lying distally.
Globus Pharyngeus
This is not a true dysphagia. It is a condition with classic symptoms of an intermittent sensation of a lump in the throat. This is perceived to be in the midline at the level of the cricoid cartilage and is worse when swallowing saliva; indeed it often disappears when ingesting food or liquids. ENT examination is usually clear and normal laryngeal mobility can be felt when gently rocking the larynx across the postcricoid tissues. A contrast swallow will show not only the structures below the pharynx but also assess the swallowing dynamically. Any suspicious area will require an endoscopy with biopsy.
Pharyngeal pouch can cause difficulty in swallowing
A pharyngeal pouch is a herniation of mucosa through the fibres of the inferior pharyngeal constrictor muscle (cricopharyngeus) . An area of weakness known as Killian's dehiscence allows a pulsion diverticulum to form. This will collect food which may regurgitate into the mouth or even down to the lungs at night with secondary pneumonia.
Diagnosis is made radiologically and treatment is surgical, either via an external approach through the neck where the pouch is excised or more commonly endoscopically with stapling of the gaping wall.
Foreign bodies can cause difficulty on swallowing
Foreign bodies in the pharynx can be divided into three general categories: soft food bolus, coins (smooth), bones (sharp). Soft food bolus can be initially treated conservatively with muscle relaxants for 24 hours. Impacted coins should be removed at the earliest opportunity but sharp objects require emergency removal to avoid perforation of the muscle wall. If the patient perceives the foreign body to be to one side, then it should be above cricopharyngeus, the constrictor muscle and an ENT examination will locate it; common areas are the tonsillar fossae, base of tongue, posterior pharyngeal wall and valleculae. Radiology will identify coins, and it can be a clinical decision to see whether a coin will pass down to the stomach, in which case no further treatment is required as it will exit naturally.
Fish can be divided into those with a bony skeleton (teleosts) and those with a cartilaginous skeleton (elasmobranchs), and therefore radiology may only be useful in some cases. Radiology can also identify air in the cervical oesophagus indicating a radiolucent foreign body lying distally.
Globus Pharyngeus
This is not a true dysphagia. It is a condition with classic symptoms of an intermittent sensation of a lump in the throat. This is perceived to be in the midline at the level of the cricoid cartilage and is worse when swallowing saliva; indeed it often disappears when ingesting food or liquids. ENT examination is usually clear and normal laryngeal mobility can be felt when gently rocking the larynx across the postcricoid tissues. A contrast swallow will show not only the structures below the pharynx but also assess the swallowing dynamically. Any suspicious area will require an endoscopy with biopsy.
Causes and Remedies of Hoarseness of voice (Dysphonia)
There are three essential components for voice production: an air source (the lungs); a vibratory source (the vocal cords); and a resonating chamber (the pharynx, the nasal and oral cavities). Although chest and nasal disorders can affect the voice, the majority of hoarseness is due to laryngeal pathology.
Inflammation which increases the 'mass' of the vocal cords will cause the vocal cord frequency to fall, giving a much deeper voice. Thus listening to a patient's voice can often give a diagnosis before the vocal cords are examined.
Vocal Nodules
Nodules (always bilateral and commoner in females) and polyps are found on the free edge of the vocal cord preventing full closure and giving a 'breathy, harsh' voice. They are commonly found in professions that rely on their voice for their livelihood, such as teachers, singers and lawyers. They are usually related to poor technique of voice production and can usually be cured with speech therapy. If surgery is needed, great care must be taken to remain in the superficial layers of the vocal cord in order to prevent deep scarring which may leave the voice permanently hoarse.
Reinke's oedema
This is due to a collection of tissue fluid in the sub epithelial layer of the vocal cord. The vocal cord has poor lymphatic drainage, predisposing it to edema. Reinke's edema is associated with irritation of the vocal cords as in smoking, voice abuse, acid reflux and vary rarely hypothyroidism.
Treatment is to remove the irritation in most cases but surgery to thin the cords will also allow the voice to return to its normal pitch.
Acute-onset hoarseness
This, in a smoker is a danger sign. Any patient with a hoarse voice for over 6 weeks should be seen by an ENT surgeon. The voice may be deep, harsh and breathy indicating a mass on the vocal cord or can be weak suggesting a paralyzed left vocal cord secondary to mediastinal disease, e.g. bronchial carcinoma.
Early squamous cell carcinoma of the larynx has a good prognosis. Treatment is with carbon dioxide resection or radiotherapy. Spread of the tumor can lead to referred otalgia (Ear pain) which may then require a laryngectomy with possible neck dissection. A patient with a paralyzed left vocal cord must have a chest X-ray. Medialization of the paralysed cord to allow contact with the opposite cord can return the voice and give a competent larynx. This can be done under local anesthesia, giving an immediate result whatever the long-term prognosis of the chest pathology.
Inflammation which increases the 'mass' of the vocal cords will cause the vocal cord frequency to fall, giving a much deeper voice. Thus listening to a patient's voice can often give a diagnosis before the vocal cords are examined.
Vocal Nodules
Nodules (always bilateral and commoner in females) and polyps are found on the free edge of the vocal cord preventing full closure and giving a 'breathy, harsh' voice. They are commonly found in professions that rely on their voice for their livelihood, such as teachers, singers and lawyers. They are usually related to poor technique of voice production and can usually be cured with speech therapy. If surgery is needed, great care must be taken to remain in the superficial layers of the vocal cord in order to prevent deep scarring which may leave the voice permanently hoarse.
Reinke's oedema
This is due to a collection of tissue fluid in the sub epithelial layer of the vocal cord. The vocal cord has poor lymphatic drainage, predisposing it to edema. Reinke's edema is associated with irritation of the vocal cords as in smoking, voice abuse, acid reflux and vary rarely hypothyroidism.
Treatment is to remove the irritation in most cases but surgery to thin the cords will also allow the voice to return to its normal pitch.
Acute-onset hoarseness
This, in a smoker is a danger sign. Any patient with a hoarse voice for over 6 weeks should be seen by an ENT surgeon. The voice may be deep, harsh and breathy indicating a mass on the vocal cord or can be weak suggesting a paralyzed left vocal cord secondary to mediastinal disease, e.g. bronchial carcinoma.
Early squamous cell carcinoma of the larynx has a good prognosis. Treatment is with carbon dioxide resection or radiotherapy. Spread of the tumor can lead to referred otalgia (Ear pain) which may then require a laryngectomy with possible neck dissection. A patient with a paralyzed left vocal cord must have a chest X-ray. Medialization of the paralysed cord to allow contact with the opposite cord can return the voice and give a competent larynx. This can be done under local anesthesia, giving an immediate result whatever the long-term prognosis of the chest pathology.
Sinusitis - A very common problem
What is sinusitis and what are the symptoms?
Sinusitis is an infection of the paranasal sinuses that may be bacterial (mainly Streptococcus pneumoniae an Haemophilus influenzae) or occasionally fungal. It is most commonly associated with an upper respiratory tract infection and can occur with severe asthma. Symptoms
include frontal headache, purulent rhinorrhoea (nasal discharge), facial pain with tenderness and fever. It can be confused with a variety of other conditions such as migraine, trigeminal neuralgia, and cranial arteritis.
Treatment of sinusitis
Treatment for a bacterial sinusitis includes nasal decongestants, e.g. xylomethazoline, broad-spectrum antibiotics, e.g. co-amoxiclav (Augmentin) because H. influenzae can be resistant to amoxicillin, anti-inflammatory therapy with topical corticosteroids such as fluticasone propionate nasal spray to reduce mucosal swelling, and steam inhalations.
If the symptoms of sinusitis are recurrent or, complications such as orbital cellulitis arise, then an ENT opinion is appropriate and a CT scan of the paranasal sinuses is undertaken. Plain sinus X-rays are now rarely used to image the sinuses.
CT scan of the sinuses or an MRI scan can demonstrate soft tissue planes.
Functional endoscopic sinus surgery (FESS) is used for ventilation and drainage of the sinuses.
Sinusitis is an infection of the paranasal sinuses that may be bacterial (mainly Streptococcus pneumoniae an Haemophilus influenzae) or occasionally fungal. It is most commonly associated with an upper respiratory tract infection and can occur with severe asthma. Symptoms
include frontal headache, purulent rhinorrhoea (nasal discharge), facial pain with tenderness and fever. It can be confused with a variety of other conditions such as migraine, trigeminal neuralgia, and cranial arteritis.
Treatment of sinusitis
Treatment for a bacterial sinusitis includes nasal decongestants, e.g. xylomethazoline, broad-spectrum antibiotics, e.g. co-amoxiclav (Augmentin) because H. influenzae can be resistant to amoxicillin, anti-inflammatory therapy with topical corticosteroids such as fluticasone propionate nasal spray to reduce mucosal swelling, and steam inhalations.
If the symptoms of sinusitis are recurrent or, complications such as orbital cellulitis arise, then an ENT opinion is appropriate and a CT scan of the paranasal sinuses is undertaken. Plain sinus X-rays are now rarely used to image the sinuses.
CT scan of the sinuses or an MRI scan can demonstrate soft tissue planes.
Functional endoscopic sinus surgery (FESS) is used for ventilation and drainage of the sinuses.
Unstable diabetes with repeated fall of blood sugar (Hypoglycemia)
This term is used to describe patients with recurrent ketoacidosis and/or recurrent hypoglycaemic coma. Of these, the largest group is made up of those who experience recurrent severe hypoglycaemia.
Recurrent severe hypoglycaemia
This affects 1-3% of insulin-dependent patients. Most are adults who have had diabetes for more than 10 years. By this stage, endogenous insulin secretion is negligible in the great majority of patients. Pancreatic alpha -cells are still present in undiminished numbers, but the glucagon response (Opposite action of insulin) to hypoglycaemia is virtually absent. Long term patients are thus subject to fluctuating hyperinsulinaemia owing to erratic absorption of insulin from injection sites, and lack a major component of the hormonal defense against hypoglycaemia. In this situation adrenaline (epinephrine) secretion becomes vital, but this too may become impaired in the course of diabetes. Loss of adrenaline (epinephrine) secretion has been attributed to autonomic neuropathy, but this is unlikely to be the sole cause; central adaptation to recurrent hypoglycaemia may also be a factor.
The following factors may also predispose to recurrent hypoglycaemia:
Overtreatment with insulin. Frequent biochemical hypoglycaemia lowers the glucose level at which symptoms develop. Symptoms often reappear when overall
glucose control is relaxed.
An unrecognized low renal threshold for glucose. Attempts to render the urine sugar -free will inevitably produce hypoglycaemia.
Excessive insulin doses. A common error is to increase the dose when a patient needs more frequent injections to overcome a problem of timing.
Endocrine causes. These include pituitary insufficiency, adrenal insufficiency and premenstrual insulin sensitivity.
Alimentary causes. These include exocrine pancreatic failure and diabetic gastroparesis.
Renal failure. Clearance of insulin is diminished.
Patient causes. Patient s may be unintelligent, uncooperative or may manipulate their therapy.
Recurrent severe hypoglycaemia
This affects 1-3% of insulin-dependent patients. Most are adults who have had diabetes for more than 10 years. By this stage, endogenous insulin secretion is negligible in the great majority of patients. Pancreatic alpha -cells are still present in undiminished numbers, but the glucagon response (Opposite action of insulin) to hypoglycaemia is virtually absent. Long term patients are thus subject to fluctuating hyperinsulinaemia owing to erratic absorption of insulin from injection sites, and lack a major component of the hormonal defense against hypoglycaemia. In this situation adrenaline (epinephrine) secretion becomes vital, but this too may become impaired in the course of diabetes. Loss of adrenaline (epinephrine) secretion has been attributed to autonomic neuropathy, but this is unlikely to be the sole cause; central adaptation to recurrent hypoglycaemia may also be a factor.
