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Dilation And Curettage

Dilation and curettage

Dilation and curettage (D&C) is a gynaecological procedure performed on the female reproductive system often as a form of abortion. The procedure involves dilating the cervix and inserting instruments to clean out the lining of the uterus, which usually includes among other things a developing fetus, while the woman is under an anaesthetic. A curettage is performed with a curette, a metal rod with a handle on one end and a sharp loop on the other. D&Cs are most commonly performed for the purposes of abortion, but this is far from the only reason that one may be performed. Other typical reasons for a D&C are to resolve abnormal uterine bleeding (too much, too often or too heavy a menstrual flow); to remove the excess uterine lining in women who have conditions such as PCOS which cause a prolonged buildup of tissue with no natural period to remove it; and to remove uterine fibroids or other suspected abnormalities such as premalignant cells in their uterine lining. Other procedures include dilation and evacuation and dilation and extraction. The latter is often referred to as partial-birth abortion. If the procedure is performed too roughly, scar tissue may form and seal the uterus shut (Asherman's syndrome), resulting in infertility.

External link

- [http://www.kuro5hin.org/story/2004/3/22/20565/6275 HOWTO: Perform the Dilation & Curettage Surgical Procedure] by "ti_dave", March 24th, 2004. Article and discussion published on Kuro5hin. Category:Gynecology

Gynaecology

is kneeling before the woman but cannot see her genitalia. Modern gynaecology has overcome these inhibitions.]] Gynaecology (British) or gynecology (North American) literally means 'the science of women', but in medicine this is the specialty of diseases of the female reproductive system (uterus, vagina and ovaries). Almost all modern gynaecologists are also obstetricians; see Obstetrics and gynaecology.

Examination

Gynaecology is typically a consultant specialty. In most countries, women must see a general practitioner first. If their condition requires knowledge or equipment unavailable to the GP, they are referred to a gynaecologist. However, in the United States, law and many health insurance plans allow gynaecologists to provide primary care, and some women select that option. As in all of medicine, the main tools of diagnosis are clinical history and examination. Gynaecological examination is special in that it is quite intimate, and that it involves special equipment -- the speculum. The speculum consists of two hinged blades of flat metal, which are used to open the vagina, to permit examination of the cervix uteri. Gynaecologists may also do a bimanual examination (one hand on the abdomen, two fingers in the vagina), to palpate the uterus and ovaries. They may occasionally do a rectal exam. Male gynaecologists often have a female chaperone (nurse or medical student) for their examination. Virgins are not usually examined vaginally. An abdominal ultrasound is used normally to confirm the bimanual examination.

Investigations

Some of the investigations used in gynaecology are: # abdominal ultrasound, to give a low-power view of the pelvic organs. # vaginal ultrasound. A probe is passed into the vagina, which allows a detailed view of the uterus and its contents. # blood tests. Levels of hormones such as estradiol, luteinizing hormone, follicle stimulating hormone and progesterone are measured, as well as prolactin. # hysteroscopy -- a fine tube is passed into the uterus via the cervix under a general anaesthetic. # laparoscopy -- tubes are passed into the peritoneal cavity, which is then insufflated with carbon dioxide. This is commonly used to diagnose endometriosis. MRI and CT scans are rarely used, apart from tumor staging in gynecological cancer. Pelvic X-ray is rare. It can be used to delineate the uterine cavity with an injected dye (hysterosalpingogram) and to measure the pelvic girdle.

Diseases

The main conditions dealt with by a gynaecologist are: # cancer of the cervix. The Papanicolaou (Pap) smear is a means of detecting this, by obtaining a sample of cervical epithelial cells and examining them under a microscope for malignant changes. All women are encouraged to have pap smears at regular intervals after commencing intercourse. # incontinence of urine. # amenorrhoea (absent periods) # dysmenorrhoea (painful periods) # infertility # menorrhagia (heavy periods). This is a main indication for hysterectomy. # prolapse Obviously there is some crossover in these areas. Amenorrhoea in a young girl may be referred to a paediatrician, incontinence to a urologist.