The following factors may also predispose to recurrent hypoglycaemia:
Overtreatment with insulin. Frequent biochemical hypoglycaemia lowers the glucose level at which symptoms develop. Symptoms often reappear when overall
glucose control is relaxed.
An unrecognized low renal threshold for glucose. Attempts to render the urine sugar -free will inevitably produce hypoglycaemia.
Excessive insulin doses. A common error is to increase the dose when a patient needs more frequent injections to overcome a problem of timing.
Endocrine causes. These include pituitary insufficiency, adrenal insufficiency and premenstrual insulin sensitivity.
Alimentary causes. These include exocrine pancreatic failure and diabetic gastroparesis.
Renal failure. Clearance of insulin is diminished.
Patient causes. Patient s may be unintelligent, uncooperative or may manipulate their therapy.
Pregnancy and Diabetes
Meticulous metabolic control of the diabetes and careful medical and obstetric management is required.
Gestational diabetes
This term refers to glucose intolerance that develops in the course of pregnancy and usually remits following delivery. The condition is typically asymptomatic. Women who have a previous history of gestational diabetes, older or overweight women, those with a history of large for gestational age babies and women from certain ethnic groups are at particular risk, but many cases occur in women who are not in any of these categories. For this reason some advocate screening of all pregnant women on the basis of random plasma glucose testing in each trimester and by oral glucose tolerance testing if the glucose concentration is, for example, 7 mmol/L or more. There is no consensus concerning the level of blood glucose which is harmful for the baby, and therefore no consensus concerning cut- off levels for screening and intervention.
Treatment is with diet in the first instance, but most patients require insulin cover during the pregnancy. Insulin does not cross the placenta. Many oral agents cross the placenta and are usually avoided because of the potential risk to the fetus.
Gestational diabetes has been associated with all the obstetric and neonatal problems described above for pre existing diabetes, except that there is no increase in the rate of congenital abnormalities. It is likely to recur in subsequent pregnancies. Gestational diabetes is often the harbinger of type 2 diabetes in later life. Not all diabetes presenting in pregnancy is gestational. True type 1 diabetes may develop, and swift diagnosis is essential to prevent the development of ketoacidosis. Hospital admission is required if the patient is symptomatic, or has ketonuria or a markedly elevated blood glucose level
Treatment of diabetes in pregnancy
The patient should perform daily home blood glucose profiles, recording blood tests before and 2 hours after meals. The renal threshold falls in pregnancy, and urine tests are therefore of little or no value. Insulin requirements rise progressively, and intensified insulin regimens are generally used. The aim is to maintain blood glucose and fructosamine (or HbA1c) levels as close to the normal
range as can be tolerated.
The patient is seen at intervals of 2 weeks or less at a clinic managed jointly by physician and obstetrician. Circum stances permitting, the aim should be outpatient management with a spontaneous vaginal delivery at term.
Retinopathy and nephropathy may deteriorate during pregnancy. Expert fundoscopy and urine testing for protein should be undertaken at booking, at 28 weeks and before delivery.
Obstetric problems associated with diabetes
Poorly controlled diabetes is associated with stillbirth, mechanical problems in the birth canal owing to fetal macrosomia (large baby), hydramnios (Excess water) and pre-eclampsia. Ketoacidosis in pregnancy carries a 50% fetal mortality, but maternal hypoglycaemia is relatively well tolerated.
Neonatal problems (Problems of new born) associated with diabetes
Maternal diabetes, especially when poorly controlled, is associated with fetal macrosomia. The infant of a diabetic mother is more susceptible to hyaline membrane disease (Respiratory distress following delivery) than non-diabetic infants of similar maturity. In addition, neonatal hypoglycaemia (Low blood sugar) may occur. The mechanism is as follows: maternal glucose crosses the placenta, but insulin does not; the fetal islets hyper secrete insulin to combat maternal hyperglycaemia, and a rebound to hypoglycaemic levels occurs when the umbilical cord is severed. These complications are due to hyperglycaemia in the third trimester. Poor glycaemic control around the time of conception carries an increased risk of major congenital malformations. When a pregnancy is planned, optimal metabolic control should be sought before conception.
Gestational diabetes
This term refers to glucose intolerance that develops in the course of pregnancy and usually remits following delivery. The condition is typically asymptomatic. Women who have a previous history of gestational diabetes, older or overweight women, those with a history of large for gestational age babies and women from certain ethnic groups are at particular risk, but many cases occur in women who are not in any of these categories. For this reason some advocate screening of all pregnant women on the basis of random plasma glucose testing in each trimester and by oral glucose tolerance testing if the glucose concentration is, for example, 7 mmol/L or more. There is no consensus concerning the level of blood glucose which is harmful for the baby, and therefore no consensus concerning cut- off levels for screening and intervention.
Treatment is with diet in the first instance, but most patients require insulin cover during the pregnancy. Insulin does not cross the placenta. Many oral agents cross the placenta and are usually avoided because of the potential risk to the fetus.
Gestational diabetes has been associated with all the obstetric and neonatal problems described above for pre existing diabetes, except that there is no increase in the rate of congenital abnormalities. It is likely to recur in subsequent pregnancies. Gestational diabetes is often the harbinger of type 2 diabetes in later life. Not all diabetes presenting in pregnancy is gestational. True type 1 diabetes may develop, and swift diagnosis is essential to prevent the development of ketoacidosis. Hospital admission is required if the patient is symptomatic, or has ketonuria or a markedly elevated blood glucose level
Treatment of diabetes in pregnancy
The patient should perform daily home blood glucose profiles, recording blood tests before and 2 hours after meals. The renal threshold falls in pregnancy, and urine tests are therefore of little or no value. Insulin requirements rise progressively, and intensified insulin regimens are generally used. The aim is to maintain blood glucose and fructosamine (or HbA1c) levels as close to the normal
range as can be tolerated.
The patient is seen at intervals of 2 weeks or less at a clinic managed jointly by physician and obstetrician. Circum stances permitting, the aim should be outpatient management with a spontaneous vaginal delivery at term.
Retinopathy and nephropathy may deteriorate during pregnancy. Expert fundoscopy and urine testing for protein should be undertaken at booking, at 28 weeks and before delivery.
Obstetric problems associated with diabetes
Poorly controlled diabetes is associated with stillbirth, mechanical problems in the birth canal owing to fetal macrosomia (large baby), hydramnios (Excess water) and pre-eclampsia. Ketoacidosis in pregnancy carries a 50% fetal mortality, but maternal hypoglycaemia is relatively well tolerated.
Neonatal problems (Problems of new born) associated with diabetes
Maternal diabetes, especially when poorly controlled, is associated with fetal macrosomia. The infant of a diabetic mother is more susceptible to hyaline membrane disease (Respiratory distress following delivery) than non-diabetic infants of similar maturity. In addition, neonatal hypoglycaemia (Low blood sugar) may occur. The mechanism is as follows: maternal glucose crosses the placenta, but insulin does not; the fetal islets hyper secrete insulin to combat maternal hyperglycaemia, and a rebound to hypoglycaemic levels occurs when the umbilical cord is severed. These complications are due to hyperglycaemia in the third trimester. Poor glycaemic control around the time of conception carries an increased risk of major congenital malformations. When a pregnancy is planned, optimal metabolic control should be sought before conception.
Wednesday, March 25, 2009
Pain and Tingling in the Hand? It can be Carpal Tunnel Syndrome.
Carpal Tunnel Syndrome
This is a kind of entrapment neuropathy, carpal tunnel syndrome is a painful condition caused by pressure on the median nerve stuck between the carpal ligament and other structures inside the carpal tunnel. The contents of the tunnel can be swelled up by organic lesions such as synovitis of the tendon sheaths or carpal joints, recent or not properly healed fractures, tumors, and rarely congenital anomalies. Though there is no structural lesion is evident, flattening or even circumferential compression of the median nerve may be seen during operative section of the ligament. This condition sometimes complicate pregnancy and is found in peoples with a history of recurring use of the hands like knitting sweaters, and may also occur after injuries of the wrists. In certain familial type of carpal tunnel syndrome no etiologic factor can be found.
Symptoms and Signs of Carpal Tunnel Syndrome
Pain, burning, and tingling along the course of the median nerve, which is on the palmer aspect involving thumb, index and half of the middle finger usually the symptoms to start with. Aching pain may spread out to the forearm and even sometimes to the shoulder and over the neck and chest. Pain is often increased by manual exercise, particularly by extreme folding of the wrist in either side. It is most niggling at night. Diminished sensation along the median nerve route may or may not be apparent. Slight inequality between the affected and healthy sides can be demonstrated by asking patient to feel different textures of cloth by thumb and index finger on either side and they can then tell the different feel in two hands. Tinel's sign is tingling or shock-like pain on tapping of the ventral aspect of the wrist. The carpal compression test, where lack of feeling and tingling are produced by the application of direct pressure over the carpal tunnel. Weakness and atrophy of the muscle, particularly of the thenar eminence (adjacent to the thumb on palm), appears late and usually follows sensory disturbances. Electromyography and nerve conduction tests can show precisely the affection of the nerves.
Conditions May Mimic Carpal Tunnel Syndrome
Carpal tunnel syndrome has similarity with other cervicobrachial pain syndromes, from compression syndromes of the median nerve in the forearm or arm, and from mononeuritis multiplex and must be differentiated from these prior to start of specific treatment. When on the left side, it may sometimes be confused with angina pectoris.
Treatment of Carpal Tunnel Syndrome
Treatment of this condition is to release the compression on the median nerve. When a causative factor is found, that is treated. In others, where cause of carpal tunnel syndrome is suspected due to repetitive hand works, should alter their hand actions and their affected wrist is splinted for 2 to 6 weeks. NSAIDs is also prescribed to relieve pain. Corticosteroid injection into the carpal tunnel or operation is required in case of non improvement and when there is thenar muscle atrophy or weakness. Muscle strength is regained following the treatment, but complete recovery may not be possible when there is extreme atrophy.
This is a kind of entrapment neuropathy, carpal tunnel syndrome is a painful condition caused by pressure on the median nerve stuck between the carpal ligament and other structures inside the carpal tunnel. The contents of the tunnel can be swelled up by organic lesions such as synovitis of the tendon sheaths or carpal joints, recent or not properly healed fractures, tumors, and rarely congenital anomalies. Though there is no structural lesion is evident, flattening or even circumferential compression of the median nerve may be seen during operative section of the ligament. This condition sometimes complicate pregnancy and is found in peoples with a history of recurring use of the hands like knitting sweaters, and may also occur after injuries of the wrists. In certain familial type of carpal tunnel syndrome no etiologic factor can be found.
Symptoms and Signs of Carpal Tunnel Syndrome
Pain, burning, and tingling along the course of the median nerve, which is on the palmer aspect involving thumb, index and half of the middle finger usually the symptoms to start with. Aching pain may spread out to the forearm and even sometimes to the shoulder and over the neck and chest. Pain is often increased by manual exercise, particularly by extreme folding of the wrist in either side. It is most niggling at night. Diminished sensation along the median nerve route may or may not be apparent. Slight inequality between the affected and healthy sides can be demonstrated by asking patient to feel different textures of cloth by thumb and index finger on either side and they can then tell the different feel in two hands. Tinel's sign is tingling or shock-like pain on tapping of the ventral aspect of the wrist. The carpal compression test, where lack of feeling and tingling are produced by the application of direct pressure over the carpal tunnel. Weakness and atrophy of the muscle, particularly of the thenar eminence (adjacent to the thumb on palm), appears late and usually follows sensory disturbances. Electromyography and nerve conduction tests can show precisely the affection of the nerves.
Conditions May Mimic Carpal Tunnel Syndrome
Carpal tunnel syndrome has similarity with other cervicobrachial pain syndromes, from compression syndromes of the median nerve in the forearm or arm, and from mononeuritis multiplex and must be differentiated from these prior to start of specific treatment. When on the left side, it may sometimes be confused with angina pectoris.
Treatment of Carpal Tunnel Syndrome
Treatment of this condition is to release the compression on the median nerve. When a causative factor is found, that is treated. In others, where cause of carpal tunnel syndrome is suspected due to repetitive hand works, should alter their hand actions and their affected wrist is splinted for 2 to 6 weeks. NSAIDs is also prescribed to relieve pain. Corticosteroid injection into the carpal tunnel or operation is required in case of non improvement and when there is thenar muscle atrophy or weakness. Muscle strength is regained following the treatment, but complete recovery may not be possible when there is extreme atrophy.
Saturday, March 21, 2009
Special and sophisticated investigations required for the infertile couple:
Once the initial tests have been completed, the doctor usually has a good idea of what may be causing a couple to be infertile. She or he may suggest extra tests to confirm the diagnosis. Alternatively, all tests may be normal, and additional tests may be done to find a cause.
Cultures for Infection
Cultures can identify the type of organism causing an infection. Some of the organisms that may cause infection include Chlamydia, Gonorrhea, Urea-plasma, and Mycoplasma, as well as the organism that causes tuberculosis. Knowing the cause of infection is the first step toward proper treatment.
If there are signs of infection in the cervical mucus tests, cervicitis (inflammation of the cervix) may be interfering with the production of mucus. Cultures may be done to find out what type of infection, if any, is present. Cultures also may be done if an endometrial biopsy suggests endometritis. In men, cultures of the semen are sometimes done as well.
Hysteroscopy
With hysteroscopy, the doctor uses a thin, lighted telescope like tube to examine the inside of the uterus. After the scope is passed through the cervical opening, the doctor inspects the uterus, its lining, and the opening of the tubes into the uterus. Because the procedure allows viewing the uterus itself, and not just an image of it, it can confirm other tests such as hysterosalpingography. Surgical correction like removal of polyps, opening of flimsy adhesion in the opening of the fallopian tubes, or any adhesion in the cavity can be done through hysteroscope.
Imaging Techniques
When the doctor suspects a blockage in the man's reproductive system, imaging techniques such as ultrasound or special X-rays may be used. Ultrasound uses high frequency sound waves to form clear images of the reproductive tract. In a woman, ultrasound also can monitor follicle development to see if ovaries are producing eggs ready for ripening and fertilization. Using a series of ultrasound scans a few days apart, experts have even found that up to 30 percent of women with previously undetermined infertility produce eggs that ripen but never release from the ovaries. Ultrasound can show how thick or receptive the uterine lining is at mid cycle. Pelvic abnormalities or adhesions can be detected as well.
Sperm Antibody Testing
If the doctor suspects an immunological cause for the infertility or, if no cause has been found, then sperm antibody testing may be done. In this test, the semen and sperm are mixed with special substances, such as beads coated with an antibody. The sperm are then checked to see if they bind to the beads.
Sperm Penetration Tests
If the ability of the sperm to fertilize an egg needs to be examined, sperm penetration tests may be done. In these tests, sperm are mixed with specially treated hamster eggs to measure how often penetration of the eggs occurs. (The difference between humans and hamsters is so great that nothing grows from the pen¬etrated egg.) Similar tests can be done with human eggs.
Cultures for Infection
Cultures can identify the type of organism causing an infection. Some of the organisms that may cause infection include Chlamydia, Gonorrhea, Urea-plasma, and Mycoplasma, as well as the organism that causes tuberculosis. Knowing the cause of infection is the first step toward proper treatment.
If there are signs of infection in the cervical mucus tests, cervicitis (inflammation of the cervix) may be interfering with the production of mucus. Cultures may be done to find out what type of infection, if any, is present. Cultures also may be done if an endometrial biopsy suggests endometritis. In men, cultures of the semen are sometimes done as well.
Hysteroscopy
With hysteroscopy, the doctor uses a thin, lighted telescope like tube to examine the inside of the uterus. After the scope is passed through the cervical opening, the doctor inspects the uterus, its lining, and the opening of the tubes into the uterus. Because the procedure allows viewing the uterus itself, and not just an image of it, it can confirm other tests such as hysterosalpingography. Surgical correction like removal of polyps, opening of flimsy adhesion in the opening of the fallopian tubes, or any adhesion in the cavity can be done through hysteroscope.
Imaging Techniques
When the doctor suspects a blockage in the man's reproductive system, imaging techniques such as ultrasound or special X-rays may be used. Ultrasound uses high frequency sound waves to form clear images of the reproductive tract. In a woman, ultrasound also can monitor follicle development to see if ovaries are producing eggs ready for ripening and fertilization. Using a series of ultrasound scans a few days apart, experts have even found that up to 30 percent of women with previously undetermined infertility produce eggs that ripen but never release from the ovaries. Ultrasound can show how thick or receptive the uterine lining is at mid cycle. Pelvic abnormalities or adhesions can be detected as well.
Sperm Antibody Testing
If the doctor suspects an immunological cause for the infertility or, if no cause has been found, then sperm antibody testing may be done. In this test, the semen and sperm are mixed with special substances, such as beads coated with an antibody. The sperm are then checked to see if they bind to the beads.
Sperm Penetration Tests
If the ability of the sperm to fertilize an egg needs to be examined, sperm penetration tests may be done. In these tests, sperm are mixed with specially treated hamster eggs to measure how often penetration of the eggs occurs. (The difference between humans and hamsters is so great that nothing grows from the pen¬etrated egg.) Similar tests can be done with human eggs.
First Line of investigations done on infertile couple
Basal Body Temperature
Developed in the 1930s, the basal body temperature (BBT) test is based on the fact that a woman's body temperature rises with ovulation. Most women have lower readings in the beginning of their menstrual cycles, before ovulation. Then, there is a small rise of 0.5-1 °F just after ovulation. Because this test measures a change that occurs after ovulation, it cannot help predict when ovulation will occur in a given cycle. However, looking at the results for the past few cycles can show a pattern. Ovulation can be anticipated from this pattern.
For this test, a woman should measure her body temperature each morning while she is still in bed and before eating, drinking, smoking, or going to the bathroom. The temperature may be taken with an ordinary thermometer or with a special one designed for this purpose. If you aren't comfortable reading a mercury-based thermometer, buy one of the varieties that offers an instant digital readout. Whichever you choose, however, be prepared to use the same one each day.
Record the temperature carefully. You may find that it helps to keep track on a chart. Your doctor's office may be able to provide one for you. Because a lack of sleep, drinking alcohol, a fever, or any illness or emotional upset can affect your temperature, mark these changes on your chart, too.
Although keeping a BBT chart may prove to be boring or a nuisance but it can provide valuable information. Record your results each day and bring your chart with you for every visit. Not only can it help your doctor determine when or if you are ovulating but a BBT chart also can suggest hormonal problems interfering with conception.
Blood Tests
Blood tests may be done for both partners. Often the purpose is to measure the levels of hormones that play a role in fertility. These tests may be done at the beginning, middle, and end of the menstrual cycle. Some of the wide varieties of hormones that may be tested include:
FSH (follicle-stimulating hormone)
LH (luteinizing hormone)
Prolactin
Progesterone
Testosterone
Thyroid-stimulating hormone
Blood tests also can detect the presence of antibodies to sperm.
Hysterosalpingography
Hysterosalpingography (HSG) is a series of X rays performed to see a woman's reproductive organs. A technician injects a radio opaque dye into the cervix. This dye fills up the uterus and travels up into the fallopian tubes. On an X ray, it reveals any scarring or blocking. Done on an outpatient basis, a HSG helps the doctor find blockages in your tubes and any abnormalities in the uterus such as polyps (small growths in the uterus) or fibroids. Conditions detected by HSG are often confirmed by hysteroscopy, a procedure that allows the doctor to look directly inside the uterus and perform surgical corrections if required.
Laparoscopy
In laparoscopy, a thin, lighted tube (like a telescope) is inserted into a small cut in the abdomen. By look¬ing through the scope, the doctor can inspect the ovaries, tubes, and the outside of the uterus. Laparoscopy can check for endometriosis, blockages in the tubes, and adhesions. Operative procedure if required, can be done in the same sitting.
Post coital Test
The post coital test often is performed along with cervical mucus tests. It is done soon after intercourse, around the time of ovulation. The doctor examines the mucus and checks the number of active sperm cells in the vagina, cervix, and uterine cavity. If the cervical mucus is inhibiting healthy sperm, this will be clear from the test. Tests 2-8 hours after inter¬course can show how well the sperm get through the mucus. Later tests, 12-18 hours after intercourse, can again check how well the sperm survive.
Cervical Mucus Tests
Your doctor will examine the cervical mucus when you are most likely to be fertile, around ovulation. At that time, mucus is abundant, clear, glistening, and slippery. The doctor measures how far the mucus stretches. Mucus that stretches a lot is better for fertilization than mucus that is not stretchy. At other times during the menstrual cycle the cervical mucus is less hospitable to sperm. It is thick and cloudy and does not stretch so easily.
Endometrial Biopsy
In an endometrial biopsy, a small piece of tissue is taken from the lining of your uterus and studied for evidence of ovulation. This biopsy is performed during the last phase of your cycle, 10-12 days after the LH surge (around days 21-26). The result of an endometrial biopsy is usually compared with the BBT and a blood test for progesterone.
By testing the thickness of the uterine lining, the endometrial biopsy shows whether enough proges¬terone is present. If there isn't enough progesterone, this may be called a luteal phase defect. Even though it is linked to infertility and miscarriage, this defect is poorly understood. It can be treated with ovulation drugs or progesterone. For study of ovulation this test is rarely done nowadays as ovulation can be seen perfectly by USG. This is mostly done nowadays to rule out tuberculosis of the endometrium and if dating of endometrium becomes necessary.
Semen Analysis
Semen analysis determines the concentration, normal movement or motility, and percentage of normal sperm cells in semen. Usually, a sample of sperm is collected through masturbation at the lab. Men opposed to masturbation or who cannot perform on demand can use special collection pouches during sex. A sample not produced at the lab should be brought in within 1 hour. The sperm count is conducted by examining the sample under a microscope. The shape of the sperm is another important factor. Most experts believe that abnormally shaped sperm can't fertilize an egg. How well the sperm move also is studied. Keep in mind that sperm production is not always the same, even in the same man. Probably the doctor will want to do the semen analysis at least three times over a 2- to 4-week period. The only exception to this might be if a man has a zero sperm count. When this happens, the doctor could halt the analysis after two tests, instead of prolonging the process.
After the initial investigations if nothing found abnormal, then more sophisticated investigations become necessary.
Developed in the 1930s, the basal body temperature (BBT) test is based on the fact that a woman's body temperature rises with ovulation. Most women have lower readings in the beginning of their menstrual cycles, before ovulation. Then, there is a small rise of 0.5-1 °F just after ovulation. Because this test measures a change that occurs after ovulation, it cannot help predict when ovulation will occur in a given cycle. However, looking at the results for the past few cycles can show a pattern. Ovulation can be anticipated from this pattern.
For this test, a woman should measure her body temperature each morning while she is still in bed and before eating, drinking, smoking, or going to the bathroom. The temperature may be taken with an ordinary thermometer or with a special one designed for this purpose. If you aren't comfortable reading a mercury-based thermometer, buy one of the varieties that offers an instant digital readout. Whichever you choose, however, be prepared to use the same one each day.
Record the temperature carefully. You may find that it helps to keep track on a chart. Your doctor's office may be able to provide one for you. Because a lack of sleep, drinking alcohol, a fever, or any illness or emotional upset can affect your temperature, mark these changes on your chart, too.
Although keeping a BBT chart may prove to be boring or a nuisance but it can provide valuable information. Record your results each day and bring your chart with you for every visit. Not only can it help your doctor determine when or if you are ovulating but a BBT chart also can suggest hormonal problems interfering with conception.