Therapies

Occasionally gynaecologists will use drugs, such as clomiphene (which stimulates ovulation), and, most famously, oral contraceptives (which are also used for dysmenorrhoea). Surgery, however, is the mainstay of gynaelogical therapy. For historical reasons, gynaecologists are not usually considered "surgeons" - this has always been the source of some controversy - though modern advancements in both fields have blurred many of the once rigid lines of distinction. The rise of sub-speciatlies within gynaecology which are primarily surgical in nature (for example, urogynaecology and gynecological oncology) have stregthened the reputations of gynaecologists as surgical practitioners, and many surgeons and surgical societies have come to view gynaecologists as comrades of sorts. As proof of this changing attitude, gynaecologists are now eligible for fellowship in both the American and Royal Colleges of Surgerons, and many newer surgical textbooks include chapters on (at least basic) gynecological surgery. Some of the more common operations that gynaecologists perform include: # termination of pregnancy # dilation and curettage (removal of the uterine contents, for various reasons, including miscarriage and menorrhagia; procedurally very similar to the above); # hysterectomy (removal of the uterus); # oophorectomy (removal of the ovaries); # tubal ligation; # Exploratory laporoscopy or laporotomy (used to diagnose and treat sources of pelvic and abdominal pain, dysmenorrhea, vaginal bleeding, etc.) # colposuspension ('tightening' of the ligaments around the vagina, a common therapy for incontinence and discomfort in older women); # Large Loop Excision of the Transition Zone (LLETZ), where the surface of the cervix, containing pre-cancerous cells identified on Pap smear are removed).

Cervix

The cervix (from Latin "neck") is actually the lower, narrow portion of the uterus where it joins with the top end of the vagina. It is cylindrical or conical in shape and protrudes through the upper anterior vaginal wall. Approximately half its length is visible with appropriate medical equipment; the remainder lies above the vagina beyond view. It is occasionally called "cervix uteri", or "neck of the uterus".

Anatomy

Ectocervix

The portion projecting into the vagina is referred to as the portio vaginalis or ectocervix. On average, the ectocervix is 3 cm long and 2.5 cm wide. It has a convex, elliptical surface and is divided into anterior and posterior lips.

External Os

The ectocervix's opening is called the external os. The size and shape of the external os and the ectocervix varies widely with age, hormonal state, and whether the woman has had a vaginal birth. In women who have not had a vaginal birth the external os appears as a small, circular opening. In women who have had a vaginal birth, the ectocervix appears bulkier and the external os appears wider, more slit-like and gaping.

Endocervical Canal

The passageway between the external os and the uterine cavity is referred to as the endocervical canal. It varies widely in length and width, along with the cervix overall. Flattened anterior to posterior, the endocervical canal measures 7 to 8 mm at its widest in reproductive-aged women.

Internal Os

The endocervical canal terminates at the internal os which is the opening of the cervix inside the uterine cavity.

Cervical Mucus

Normally the external os is blocked by a thick mucus that prevents infection, however the mucus thins when ovum are ready to be fertilized, allowing spermatazoa to pass through the cervix. Most oral contraceptives increase their effectiveness by not allowing this mucus to thin, therefore blocking spermatazoa from passing even when ovum are ready to be fertilized. During pregnancy the cervix is completely blocked by a special antibacterial mucosal plug which prevents infection as before. The mucous plug comes out as the cervix dialates in labor or shortly before.

Functionality

During orgasm, the cervix convulses and the external os dilates. Dr. R. Robin Baker and Dr. Mark A. Bellis, both at the University of Manchester, first proposed that this behavior worked in such a way as to draw any semen in the vagina into the uterus, increasing the likelihood of conception. Later researchers, most notably Elisabeth A. Lloyd, have questioned the logic of this theory and the quality of the experimental data used to back it. During menstruation the cervix stretches open slightly to allow the endometrium to be shed. This stretching is believed to be part of the cramping pain that many women experience. Evidence for this is given by the fact that some women's cramps subside or disappear after their first baby because the cervical opening has widened. During childbirth, contractions of the uterus will dilate the cervix up to 10cm in diameter to allow the child to pass through.