Blood Tests
Blood tests may be done for both partners. Often the purpose is to measure the levels of hormones that play a role in fertility. These tests may be done at the beginning, middle, and end of the menstrual cycle. Some of the wide varieties of hormones that may be tested include:
FSH (follicle-stimulating hormone)
LH (luteinizing hormone)
Prolactin
Progesterone
Testosterone
Thyroid-stimulating hormone
Blood tests also can detect the presence of antibodies to sperm.
Hysterosalpingography
Hysterosalpingography (HSG) is a series of X rays performed to see a woman's reproductive organs. A technician injects a radio opaque dye into the cervix. This dye fills up the uterus and travels up into the fallopian tubes. On an X ray, it reveals any scarring or blocking. Done on an outpatient basis, a HSG helps the doctor find blockages in your tubes and any abnormalities in the uterus such as polyps (small growths in the uterus) or fibroids. Conditions detected by HSG are often confirmed by hysteroscopy, a procedure that allows the doctor to look directly inside the uterus and perform surgical corrections if required.
Laparoscopy
In laparoscopy, a thin, lighted tube (like a telescope) is inserted into a small cut in the abdomen. By look¬ing through the scope, the doctor can inspect the ovaries, tubes, and the outside of the uterus. Laparoscopy can check for endometriosis, blockages in the tubes, and adhesions. Operative procedure if required, can be done in the same sitting.
Post coital Test
The post coital test often is performed along with cervical mucus tests. It is done soon after intercourse, around the time of ovulation. The doctor examines the mucus and checks the number of active sperm cells in the vagina, cervix, and uterine cavity. If the cervical mucus is inhibiting healthy sperm, this will be clear from the test. Tests 2-8 hours after inter¬course can show how well the sperm get through the mucus. Later tests, 12-18 hours after intercourse, can again check how well the sperm survive.
Cervical Mucus Tests
Your doctor will examine the cervical mucus when you are most likely to be fertile, around ovulation. At that time, mucus is abundant, clear, glistening, and slippery. The doctor measures how far the mucus stretches. Mucus that stretches a lot is better for fertilization than mucus that is not stretchy. At other times during the menstrual cycle the cervical mucus is less hospitable to sperm. It is thick and cloudy and does not stretch so easily.
Endometrial Biopsy
In an endometrial biopsy, a small piece of tissue is taken from the lining of your uterus and studied for evidence of ovulation. This biopsy is performed during the last phase of your cycle, 10-12 days after the LH surge (around days 21-26). The result of an endometrial biopsy is usually compared with the BBT and a blood test for progesterone.
By testing the thickness of the uterine lining, the endometrial biopsy shows whether enough proges¬terone is present. If there isn't enough progesterone, this may be called a luteal phase defect. Even though it is linked to infertility and miscarriage, this defect is poorly understood. It can be treated with ovulation drugs or progesterone. For study of ovulation this test is rarely done nowadays as ovulation can be seen perfectly by USG. This is mostly done nowadays to rule out tuberculosis of the endometrium and if dating of endometrium becomes necessary.
Semen Analysis
Semen analysis determines the concentration, normal movement or motility, and percentage of normal sperm cells in semen. Usually, a sample of sperm is collected through masturbation at the lab. Men opposed to masturbation or who cannot perform on demand can use special collection pouches during sex. A sample not produced at the lab should be brought in within 1 hour. The sperm count is conducted by examining the sample under a microscope. The shape of the sperm is another important factor. Most experts believe that abnormally shaped sperm can't fertilize an egg. How well the sperm move also is studied. Keep in mind that sperm production is not always the same, even in the same man. Probably the doctor will want to do the semen analysis at least three times over a 2- to 4-week period. The only exception to this might be if a man has a zero sperm count. When this happens, the doctor could halt the analysis after two tests, instead of prolonging the process.
After the initial investigations if nothing found abnormal, then more sophisticated investigations become necessary.
Thursday, March 19, 2009
Procedure expected on initial visit to an infertility clinic
Before any therapy begins, a doctor conducts a complete investigation of both partners; therefore, both must be present at the first visit. It is essential that both be committed in any quest for conception and willing to support each other through the emotional ups and downs of therapy.
The basic workup for infertility involves four areas:
1. Semen analysis
2. Evaluation of ovulation
3. Post coital test
4. Evaluation of tubes
A detailed medical and sexual history are taken, and various tests and procedures performed to check each area. Even if a difficulty is found in one area, the whole workup is completed in the event other problems need to be considered. If a man produces few sperm, for instance, it would not be helpful to try artificial insemination when his partner has blocked tubes.
What will be the questions to both of you at an infertility clinic on first visit:
At the initial visit for infertility, the doctor takes a thorough family and personal medical history.
Typically the following information you have to provide:
#Nature of jobs of both the partners e.g, night shifts, stress, humid working conditions, prolonged traveling etc.
#Length and regularity of menstrual cycle
#Any unusual pain or cramping, vaginal discharge, or bleeding
#Previous marriages or pregnancies
#Contraception used
#Sexual habits (frequency, technique, use of lubricants during sex)
#General health (any operations, infections, injuries to reproductive organs)
#Any drug or medication usage (including alcohol and tobacco)
Length of time you've been trying to get pregnant
#Birth defects in either partner or families
Don't hold back any information out of embarrassment. In fact, before you go, try to think back over your sexual, reproductive, and medical history. Even information that may seem unrelated may be helpful. For example, tuberculosis can affect the uterus as well as the lungs.
Though laboratory tests may be done at that first visit, testing often is scheduled for later. Often, tests must be precisely timed for certain days during the woman's menstrual cycle.
The basic workup for infertility involves four areas:
1. Semen analysis
2. Evaluation of ovulation
3. Post coital test
4. Evaluation of tubes
A detailed medical and sexual history are taken, and various tests and procedures performed to check each area. Even if a difficulty is found in one area, the whole workup is completed in the event other problems need to be considered. If a man produces few sperm, for instance, it would not be helpful to try artificial insemination when his partner has blocked tubes.
What will be the questions to both of you at an infertility clinic on first visit:
At the initial visit for infertility, the doctor takes a thorough family and personal medical history.
Typically the following information you have to provide:
#Nature of jobs of both the partners e.g, night shifts, stress, humid working conditions, prolonged traveling etc.
#Length and regularity of menstrual cycle
#Any unusual pain or cramping, vaginal discharge, or bleeding
#Previous marriages or pregnancies
#Contraception used
#Sexual habits (frequency, technique, use of lubricants during sex)
#General health (any operations, infections, injuries to reproductive organs)
#Any drug or medication usage (including alcohol and tobacco)
Length of time you've been trying to get pregnant
#Birth defects in either partner or families
Don't hold back any information out of embarrassment. In fact, before you go, try to think back over your sexual, reproductive, and medical history. Even information that may seem unrelated may be helpful. For example, tuberculosis can affect the uterus as well as the lungs.
Though laboratory tests may be done at that first visit, testing often is scheduled for later. Often, tests must be precisely timed for certain days during the woman's menstrual cycle.
To Do's for the Infertile Couples
In some couples, infertility may be the result of a complex medical problem. In others, it may be due to something easily correctable. These suggestions can help you create the best possible conditions for conception:
Both women and men should avoid getting sexually transmitted diseases, a cause of infertility. If either partner has symptoms of an STD, avoid having sex and see a doctor. Early treatment is important to prevent STDs from damaging the reproductive system.
You are most likely to conceive around 14 days before your next menstrual period is due to begin. If you have a 28-day cycle, this would be days 13-15 of your menstrual cycle (with day 1 being the first day of the last menstrual period). Mark the dates when pregnancy is most likely on a calendar and make time for sex without stress. There is no need for your partner to save up sperm by delaying intercourse before these times. Just try to have intercourse during the middle of your cycle.
Because sperm need to be kept cool, your partner should avoid tight clothing or underwear, long, hot baths; and especially soaks in hot tubs, whirlpools, or saunas.
During intercourse, all positions can produce pregnancy. After ejaculation, stay in bed for at least a half hour. Don't use any jellies, douches or creams because they can inhibit sperm. Some lubricants affect sperm as well.
Both you and your partner should avoid the use of any illicit (street) drugs. Some affect fertility, and others harm the fetus if conception occurs.
Stop smoking and limit your alcohol consumption, since these things may interfere with ovulation and sperm production. Some experts even suggest limiting caffeinated beverages, but less is known about the effects of caffeine.
Maintain a normal weight. Women who are either very overweight or underweight may have problems becoming pregnant.
Avoid exercising excessively, as too much exercise can interfere with ovulation.
Infertility may not be permanent. Many couples simply have reduced fertility and take longer to get pregnant.
First thing to do if failed to get pregnant:
If pregnancy has not occurred after a year of intercourse without birth control, you may wish to consult a doctor. Because fertility naturally declines with age, couples in their late thirties or forties may not want to wait this long to seek help.
Some couples are able to conceive almost immediately during the two to three months that it takes for the initial medical workup. Others need several months of diagnostic testing and treatment. About 30-40 percent of couples treated for infertility are able to conceive eventually.
Today, even the most difficult cases often can be treated successfully because of medical advances in the study and treatment of infertility during in the last 30 years. Your likelihood of getting pregnant depends on several factors: how long you've been trying to conceive, how old you are, and the exact cause of your infertility.
A variety of physicians may be able to help you find the cause of your infertility and treat it. Start with your obstetrician-gynecologist, who will perform the initial series of tests and further procedures if needed. Although men sometimes seek the assistance of urologists, some gynecologists can help them, too, as a part of treating the couple.
Some gynecologists have special interests or training in fertility issues and can coordinate most of the needed care themselves. Some have extra training in reproductive endocrinology, the study of how hormones affect fertility.
Both women and men should avoid getting sexually transmitted diseases, a cause of infertility. If either partner has symptoms of an STD, avoid having sex and see a doctor. Early treatment is important to prevent STDs from damaging the reproductive system.
You are most likely to conceive around 14 days before your next menstrual period is due to begin. If you have a 28-day cycle, this would be days 13-15 of your menstrual cycle (with day 1 being the first day of the last menstrual period). Mark the dates when pregnancy is most likely on a calendar and make time for sex without stress. There is no need for your partner to save up sperm by delaying intercourse before these times. Just try to have intercourse during the middle of your cycle.
Because sperm need to be kept cool, your partner should avoid tight clothing or underwear, long, hot baths; and especially soaks in hot tubs, whirlpools, or saunas.
During intercourse, all positions can produce pregnancy. After ejaculation, stay in bed for at least a half hour. Don't use any jellies, douches or creams because they can inhibit sperm. Some lubricants affect sperm as well.
Both you and your partner should avoid the use of any illicit (street) drugs. Some affect fertility, and others harm the fetus if conception occurs.
Stop smoking and limit your alcohol consumption, since these things may interfere with ovulation and sperm production. Some experts even suggest limiting caffeinated beverages, but less is known about the effects of caffeine.
Maintain a normal weight. Women who are either very overweight or underweight may have problems becoming pregnant.
Avoid exercising excessively, as too much exercise can interfere with ovulation.
Infertility may not be permanent. Many couples simply have reduced fertility and take longer to get pregnant.
First thing to do if failed to get pregnant:
If pregnancy has not occurred after a year of intercourse without birth control, you may wish to consult a doctor. Because fertility naturally declines with age, couples in their late thirties or forties may not want to wait this long to seek help.
Some couples are able to conceive almost immediately during the two to three months that it takes for the initial medical workup. Others need several months of diagnostic testing and treatment. About 30-40 percent of couples treated for infertility are able to conceive eventually.
Today, even the most difficult cases often can be treated successfully because of medical advances in the study and treatment of infertility during in the last 30 years. Your likelihood of getting pregnant depends on several factors: how long you've been trying to conceive, how old you are, and the exact cause of your infertility.
A variety of physicians may be able to help you find the cause of your infertility and treat it. Start with your obstetrician-gynecologist, who will perform the initial series of tests and further procedures if needed. Although men sometimes seek the assistance of urologists, some gynecologists can help them, too, as a part of treating the couple.
Some gynecologists have special interests or training in fertility issues and can coordinate most of the needed care themselves. Some have extra training in reproductive endocrinology, the study of how hormones affect fertility.
Wednesday, March 18, 2009
Female factors as a cause of infertility
Ovulation Factors as a Cause of Infertility
As women age, their ovaries and the immature eggs contained therein age as well. Unlike men who produce new sperm on a regular basis, women are born with all the eggs they'll ever have. Their eggs may become damaged from years of exposure to hazards such as chemicals or radiation.
Too little estrogen also can cause infertility. As a woman ages and nears menopause, the amount of estrogen produced drops gradually. With less estrogen, the ovaries may not produce an egg each month. The result is fewer babies as a woman ages. Another cause for low estrogen levels is too little body fat. Women who exercise too much or diet excessively— sometimes due to eating disorders—may not produce enough estrogen for ovulation to occur.
Other women with ovulatory problems have sufficient supplies of estrogen but lack other hormones, such as FSH, LH, and prolactin, that affect other aspects of the cycle.
Certain kinds of birth control continue to reduce ovulation even after they are no longer used. For example, some women who take birth control pills find that it takes them a few months to begin ovulat¬ing again once they've stopped taking the pill. After 2-3 years off the pill, however, their rates of ovulation are the same as for other women who use barrier contraception. Contraceptive implants that contain hormones offer a rapid return of fertility. On the other hand, contraceptive injections of hormones may sub¬stantially delay the return of fertility. It can take anywhere from 4 to more than 30 months for fertility to return.
Tubal and Peritoneal Factors as a cause of Infertility
Conditions affecting the fallopian tubes or the peritoneum sometimes cause infertility. The peritoneum is a strong sac that lines the inside of the abdomen. It forms a sort of bag that contains the digestive organs and runs alongside the fallopian tubes.
Scarring or blockage in the tubes may cause infertility. One of the most common causes of damaged tubes is infections. When STDs are untreated, they can worsen and move up the uterus into the tubes. This is pelvic inflammatory disease, a major cause of blocked tubes. Use of an intrauterine device increases the risk of infection, especially in young women with several sexual partners. Some researchers say that smoking cigarettes changes the lining of the fallopian tubes, inflaming them and making them less hospitable to conception.
When tubes are damaged, an ectopic pregnancy is more likely if conception occurs. In an ectopic pregnancy, the egg is fertilized as in a normal pregnancy but it does not implant in the uterus. Instead, often because the fallopian tubes are damaged, it implants in the tube or somewhere in the peritoneum and begins to grow there. Because it can burst the tube, ectopic pregnancy can be life threatening. If you have a history of pelvic infections, your chances of ectopic pregnancy are four times greater than normal.
Other problems include adhesions, in which nearby organs or tissues bind themselves together. An adhesion that causes another organ to pull on a fallopian tube may move the tube away from the ovary. This prevents the tube from catching the egg when it is released. Adhesions may be caused by infection, previous surgery on the pelvic organs, or endometriosis.
The role of endometriosis in infertility is the subject of great debate among doctors. In endometriosis, tissue like that lining the uterus moves to other places in the abdomen where it begins growing in response to hormones, just as the endometrium does. Such growth can cause pain and inflammation. Up to one-third of infertile women are found to have endometriosis. We do not know if this is just a coincidence or if the endometriosis helps cause the infertility. Severe or extensive endometriosis can cause adhesions. Severe disease is definitely thought to be linked to infertility.
Cervical and Uterine Factors as a cause of Infertility
The cervix is the narrow neck that forms the opening of the uterus to the vagina. It produces mucus that either helps or hinders the movement of sperm depending on where a woman is in her menstrual cycle. As a woman nears ovulation, mucus thins and becomes slippery and stretchy to help move the sperm through the cervix. The mucus looks much like raw egg white. If the mucus is thick or scanty instead, it is much more difficult for the sperm to move. High levels of nicotine have been found in the cervical mucus of women who smoke. Nicotine can be toxic to sperm.
Surgery on the cervix may also interfere with fertility. Some types of operations, such as conization (removing a wedge of tissue from the cervix), may result in scarring or little to no mucus production.
Other Factors of Uterus as cause of Infertility
The uterus may be affected by infections or adhesions. An infection of the lining of the uterus, endometritis, can be caused by STDs such as gonorrhea. Tuberculosis also can cause endometritis. Overgrowth of the uterine lining, called endometrial hyperplasia, or endometrial cancer can cause infertility as well.
If a woman has had the lining of her uterus scraped by D&C, or dilation and curettage after a pregnancy or for abnormal bleeding, the lining may not grow back properly. Adhesions may form, or the lining may be thin; either condition can contribute to infertility. The condition is known as Asherman’s Syndrome.
Growths in the uterus, such as fibroids, have been studied as possible causes of infertility. Although they may play a small role, if any in infertility, a doctor may remove them if no other cause for infertility is found.
An abnormally shaped uterus, such as one with a thin wall (septum) running down its middle, also known as septate uterus, can affect a woman's ability to have a child. Affected women are born with these defects that cause miscarriage (loss of the baby before it is ready to be born) rather than inability to conceive.
Antibodies against Sperm prevent Fertilization
Some women and men produce antibodies against sperm. When the immune system malfunctions, it sees the sperm as a foreign threat and produces anti¬bodies to fight them. The antibodies affect the ability of the sperm to move freely.
Unexplained Infertility
Sometimes a reason cannot be found for a couple's infertility. Even without knowing a cause, however, certain steps can be taken to increase the chance of conceiving. Some measures a couple can take them¬selves. Each month, approximately 3 percent of cou¬ples with unexplained infertility conceive on their own.
As women age, their ovaries and the immature eggs contained therein age as well. Unlike men who produce new sperm on a regular basis, women are born with all the eggs they'll ever have. Their eggs may become damaged from years of exposure to hazards such as chemicals or radiation.
Too little estrogen also can cause infertility. As a woman ages and nears menopause, the amount of estrogen produced drops gradually. With less estrogen, the ovaries may not produce an egg each month. The result is fewer babies as a woman ages. Another cause for low estrogen levels is too little body fat. Women who exercise too much or diet excessively— sometimes due to eating disorders—may not produce enough estrogen for ovulation to occur.
Other women with ovulatory problems have sufficient supplies of estrogen but lack other hormones, such as FSH, LH, and prolactin, that affect other aspects of the cycle.
Certain kinds of birth control continue to reduce ovulation even after they are no longer used. For example, some women who take birth control pills find that it takes them a few months to begin ovulat¬ing again once they've stopped taking the pill. After 2-3 years off the pill, however, their rates of ovulation are the same as for other women who use barrier contraception. Contraceptive implants that contain hormones offer a rapid return of fertility. On the other hand, contraceptive injections of hormones may sub¬stantially delay the return of fertility. It can take anywhere from 4 to more than 30 months for fertility to return.
Tubal and Peritoneal Factors as a cause of Infertility
Conditions affecting the fallopian tubes or the peritoneum sometimes cause infertility. The peritoneum is a strong sac that lines the inside of the abdomen. It forms a sort of bag that contains the digestive organs and runs alongside the fallopian tubes.
Scarring or blockage in the tubes may cause infertility. One of the most common causes of damaged tubes is infections. When STDs are untreated, they can worsen and move up the uterus into the tubes. This is pelvic inflammatory disease, a major cause of blocked tubes. Use of an intrauterine device increases the risk of infection, especially in young women with several sexual partners. Some researchers say that smoking cigarettes changes the lining of the fallopian tubes, inflaming them and making them less hospitable to conception.
When tubes are damaged, an ectopic pregnancy is more likely if conception occurs. In an ectopic pregnancy, the egg is fertilized as in a normal pregnancy but it does not implant in the uterus. Instead, often because the fallopian tubes are damaged, it implants in the tube or somewhere in the peritoneum and begins to grow there. Because it can burst the tube, ectopic pregnancy can be life threatening. If you have a history of pelvic infections, your chances of ectopic pregnancy are four times greater than normal.
Other problems include adhesions, in which nearby organs or tissues bind themselves together. An adhesion that causes another organ to pull on a fallopian tube may move the tube away from the ovary. This prevents the tube from catching the egg when it is released. Adhesions may be caused by infection, previous surgery on the pelvic organs, or endometriosis.
The role of endometriosis in infertility is the subject of great debate among doctors. In endometriosis, tissue like that lining the uterus moves to other places in the abdomen where it begins growing in response to hormones, just as the endometrium does. Such growth can cause pain and inflammation. Up to one-third of infertile women are found to have endometriosis. We do not know if this is just a coincidence or if the endometriosis helps cause the infertility. Severe or extensive endometriosis can cause adhesions. Severe disease is definitely thought to be linked to infertility.
Cervical and Uterine Factors as a cause of Infertility
The cervix is the narrow neck that forms the opening of the uterus to the vagina. It produces mucus that either helps or hinders the movement of sperm depending on where a woman is in her menstrual cycle. As a woman nears ovulation, mucus thins and becomes slippery and stretchy to help move the sperm through the cervix. The mucus looks much like raw egg white. If the mucus is thick or scanty instead, it is much more difficult for the sperm to move. High levels of nicotine have been found in the cervical mucus of women who smoke. Nicotine can be toxic to sperm.
Surgery on the cervix may also interfere with fertility. Some types of operations, such as conization (removing a wedge of tissue from the cervix), may result in scarring or little to no mucus production.
Other Factors of Uterus as cause of Infertility
The uterus may be affected by infections or adhesions. An infection of the lining of the uterus, endometritis, can be caused by STDs such as gonorrhea. Tuberculosis also can cause endometritis. Overgrowth of the uterine lining, called endometrial hyperplasia, or endometrial cancer can cause infertility as well.
If a woman has had the lining of her uterus scraped by D&C, or dilation and curettage after a pregnancy or for abnormal bleeding, the lining may not grow back properly. Adhesions may form, or the lining may be thin; either condition can contribute to infertility. The condition is known as Asherman’s Syndrome.
Growths in the uterus, such as fibroids, have been studied as possible causes of infertility. Although they may play a small role, if any in infertility, a doctor may remove them if no other cause for infertility is found.
An abnormally shaped uterus, such as one with a thin wall (septum) running down its middle, also known as septate uterus, can affect a woman's ability to have a child. Affected women are born with these defects that cause miscarriage (loss of the baby before it is ready to be born) rather than inability to conceive.
Antibodies against Sperm prevent Fertilization
Some women and men produce antibodies against sperm. When the immune system malfunctions, it sees the sperm as a foreign threat and produces anti¬bodies to fight them. The antibodies affect the ability of the sperm to move freely.
Unexplained Infertility
Sometimes a reason cannot be found for a couple's infertility. Even without knowing a cause, however, certain steps can be taken to increase the chance of conceiving. Some measures a couple can take them¬selves. Each month, approximately 3 percent of cou¬ples with unexplained infertility conceive on their own.
How the male partners can be responsible for inferilty
Male factors are responsible for infertility in 30 – 40% of couples. Male factor infertility includes problems with the man's sperm. The difficulty may be with the sperm themselves or the delivery system that takes them from the testicles, where they are formed, through the penis and into the woman's vagina.
Normally, there are at least 20 million healthy sperm in each milliliter of semen ejaculated. Some men produce no sperm at all or very few. Others may have sperm that are oddly shaped or unable to move properly. Any of these problems can cause infertility.