Cervical cancer

In humans the cervix is associated with cervical cancer, a particular form of cancer which is detectable by cytological study of epidermal cells removed from the cervix in a process known as the pap smear. Evidence now shows that those with exposure to HPV, or the Human Papilloma Virus are at increased risk for cervical cancer. This virus is related to the virus that causes warts.

Lymphatic Drainage

The lymphatic drainage of the cervix is along the uterine arteries and cardinal ligaments to the parametrial, external iliac, internal iliac, obturator, and presacral lymph nodes. From these pelvic lymph nodes, drainage then proceeds to the paraaortic lymph nodes.

Fetus

:"Foetus" redirects here. For the musical group Foetus, see Foetus (band). A fetus (also foetus) is a developing mammal after the embryonic stage and before birth. In humans, a fetus develops from the end of the 8th week of pregnancy (when the major structures have formed), until birth. Fetus, in Latin, literally means 'young one'. When speaking in the most literal of terms, a fetus is an organism, as yet undeveloped, in the process of becoming a functional individual of a species.

Fetal growth

There is much natural variation in the growth of the fetus. Approximately 40% of the variation in birth weight can be accounted for by genetic factors, whereas 60% can be accounted for by environmental factors. Ultimately, the offspring should be able to live up to its term growth potential. Factors affecting fetal growth can be maternal, placental, or fetal. Maternal factors include maternal size, weight, weight for height, nutritional state, anemia, cigarette smoking, substance abuse, or uterine blood flow. Placental factors include size, microstructure (densities and architecture), umbilical blood flow, transporters and binding proteins, nutrient utilization and nutrient production. Fetal factors include the fetus genome, nutrient production, and hormone output. Inappropriate growth can result in low birth weight. If the newborn is small for gestational age, he or she will have an increased risk for perinatal mortality (death shortly after birth), asphyxia, hypothermia, polycythemia, hypocalcemia, immune dysfunction, neurologic abnormalities, and other long-term health problems. This can be the result of fetal growth restriction.

Circulatory system

The circulatory system of a human fetus works differently from that of born humans, mainly because the lungs are not in use: the fetus obtains oxygen and nutrients from the mother through the placenta and the umbilical cord. Blood from the placenta is carried by the umbilical vein. About half of this enters the ductus venosus and is carried to the inferior vena cava, while the other half enters the liver proper from the inferior border of the liver. The branch of the umbilical vein that supplies the right lobe of the liver first joins with the portal vein. The blood then moves to the right atrium of the heart. In the fetus, there is an opening between the right and left atrium (the foramen ovale), and most of the blood flows from the right into the left atrium, then into the left ventricle from where it is pumped through the aorta into the body. Some of the blood moves from the aorta through the internal iliac arteries to the placental arteries, and re-enters the placenta, where carbon dioxide and other waste products from the fetus are taken up and enter the mother's circulation. Some of the blood from the right atrium does not enter the left atrium, but enters the right ventricle and is pumped into the pulmonary artery. In the fetus, there is a special connection between the pulmonary artery and the aorta, called the ductus arteriosus, which directs most of this blood away from the lungs (which aren't being used for respiration at this point as the fetus is suspended in amniotic fluid).

Postnatal development

See Adaptation to extrauterine life for more details With the first breath after birth, the system changes suddenly. The pulmonary resistance is dramatically reduced. More blood moves from the right atrium to the right ventricle and into the pulmonary arteries, and less flows through the foramen ovale to the left atrium. The blood from the lungs travels through the pulmonary veins to the left atrium, increasing the pressure there. The decreased right atrial pressure and the increased left atrial pressure pushes the septum primum against the septum secundum, closing the foramen ovale, which now becomes the fosse ovalis. This completes the separation of the circulatory system into two halves, the left and the right. The ductus arteriosus normally closes off within one or two days of birth. The umbilical vein and the ductus venosus closes off within two to five days after birth, leaving behind the ligamentum teres and the ligamentum venosus of the liver respectively.