Even if a man produces healthy sperm, exposure to certain conditions or substances may kill them. For example, heat is harmful to sperm. Fevers, long soaks in hot tubs, and tight underwear that keeps the testicles close to the body all can result in temporary drops in sperm counts. It takes 90 days for sperm to mature, so any man who has had a high fever within 3 months may have a low sperm count also.
AGENTS HARMFUL TO SPERM
Chemotherapy, Radiation treatment Alcohol, Antibiotics (nitrofurantoin, sulfa drugs), Ulcer treatments (cimetidine), Marijuana, Nicotine, Diethylstilbestrol (DES), Anabolic steroids (used for body building), Some lubricants used during sex.
A man's reproductive system can be affected if his mother took DES while pregnant with him.
Some substances have a permanent effect, while others are only temporary. A man trying to father a child may want to consult with his doctor if he has been exposed to any of these agents.
Other men have difficulty in getting the sperm to the right place. Some are impotent or cannot maintain an erection sufficient to allow intercourse. Others have blockages in the tubes that carry the sperm from the testicles through the penis. These blockages may be caused by infections, some sexually transmitted. In other men, a condition called retrograde ejaculation results in sperm going the wrong way once they reach the penis. Instead of going out the penis, they move backward up into the bladder.
Normally, there are at least 20 million healthy sperm in each milliliter of semen ejaculated. Some men produce no sperm at all or very few. Others may have sperm that are oddly shaped or unable to move properly. Any of these problems can cause infertility.
Even if a man produces healthy sperm, exposure to certain conditions or substances may kill them. For example, heat is harmful to sperm. Fevers, long soaks in hot tubs, and tight underwear that keeps the testicles close to the body all can result in temporary drops in sperm counts. It takes 90 days for sperm to mature, so any man who has had a high fever within 3 months may have a low sperm count also.
AGENTS HARMFUL TO SPERM
Chemotherapy, Radiation treatment Alcohol, Antibiotics (nitrofurantoin, sulfa drugs), Ulcer treatments (cimetidine), Marijuana, Nicotine, Diethylstilbestrol (DES), Anabolic steroids (used for body building), Some lubricants used during sex.
A man's reproductive system can be affected if his mother took DES while pregnant with him.
Some substances have a permanent effect, while others are only temporary. A man trying to father a child may want to consult with his doctor if he has been exposed to any of these agents.
Other men have difficulty in getting the sperm to the right place. Some are impotent or cannot maintain an erection sufficient to allow intercourse. Others have blockages in the tubes that carry the sperm from the testicles through the penis. These blockages may be caused by infections, some sexually transmitted. In other men, a condition called retrograde ejaculation results in sperm going the wrong way once they reach the penis. Instead of going out the penis, they move backward up into the bladder.
Causes of Infertility - An overview
The causes of infertility are multiple, and some are hotly debated in medical circles. In some cases, the reasons are found in the woman (female-factor infertility); in other cases, the cause lies in the man (male-factor infertility). In still other couples, the infertility may be due to a combination of medical problems in both partners. For some couples with infertility, a cause is never found. This can be very upsetting.
One important cause of infertility in both men and women is sexually transmitted diseases. Even STDs with no symptoms can cause scarring in a man or woman's reproductive system; such scars block passageways for sperm or eggs. Having several sexual partners increases the chance of getting an STD. An STD can lead to a pelvic inflammatory disease (PID), a severe infection of the uterus and tubes; it can scar and block the tubes, causing infertility later on. To avoid getting STDs, limit sexual partners and use a condom during sex.
One important cause of infertility in both men and women is sexually transmitted diseases. Even STDs with no symptoms can cause scarring in a man or woman's reproductive system; such scars block passageways for sperm or eggs. Having several sexual partners increases the chance of getting an STD. An STD can lead to a pelvic inflammatory disease (PID), a severe infection of the uterus and tubes; it can scar and block the tubes, causing infertility later on. To avoid getting STDs, limit sexual partners and use a condom during sex.
What is ovulation and how one gets pregnant?
To achieve pregnancy a series of complicated events occurs, which otherwise happens so simply! It is essential to know the normal process so that we can understand the reason; when there is difficulty of getting pregnant.
Ovulation and menstruation – What actually happens?
A woman is born with a lifetime supply of immature eggs in her ovaries. Each month, one matures and is released in a process called ovulation. Ovulation is an important part of the menstrual cycle. In a typical 28-day cycle, a woman's menstrual period begins on day 1. On day 14, ovulation occurs. On day 28, if the egg has not become fertilized, the menstrual cycle begins again with another period.
For ovulation to happen, different parts of the body must all work together. The brain and the ovaries both play roles in this coordination. The ovaries are the two almond-shaped glands sitting within reach of the fallopian tubes. Ovaries produce the eggs as well as the essential sex hormones needed for menstruation and pregnancy.
Just before ovulation, the hypothalamus and pituitary glands in the brain signal the body to start producing hormones. Follicle-stimulating hormone (FSH) prompts fluid-filled chambers in the ovary called follicles to begin growing. In each follicle a single ovum starts growing. Leutinizing hormone (LH) triggers the follicle to rupture when it is matured. In each cycle one ovum is usually released. Women ovulate about 14 days before their next menstrual period would be expected—day 14 on a 28-day cycle. Ovulation occurs within about a day after the surge in LH.
Both FSH and LH play additional roles in the menstrual cycle. They instruct the ovaries to produce estrogen and progesterone, hormones that help ovulation to occur and the uterus to prepare for pregnancy. The uterus is a hollow organ, shaped like a pear and only about three inches long in a non pregnant woman. Its lining, the endometrium, is richly supplied with blood vessels. The endometrium continually renews itself, building up in response to messages sent by estrogen and progesterone.
The Luteinizing Process The menstrual cycle consists of a complex series of events that interact to stimulate ovulation, prepare the uterine lining for a pregnancy, and cause the uterine lining to be shed if pregnancy does not occur. Two glands in the brain, the hypothalamus and the pituitary, send follicle-stimulating hormone (FSH) and luteinizing hormone (LH) to the ovary just before ovulation to stimulate the development of a follicle and its release of an egg into a fallopian tube (ovulation). Follicles are the structures inside the ovary that produce the eggs to be fertilized and that release the hormone estrogen, which stimulates the lining of the uterus to thicken in preparation for pregnancy. After releasing the egg, the empty follicle, called the corpus-luteum, begins producing progesterone. This hormone continues to stimulate the uterine lining to grow and thicken. If the egg is not fertilized, a sudden drop in estrogen and progesterone triggers the uterus to shed its lining and menstruation begins. This marks the start of the next cycle
What actually happens when ovum is fertilized?
For fertilization to occur, healthy sperm must be deposited in a woman's vagina, preferably near the cervix, just about the time of ovulation. Each sperm is about 1/ 1000 inch long; its whip like tail swims up through the cervix, into the uterus, and into the fallopian tubes. Only one sperm is allowed fertilize an egg. Though millions of sperm may start their journey towards the solitary ovum, only a few hundred stay alive during the trip and one fortunate sperm ultimately fertilize the egg.
An egg, which is released during ovulation is usually picked up by the fallopian tube. Women have two fallopian tubes, each about 4 inches long. They are located just above the ovaries and have featherlike fingers called fimbria at their terminals near the ovaries. The fimbria and inner lining of the tubes are lined with cilia, which are like millions of active tiny hairs. These hairs shift the egg from the ovary inside the tubes by suction and cilliary action. An egg is fertilizable for only about 12-72 hours after its release.
The fallopian tubes have smooth tiny musculature throughout their lengths. In the middle, they help by contracting so that the sperm and egg move closer with each other and fertilization happens. At the end nearer the uterus, they are narrow to keep eggs from being released into the uterus too soon.
When sperm are present, they gather around the egg. They discharge enzymes from their heads to help make a hole in the egg to allow penetration. Once one sperm enters the egg, a chemical reaction ensues that pre¬vents other sperm from entering.
In the first half of a woman's menstrual cycle, estrogen makes the endometrial lining begin to thicken with a nutrient rich bedding in case pregnancy should occur. Progesterone then takes over. It is produced mainly in the second half of the cycle by a temporary organ called the corpus luteum. The corpus luteum is formed in the ovary from the follicle that released its egg. Progesterone causes the lining of the uterus to thicken even more. Estrogen and progesterone both play roles in ovulation as well.
If the egg is not fertilized, it dissolves and is absorbed by the body. Then hormone levels drop and the endometrium disintegrates without the hormonal nourishment. This shedding is the monthly menstrual period. The first day of a woman's period is the point at which her hormone levels are at their lowest.
How fertilized ovum is implanted in the uterus?
Inside the fertilized egg, cells begin to divide. If all goes well, the fertilized egg then journeys from the fallopian tube to the uterus where it implants itself in the spongy lining of the uterus. There it grows and develops into an embryo (weeks 2-8), then a fetus for the rest of the pregnancy, and 9 months later, a baby.
Numerous structural and hormonal factors play a part in fertility. What may look like the simplest of human activities—conceiving a baby—can become a miraculous chain of events, especially to a couple having problems getting pregnant.
Basic criteria of a fertile couple
Seven elements are essential to fertility:
1. A woman's ovaries must produce healthy eggs that are released regularly.
2. A man's testicles must be capable of producing healthy sperm that can reach the egg and then penetrate it.
3. During intercourse, the man's semen that contains his sperm has to be deposited at or at least close to the cervix. This puts the sperm in the best position to reach the egg.
4. There has to be a clear passage through the fallopian tube from the ovary to the uterus. This passage is used by both the egg moving down and the sperm moving up. Any obstruction in the fallopian tube interrupts the process of fertilization.
5. The man's sperm have to be able to move freely through the cervix. Any physical or chemical barrier can cause problems.
6. The ovum has 12 to 72 hours of life in which it can be fertilized. The sperm have up to 5 days in which they can fertilize an egg. Timing is critical.
7. Once the egg is fertilized, it has to find a suitable site for implantation in the lining of the uterus.
Ovulation and menstruation – What actually happens?
A woman is born with a lifetime supply of immature eggs in her ovaries. Each month, one matures and is released in a process called ovulation. Ovulation is an important part of the menstrual cycle. In a typical 28-day cycle, a woman's menstrual period begins on day 1. On day 14, ovulation occurs. On day 28, if the egg has not become fertilized, the menstrual cycle begins again with another period.
For ovulation to happen, different parts of the body must all work together. The brain and the ovaries both play roles in this coordination. The ovaries are the two almond-shaped glands sitting within reach of the fallopian tubes. Ovaries produce the eggs as well as the essential sex hormones needed for menstruation and pregnancy.
Just before ovulation, the hypothalamus and pituitary glands in the brain signal the body to start producing hormones. Follicle-stimulating hormone (FSH) prompts fluid-filled chambers in the ovary called follicles to begin growing. In each follicle a single ovum starts growing. Leutinizing hormone (LH) triggers the follicle to rupture when it is matured. In each cycle one ovum is usually released. Women ovulate about 14 days before their next menstrual period would be expected—day 14 on a 28-day cycle. Ovulation occurs within about a day after the surge in LH.
Both FSH and LH play additional roles in the menstrual cycle. They instruct the ovaries to produce estrogen and progesterone, hormones that help ovulation to occur and the uterus to prepare for pregnancy. The uterus is a hollow organ, shaped like a pear and only about three inches long in a non pregnant woman. Its lining, the endometrium, is richly supplied with blood vessels. The endometrium continually renews itself, building up in response to messages sent by estrogen and progesterone.
The Luteinizing Process The menstrual cycle consists of a complex series of events that interact to stimulate ovulation, prepare the uterine lining for a pregnancy, and cause the uterine lining to be shed if pregnancy does not occur. Two glands in the brain, the hypothalamus and the pituitary, send follicle-stimulating hormone (FSH) and luteinizing hormone (LH) to the ovary just before ovulation to stimulate the development of a follicle and its release of an egg into a fallopian tube (ovulation). Follicles are the structures inside the ovary that produce the eggs to be fertilized and that release the hormone estrogen, which stimulates the lining of the uterus to thicken in preparation for pregnancy. After releasing the egg, the empty follicle, called the corpus-luteum, begins producing progesterone. This hormone continues to stimulate the uterine lining to grow and thicken. If the egg is not fertilized, a sudden drop in estrogen and progesterone triggers the uterus to shed its lining and menstruation begins. This marks the start of the next cycle
What actually happens when ovum is fertilized?
For fertilization to occur, healthy sperm must be deposited in a woman's vagina, preferably near the cervix, just about the time of ovulation. Each sperm is about 1/ 1000 inch long; its whip like tail swims up through the cervix, into the uterus, and into the fallopian tubes. Only one sperm is allowed fertilize an egg. Though millions of sperm may start their journey towards the solitary ovum, only a few hundred stay alive during the trip and one fortunate sperm ultimately fertilize the egg.
An egg, which is released during ovulation is usually picked up by the fallopian tube. Women have two fallopian tubes, each about 4 inches long. They are located just above the ovaries and have featherlike fingers called fimbria at their terminals near the ovaries. The fimbria and inner lining of the tubes are lined with cilia, which are like millions of active tiny hairs. These hairs shift the egg from the ovary inside the tubes by suction and cilliary action. An egg is fertilizable for only about 12-72 hours after its release.
The fallopian tubes have smooth tiny musculature throughout their lengths. In the middle, they help by contracting so that the sperm and egg move closer with each other and fertilization happens. At the end nearer the uterus, they are narrow to keep eggs from being released into the uterus too soon.
When sperm are present, they gather around the egg. They discharge enzymes from their heads to help make a hole in the egg to allow penetration. Once one sperm enters the egg, a chemical reaction ensues that pre¬vents other sperm from entering.
In the first half of a woman's menstrual cycle, estrogen makes the endometrial lining begin to thicken with a nutrient rich bedding in case pregnancy should occur. Progesterone then takes over. It is produced mainly in the second half of the cycle by a temporary organ called the corpus luteum. The corpus luteum is formed in the ovary from the follicle that released its egg. Progesterone causes the lining of the uterus to thicken even more. Estrogen and progesterone both play roles in ovulation as well.
If the egg is not fertilized, it dissolves and is absorbed by the body. Then hormone levels drop and the endometrium disintegrates without the hormonal nourishment. This shedding is the monthly menstrual period. The first day of a woman's period is the point at which her hormone levels are at their lowest.
How fertilized ovum is implanted in the uterus?
Inside the fertilized egg, cells begin to divide. If all goes well, the fertilized egg then journeys from the fallopian tube to the uterus where it implants itself in the spongy lining of the uterus. There it grows and develops into an embryo (weeks 2-8), then a fetus for the rest of the pregnancy, and 9 months later, a baby.
Numerous structural and hormonal factors play a part in fertility. What may look like the simplest of human activities—conceiving a baby—can become a miraculous chain of events, especially to a couple having problems getting pregnant.
Basic criteria of a fertile couple
Seven elements are essential to fertility:
1. A woman's ovaries must produce healthy eggs that are released regularly.
2. A man's testicles must be capable of producing healthy sperm that can reach the egg and then penetrate it.
3. During intercourse, the man's semen that contains his sperm has to be deposited at or at least close to the cervix. This puts the sperm in the best position to reach the egg.
4. There has to be a clear passage through the fallopian tube from the ovary to the uterus. This passage is used by both the egg moving down and the sperm moving up. Any obstruction in the fallopian tube interrupts the process of fertilization.
5. The man's sperm have to be able to move freely through the cervix. Any physical or chemical barrier can cause problems.
6. The ovum has 12 to 72 hours of life in which it can be fertilized. The sperm have up to 5 days in which they can fertilize an egg. Timing is critical.
7. Once the egg is fertilized, it has to find a suitable site for implantation in the lining of the uterus.
Saturday, March 14, 2009
Common anxiety disorders found in children
The following are some of the anxiety disorders, which are commonly to be found in children and adolescents:
Children and adolescents with generalized anxiety disorder tend to be excessively anxious with the excellence of their performance in school or sporting events, even when they are not being evaluated. They also worry about punctuality, may be fanatical with concerns about disasters, tend to redo tasks if not perfect, and rely on others for endorsement and constant encouragement.
Separation anxiety disorder is diagnosed when a child exhibits abnormal anxiety about separation from home or the individual to whom he is most emotionally involved. In order to stamp it as a disorder, the problem must extend at least four weeks and cause significant suffering or disruption in performance.
Phobias diagnosed in children include specific phobias, or fears of certain stuff or places, or social phobia, fear of social circumstances. Specific phobias are quiet common in children and that they should not be diagnosed unless they obviously impede with the child’s performance (e.g., refusal to go outside due to the fear of encountering a dog). Social phobia is complicated diagnosis in children because they often do not have much control over their exposure to social situations. When a child is frequently having anxiety about communications with adults, social phobia is diagnosed. Children may express this phobia through clinging, crying and tantrums, “freezing,” or not speaking.
Children with obsessive-compulsive disorder (OCD) show symptoms alike adults with this disorder, although compulsive behaviors in children can be confused with symptoms of attention deficit or, hyperactivity disorder. Some experts consider that OCD is commoner among children than asthma.OCD in children may be evident through a child’s obsession with lucky or unlucky numbers, having parents check to make sure things are clean, needing things to be arranged in a certain order, hoarding, or constantly asking for reassurance.
Posttraumatic stress disorder (PTTS) in a child may become apparent through his report of nightmares and repeating of the trauma through play.
Panic disorder is not very common in childhood and often first diagnosed in late adolescence.
Children and adolescents with generalized anxiety disorder tend to be excessively anxious with the excellence of their performance in school or sporting events, even when they are not being evaluated. They also worry about punctuality, may be fanatical with concerns about disasters, tend to redo tasks if not perfect, and rely on others for endorsement and constant encouragement.
Separation anxiety disorder is diagnosed when a child exhibits abnormal anxiety about separation from home or the individual to whom he is most emotionally involved. In order to stamp it as a disorder, the problem must extend at least four weeks and cause significant suffering or disruption in performance.
Phobias diagnosed in children include specific phobias, or fears of certain stuff or places, or social phobia, fear of social circumstances. Specific phobias are quiet common in children and that they should not be diagnosed unless they obviously impede with the child’s performance (e.g., refusal to go outside due to the fear of encountering a dog). Social phobia is complicated diagnosis in children because they often do not have much control over their exposure to social situations. When a child is frequently having anxiety about communications with adults, social phobia is diagnosed. Children may express this phobia through clinging, crying and tantrums, “freezing,” or not speaking.
Children with obsessive-compulsive disorder (OCD) show symptoms alike adults with this disorder, although compulsive behaviors in children can be confused with symptoms of attention deficit or, hyperactivity disorder. Some experts consider that OCD is commoner among children than asthma.OCD in children may be evident through a child’s obsession with lucky or unlucky numbers, having parents check to make sure things are clean, needing things to be arranged in a certain order, hoarding, or constantly asking for reassurance.
Posttraumatic stress disorder (PTTS) in a child may become apparent through his report of nightmares and repeating of the trauma through play.
Panic disorder is not very common in childhood and often first diagnosed in late adolescence.
Types of anxiety and when treatment becomes necessary?
What are types of anxiety disorder commonly encountered?
The main types of anxiety disorders are the :
Generalized anxiety disorder is characterized by at least six months of persistent and excessive anxiety and worry in an individual.
Panic disorder has features of recurrent, unexpected panic attacks and worries about having more.
Agoraphobia is the fear of being in places or circumstances where escape may be difficult or embarrassing. Agoraphobia is often associated with concerns about having a panic attack.
Phobias, which include specific phobias and social phobia, are diagnosed when clinically significant anxiety occurs upon exposure to the feared entity or circumstances, and this fear often leads to avoidance of the entity or circumstances.
Obsessive-compulsive disorder is characterized by obsessions, which are interfering thoughts and impulses (e.g., thoughts about contamination) causing considerable anxiety, and compulsions, which are repetitive acts (e.g., excessive hand-washing) used to fight off that anxiety.
Post traumatic stress disorder and acute stress disorder involve the re-experiencing of an extremely traumatic event.
When medical treatment become necessary for anxiety?
Anxiety becomes a disorder when it seriously impairs your ability to work, love, or play. Too much anxiety also takes its toll on your body. These are some symptoms that spoil functioning and hint the need for treatment:
• You become exhausted or easily fatigued.
• You have trouble thinking through standard problems like how to sequence the responsibilities of the day.
• You are so tense that you can’t experience comfort, joy, or a sense of accomplishment.
• You engage in special rituals to fend off invasive thoughts or images.
• Your symptoms convince you that you’re dying or losing your mind.
• Preoccupation with anxiety impairs your productivity.
• You dread and avoid common social situations such as going out in public, with friends, or even to work.
• You are so much worried that it is difficult to fall asleep or stay asleep.
• Emotional tension percolates into your skeletal muscles, make you stiff, tense, and aching.
• You avoid everyday tasks and responsibilities out of fear of having a panic attack.
If you have trouble in performance, you will ultimately worry more, and a vicious cycle is set in motion. Treatment is essential to interrupt the cycle, provide hope, and restore functioning.
The main types of anxiety disorders are the :
Generalized anxiety disorder is characterized by at least six months of persistent and excessive anxiety and worry in an individual.
Panic disorder has features of recurrent, unexpected panic attacks and worries about having more.
Agoraphobia is the fear of being in places or circumstances where escape may be difficult or embarrassing. Agoraphobia is often associated with concerns about having a panic attack.
Phobias, which include specific phobias and social phobia, are diagnosed when clinically significant anxiety occurs upon exposure to the feared entity or circumstances, and this fear often leads to avoidance of the entity or circumstances.
Obsessive-compulsive disorder is characterized by obsessions, which are interfering thoughts and impulses (e.g., thoughts about contamination) causing considerable anxiety, and compulsions, which are repetitive acts (e.g., excessive hand-washing) used to fight off that anxiety.
Post traumatic stress disorder and acute stress disorder involve the re-experiencing of an extremely traumatic event.
When medical treatment become necessary for anxiety?
Anxiety becomes a disorder when it seriously impairs your ability to work, love, or play. Too much anxiety also takes its toll on your body. These are some symptoms that spoil functioning and hint the need for treatment:
• You become exhausted or easily fatigued.
• You have trouble thinking through standard problems like how to sequence the responsibilities of the day.
• You are so tense that you can’t experience comfort, joy, or a sense of accomplishment.
• You engage in special rituals to fend off invasive thoughts or images.
• Your symptoms convince you that you’re dying or losing your mind.
• Preoccupation with anxiety impairs your productivity.
• You dread and avoid common social situations such as going out in public, with friends, or even to work.
• You are so much worried that it is difficult to fall asleep or stay asleep.
• Emotional tension percolates into your skeletal muscles, make you stiff, tense, and aching.
• You avoid everyday tasks and responsibilities out of fear of having a panic attack.
If you have trouble in performance, you will ultimately worry more, and a vicious cycle is set in motion. Treatment is essential to interrupt the cycle, provide hope, and restore functioning.
Anxiety Disorder - Basic facts
What is anxiety and how is it different from fear?
Anxiety is sense of fear without a obvious threat. Whereas fear is a usual response to an apparent, truthful threat to your physical well-being, anxiety often feels abnormal and without use or function. Imagine while you are crossing a road and unexpectedly a car appears speeding in your way. You will most likely experience the following feelings of fear:
• Your heart beats faster
• Your breathing become hurried
• You may perspire
• Your mind focuses
• You mind and body become ready to take protective action
These reactions, which happen in a millisecond, will save you from hitting with car, and you should be grateful for your built-in alarm system.