Developmental problems

Infants with certain congenital anomalies of the heart can survive only as long as the ductus remains open: in such cases the closure of the ductus can be delayed by the administration of prostaglandins to permit sufficient time for the surgical correction of the anomalies. Conversely, in cases of patent ductus arteriosus, where the ductus does not properly close, drugs that inhibit prostaglandin synthesis can be used to encourage its closure, so that surgery can be avoided.

Differences to the adult circulatory system

Remnants of the fetal circulation can be found in adults:
- The fetal foramen ovale becomes the adult fosse ovalis.
- The fetal ductus arteriosus becomes the adult ligamentum arteriosum.
- The extra-hepatic portion of the fetal left umbilical vein becomes the adult ligamentum teres hepatis (the "round ligament of the liver").
- The intra-hepatic portion of the fetal left umbilical vein (the ductus venosus) becomes the adult ligamentum venosum.
- The proximal portions of the fetal left and right umbilical arteries become the adult umbilical branches of the internal iliac arteries.
- The distal portions of the fetal left and right umbilical arteries become the adult medial umbilical ligaments. In addition to differences in circulation, the developing fetus also employs a different type of oxygen transport molecule than adults (adults use adult hemoglobin). Fetal hemoglobin enhances the fetus' ability to draw oxygen from the placenta.

Legal issues

USA

An unborn child is a child in utero: "a member of the species homo sapiens, at any stage of development, who is carried in the womb," according to legislation which passed the US Senate in March 2004. Since the 1970s in the United States, a debate has alternately raged or simmered over the "personhood" of the fetus before birth. Arguments regarding the personhood of a fetus are particularly relevant to debates over the legal and moral status of abortions. See also: Unborn Victims of Violence Act

Etymology and spelling variations

The word fetus originates from the Latin fetus meaning "offspring" or "young one". Foetus is an English variation on this rather than a Latin or Greek word, but has been in use since at least 1594 according to the OED, which describes fetus as etymylogically preferable but almost unknown in actual use. In general, the medical community only permits the spelling fetus (preferred by the British Medical Journal, for example), but the spelling foetus persists in general use, especially in Britain.

Anaesthetic

For the song (Anesthesia) Pulling Teeth by Metallica, go here. here. Anesthesia (American English), also anaesthesia (British English), is the process of blocking the perception of pain and other sensations. This allows patients to undergo surgery and other procedures without the distress and pain they would otherwise experience. It comes from the Greek roots an-, "without" and aesthetos, "perceptible, able to feel".

Types

There are several forms of anesthesia:
- general anesthesia — with reversible loss of consciousness
- local anesthesia — with reversible loss of sensation in a (small) part of the body by localized administration of anesthetic drugs at the affected site.
- regional anesthesia — with reversible loss of sensation and possibly movement in a region of the body by selective blockade of sections of the spinal cord or nerves supplying the region.

Anaesthesiologists and the profession

Physicians specialising in the administration of anesthetics are known as anesthesiologists (AE) or anaesthetists (CE). Nurses specialising in the administration of anesthetics are known as nurse anesthetists (AE), who typically have gone to graduate school after nursing school, or have at least obtained certification as a CRNA (Certified Registered Nurse Anesthetist). "Anesthetist", despite typically (in the USA) referring to nurses, can refer to a physician or a nurse. Anesthesiologist Assistants are another group of health care providers who administer anesthetics. They pursue a graduate degree in anesthesia from an accredited program and are supervised directly by an anesthesiologist. In the United Kingdom, specially trained anaesthetic personnel known as ODPs (operating department practitioner, health care workers without prior medical training) or Anaesthetic nurses (nurses with prior nursing training choosing to specialize in anaesthetics) provide crucial support and aid in the administration, safety and running of the anaesthetic list

History

Non-pharmacological methods

Hypnotism and acupuncture have a long history of use as anaesthetic techniques. In China, Taoist medical practitioners developed anaesthesia by means of acupuncture. Chilling tissue with ice can achieve local effects, while hyperventilation can provide general effects (see Lamaze).

Herbal derivatives

The first herbal anaesthesia was administered in prehistory. Opium and hemp were two of the most important herbs used. They were ingested or burned and the smoke inhaled. Alcohol was also used, its vasodilatory properties being unknown. In early America preparations from datura, effectively scopolamine, were used as was coca. In Medieval Europe various preparations of mandrake were tried as was henbane (hyoscyamine).

Early gases and vapours

hyoscyamine The development of effective anaesthetics in the 19th century was, with Listerian techniques, one of the keys to successful surgery. Henry Hill Hickman experimented with carbon dioxide in the 1820s. The anaesthetic qualities of nitrous oxide (isolated by Joseph Priestley) were discovered by the British chemist Humphry Davy about 1795 when he was an assistant to Thomas Beddoes, and reported in a paper in 1800. But initially the medical uses of this so-called "laughing gas" were limited - its main role was in entertainment. It was used in December 1844 for painless tooth extraction by American dentist Horace Wells. Demonstrating it the following year, at Massachusetts General Hospital, he made a mistake and the patient suffered considerable pain. This lost Wells any support. Another dentist, William E. Clarke, performed an extraction in January 1842 using a different chemical, sulfuric ether (discovered in 1540). In March 1842 in Danielsville, Georgia, Dr. Crawford Williamson Long was the first to use anaesthesia during an operation, giving it to a boy before excising a cyst from his neck; however, he did not publicize this information until later. On the 16th of October 1846, another dentist, William Thomas Green Morton, invited to the Massachusetts General Hospital, performed the first public demonstration of sulfuric ether as an anesthetic agent, for a patient undergoing an excision of a tumour from his neck. In a letter to Morton shortly thereafter, Oliver Wendell Holmes, Sr. proposed naming the procedure anæsthesia. Despite Morton's efforts to keep "his" compound a secret, which he named "Letheon" and for which he received a US patent, the news of the discovery and the nature of the compound spread very quickly to Europe in late 1846. Here, respected surgeons, including Liston, Dieffenbach, Pirogoff, and Syme undertook numerous operations with ether. Ether had a number of drawbacks like its tendency to induce vomiting and its flammability. In England it was quickly replaced with chloroform. Discovered in 1831, its use in anaesthesia is usually linked to James Young Simpson, who, in a wide-ranging study of organic compounds, found chloroform's efficacy in 1847. Its use spread quickly and gained royal approval in 1853 when John Snow gave it to Queen Victoria during the birth of Prince Leopold. The surgical amphitheater at Massachusetts General Hospital, or "etherdome" still exists today, although it is used for lectures and not surgery. The public can visit the amphitheater on weekdays when it is not in use.

Anaesthetic equipment and physics

In modern anesthesia, a wide variety of medical equipment is desirable depending on the necessity for portable field use, surgical operations or intensive care support. An anaesthesiologist has to have a comprehensive and intricate knowledge of the production and use of various medical gases, anaesthetic agents and vapours, medical breathing circuits and the variety of anaesthetic machines (including vaporizers, ventilators and pressure gauges) and their corresponding safety features, hazards and limitations of each piece of equipment, for the safe, clinical competence and practical application for day to day practice.