Anxiety, conversely, feels more troublesome than supportive. Put side by side the logic and efficiency of the fear response to these common features of anxiety:
• You may not be able to identify why you’re afraid
• If you have a reason, it’s not a believable one (it may be illogical)
• The threat may be distant in the past or future
• The threat could be distant geographically
• When you don’t know why you are frightened, you feel a sense of apprehension
• Because the fear lacks focus, you have more difficulty finding a solution to end it.
Moreover, anxiety is vicious cycle. The more you notice yourself feeling anxious, the more anxious you may become.
What are the causes of anxiety?
Many factors contribute to anxiety, and several of them may be responsible in each particular case. Here’s a list of the causes most often related with the development of anxiety disorders:
Genes and anxiety.
Our genes are responsible for some of us up to be vulnerable to problems with anxiety. If a number of your close kin suffer from anxiety problems, you are at an enhanced risk for developing an anxiety disorder. In other words sensitive alarm system, you may inherit.
Anxiety results from early life experience.
Early life events and experiences can also make us more likely to develop problems, especially if these experiences are traumatic and leave an echoing alarm in our heads. Just seeing our parents respond to events with anxiety and worry may make it more likely that we will respond the same.
Anxiety arising out of experience later in life
Experiencing particularly upsetting events later in life can develop anxiety disorder over the short-run and, in some cases, for long period of time. Examples of this include the trauma caused by rape or war combat.
Our thought process is sometime responsible for our anxiety
Often, we are worried by our own thinking. Logical errors are common among people with anxiety problems, namely overestimating the danger in a situation and underestimating one’s ability to handle. Anxious people may always exaggerate the negative aspect of an event. They may have dilemma in sorting out what actually is unsafe in life.
Effect of drug and illness on anxiety
A variety of drugs, legal and illegal, set off the anxiety alarm, as do some medical or other psychiatric illnesses.
Dilemma within us as a cause of anxiety
Some of us become anxious when confronted with wearisome dilemmas—the lesser of two evils or the greater of two goods. Such a conflict may be based in unconscious alarms like disapproval by parents in childhood and that persist to impact us as adults. This kind of cause is referred to as “psychodynamic” because it addresses the conversations, or dynamics, that occur inside us.
Anxiety is sense of fear without a obvious threat. Whereas fear is a usual response to an apparent, truthful threat to your physical well-being, anxiety often feels abnormal and without use or function. Imagine while you are crossing a road and unexpectedly a car appears speeding in your way. You will most likely experience the following feelings of fear:
• Your heart beats faster
• Your breathing become hurried
• You may perspire
• Your mind focuses
• You mind and body become ready to take protective action
These reactions, which happen in a millisecond, will save you from hitting with car, and you should be grateful for your built-in alarm system.
Anxiety, conversely, feels more troublesome than supportive. Put side by side the logic and efficiency of the fear response to these common features of anxiety:
• You may not be able to identify why you’re afraid
• If you have a reason, it’s not a believable one (it may be illogical)
• The threat may be distant in the past or future
• The threat could be distant geographically
• When you don’t know why you are frightened, you feel a sense of apprehension
• Because the fear lacks focus, you have more difficulty finding a solution to end it.
Moreover, anxiety is vicious cycle. The more you notice yourself feeling anxious, the more anxious you may become.
What are the causes of anxiety?
Many factors contribute to anxiety, and several of them may be responsible in each particular case. Here’s a list of the causes most often related with the development of anxiety disorders:
Genes and anxiety.
Our genes are responsible for some of us up to be vulnerable to problems with anxiety. If a number of your close kin suffer from anxiety problems, you are at an enhanced risk for developing an anxiety disorder. In other words sensitive alarm system, you may inherit.
Anxiety results from early life experience.
Early life events and experiences can also make us more likely to develop problems, especially if these experiences are traumatic and leave an echoing alarm in our heads. Just seeing our parents respond to events with anxiety and worry may make it more likely that we will respond the same.
Anxiety arising out of experience later in life
Experiencing particularly upsetting events later in life can develop anxiety disorder over the short-run and, in some cases, for long period of time. Examples of this include the trauma caused by rape or war combat.
Our thought process is sometime responsible for our anxiety
Often, we are worried by our own thinking. Logical errors are common among people with anxiety problems, namely overestimating the danger in a situation and underestimating one’s ability to handle. Anxious people may always exaggerate the negative aspect of an event. They may have dilemma in sorting out what actually is unsafe in life.
Effect of drug and illness on anxiety
A variety of drugs, legal and illegal, set off the anxiety alarm, as do some medical or other psychiatric illnesses.
Dilemma within us as a cause of anxiety
Some of us become anxious when confronted with wearisome dilemmas—the lesser of two evils or the greater of two goods. Such a conflict may be based in unconscious alarms like disapproval by parents in childhood and that persist to impact us as adults. This kind of cause is referred to as “psychodynamic” because it addresses the conversations, or dynamics, that occur inside us.
Thursday, March 12, 2009
Fibrocystic Disease of the breast - Most common cause of painful breast mass
This condition is characterized by painful, frequently multiple and typically bilateral masses in the breast. Rapid variation in the size of the masses is characteristic. Usually pain starts and / or, get worse and the size increases preceding the menstruation. Commonly women of 30 to 50 years are affected. This condition is rare after menopause unless on hormone replacement therapy.
Fibrocystic disease of the breast is the commonest lesion of the breast. Estrogen is considered a contributory factor. There may be an enhanced risk in those who consume alcohol, especially young women between 18 and 22 years of age. Fibrocystic condition presents a wide range of histologic changes. These lesions are constantly show benign changes in the breast epithelium, those are so commonly found in normal breasts. Most likely they are only the variants of normal breast histology. Only some variety of histopathological changes showing proliferation and atypical cells are said to have increased incidence of breast carcinoma.
Symptoms and Signs of fibrocystic disease of the breast
Usually a mass in the breast remain asymptomatic and sudden pain and tenderness brings attention and the mass is recognized by the concerned woman. Discharge from the nipple may sometimes be present. Mostly uneasiness starts or worsens preceding the menstruation, at which time the cysts increase in their sizes too. Changes in size and rapid emergence or disappearance of mass from the breasts typical with this disease. Multiple or bilateral masses are usual findings, and many patients will give a history of cyclical breast pain and transient formation of mass in the breasts.
How fibrocystic disease of the breast is diagnosed?
Pains, multiplicity of the mass, rapidly changing size are the most helpful features in differentiating fibrocystic disease from breast carcinoma. If a persistent mass is there, the diagnosis of cancer should be suspected unless nullified by a biopsy. Ultimate diagnosis depends on histopathologic examination of the excisional biopsy specimen. Mammography may help, but the breast tissue is usually radiodense in these young women is usually much radiodense and proper study is difficult at times. Sonography can differentiate cystic mass from a solid mass. The solid mass points more towards carcinoma.
Treatment of fibrocystic disease of the breast
After diagnosis of fibrocystic disease has been established either by histopathologic study or by the classical history; aspiration of the discrete cyst can be done to ease pain. This procedure also helps to verify the cystic nature of the mass. The patient is reviewed at intervals subsequently. If no fluid is recovered by aspiration or, if fluid is blood stained or, if the mass remains after aspiration, or if in subsequent follow-up a constant or recurrent mass is noted, biopsy is done to exclude carcinoma.
Breast pain due to fibrocystic disease is best managed by wearing a good supportive brassiere for 24 hours and avoiding any kind of trauma. Hormone therapy is not indicated as it does not cure the disease and produce undesirable side effects. Danazol, a synthetic androgen in a dosage of 100–200 mg orally twice daily sometimes prescribed to alleviate severe pain in some patients. This acts by suppressing pituitary gonadotropins, but androgenic side effects like acne, edema, hair loss and hirsutism is not acceptable to many of the women.
Tamoxifen, an antiestrogen and anti cancer drug also reduces some symptoms of fibrocystic disease, but due to its side effects it is not prescribed for young women except it is prescribed to lessen the risk of carcinoma.
Postmenopausal women on hormone replacement therapy (HRT) usually get relief after stopping the hormones. Evening primrose oil, a natural form of gamolenic acid is found effective to reduce pain in around 50% of the users and can be tried for treatment. The dose of gamolenic acid is 3 g twice daily orally.
Reducing the fat in diet, lowering caffeine consumption in the form of tea coffee or chocolate are found helpful to reduce pain in several studies. Vitamin E in a dose of 400 IU daily also help some patients to get rid of the symptoms at least partly. None of these treatments are proved to to be effective beyond doubt till date.
Fibrocystic disease of the breast is the commonest lesion of the breast. Estrogen is considered a contributory factor. There may be an enhanced risk in those who consume alcohol, especially young women between 18 and 22 years of age. Fibrocystic condition presents a wide range of histologic changes. These lesions are constantly show benign changes in the breast epithelium, those are so commonly found in normal breasts. Most likely they are only the variants of normal breast histology. Only some variety of histopathological changes showing proliferation and atypical cells are said to have increased incidence of breast carcinoma.
Symptoms and Signs of fibrocystic disease of the breast
Usually a mass in the breast remain asymptomatic and sudden pain and tenderness brings attention and the mass is recognized by the concerned woman. Discharge from the nipple may sometimes be present. Mostly uneasiness starts or worsens preceding the menstruation, at which time the cysts increase in their sizes too. Changes in size and rapid emergence or disappearance of mass from the breasts typical with this disease. Multiple or bilateral masses are usual findings, and many patients will give a history of cyclical breast pain and transient formation of mass in the breasts.
How fibrocystic disease of the breast is diagnosed?
Pains, multiplicity of the mass, rapidly changing size are the most helpful features in differentiating fibrocystic disease from breast carcinoma. If a persistent mass is there, the diagnosis of cancer should be suspected unless nullified by a biopsy. Ultimate diagnosis depends on histopathologic examination of the excisional biopsy specimen. Mammography may help, but the breast tissue is usually radiodense in these young women is usually much radiodense and proper study is difficult at times. Sonography can differentiate cystic mass from a solid mass. The solid mass points more towards carcinoma.
Treatment of fibrocystic disease of the breast
After diagnosis of fibrocystic disease has been established either by histopathologic study or by the classical history; aspiration of the discrete cyst can be done to ease pain. This procedure also helps to verify the cystic nature of the mass. The patient is reviewed at intervals subsequently. If no fluid is recovered by aspiration or, if fluid is blood stained or, if the mass remains after aspiration, or if in subsequent follow-up a constant or recurrent mass is noted, biopsy is done to exclude carcinoma.
Breast pain due to fibrocystic disease is best managed by wearing a good supportive brassiere for 24 hours and avoiding any kind of trauma. Hormone therapy is not indicated as it does not cure the disease and produce undesirable side effects. Danazol, a synthetic androgen in a dosage of 100–200 mg orally twice daily sometimes prescribed to alleviate severe pain in some patients. This acts by suppressing pituitary gonadotropins, but androgenic side effects like acne, edema, hair loss and hirsutism is not acceptable to many of the women.
Tamoxifen, an antiestrogen and anti cancer drug also reduces some symptoms of fibrocystic disease, but due to its side effects it is not prescribed for young women except it is prescribed to lessen the risk of carcinoma.
Postmenopausal women on hormone replacement therapy (HRT) usually get relief after stopping the hormones. Evening primrose oil, a natural form of gamolenic acid is found effective to reduce pain in around 50% of the users and can be tried for treatment. The dose of gamolenic acid is 3 g twice daily orally.
Reducing the fat in diet, lowering caffeine consumption in the form of tea coffee or chocolate are found helpful to reduce pain in several studies. Vitamin E in a dose of 400 IU daily also help some patients to get rid of the symptoms at least partly. None of these treatments are proved to to be effective beyond doubt till date.
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