Anaesthetic agents

Local anaesthetics

The first effective local anaesthetic was cocaine. Anaesthetics were used and are still used, in modern times to relax muscles and to help uneasy patients to sleep. Isolated in 1859 it was first used by Karl Koller, at the suggestion of Sigmund Freud, in ophthalmic surgery in 1884. Prior to that doctors had used a salt and ice mix for the numbing effects of cold - which could only have limited application. Similar numbing was also induced by a spray of ether or ethyl chloride. Cocaine soon produced a number of derivatives and safer replacements, including procaine (1905), Eucaine (1900), Stovaine (1904), and lidocaine (1943). Local anaesthetics are agents which prevent transmission of nerve impulses without causing unconsciousness. They act by binding to fast Sodium channels from within (in an open state). Classification: Local anaesthetics can be either ester or amide based. - Ester local anaesthetics (eg. procaine, amethocaine, cocaine) are generally fast acting, unstable in solution, and allergic reactions are common - Amide local anaesthetics (eg. lidocaine, prilocaine, bupivicaine, levobupivicaine, ropivicaine, dibucaine) are generally heat stable with a long shelf life of 2 years, with a slower onset (longer half life) and present in a racemic mixture. It is these type of local anaesthetic agents that are generally used within regional and epidural/spinal techniques namely due to their longer duration of action providing adequate analgesia suitable for surgery, labour and symptomatic relief. NB: only local anaesthetic agents that are preservative free may be injected intrathecally (i.e within the epidural or subarachnoid space)

Early opioids and hypnotics

Opioids were first used by Racoviceanu-Pitesti, who reported his work in 1901.

Current pharmacological agents

- Thiopental (first used in 1934)
- Intravenous benzodiazepine
- Propofol (2,6-di-isopropyl-phenol)
- Etomidate (an imidazole derivative)
- Ketamine (a phencyclidine derivative, as is 'Angel Dust/Special K')
- Curare (1942) (A non-depolarizing neuromuscular blocking agent or paralyzing drug). Newer drugs of this type include vecuronium, rocuronium, atracurium, cisatracurium and mivacurium.
- Succinylcholine (A depolarizing neuromuscular blocking agent or paralyzing drug)
- Halothane (d 1951 Charles W. Suckling, 1956 James Raventos
- Enflurane (d 1963 u 1972), isoflurane (d 1965 u 1971), desflurane, sevoflurane
- New synthetic opioids - fentanyl (d 1960 Paul Janssen), alfentanil, sufentanil (1981), remifentanil, meperidine
- Neurosteroids

Volatile agents

These are specially formulated gaseous vapors for the use of induction or maintenance of general anaesthesia. The ideal anesthetic vapor or gas should be non-flammable; non-explosive; non-lipid soluble; have no end organ (heart, liver, kidney) side effects; not be metabolized and be easy and comfortable to deliver to the patient. No anesthetic gas currently in use meets all of these requirements. The vapors in current use are Halothane, Isoflurane, Desflurane and Sevoflurane. Nitrous Oxide is still in widespread use, making it one of the most long lived and successful drugs in use. Ether is still used in poorer countries as it is safe, particularly when administered by untrained personel, it also very cheap. In theory any anesthetic vapor can be used for induction of general anesthesia, however some of the vapors are very irritating to the airway. All of the modern vapors can be used alone or in combination with other medications to maintain anesthesia. Currently research into the use of Xenon as an anesthetic gas is being pursued but it is very expensive and may require special equipment for delivery and recovery to be used. Volatile agents are compared in terms of potency, which is inversely proportional to the MAC : >> For more detailed information: minimum alveolar concentration

Choice of anesthetic technique

The choice of anesthetic technique is a complex one, requiring consideration of both patient and surgical factors. In certain patient populations, however, regional anesthesia may be safer than general anesthesia. Neuraxial blockade may reduce the risk of deep vein thrombosis, pulmonary embolism, transfusion, pneumonia, respiratory depression, myocardial infarction and renal failure[http://bmj.bmjjournals.com/cgi/content/full/321/7275/1493][http://bmj.bmjjournals.com/cgi/eletters/321/7275/1493].

External links

- Patient information
- [http://www.gasnet.org/patientlinks.php Information for patients]
- [http://www.oyston.com/anaes/ Patient's guides and more anaesthesia-related information]
- Historical
- [http://www.histansoc.org.uk/ History of Anaesthesia society]
- [http://www.anesthesia-nursing.com/ether.html The Unusual History of Ether]
- [http://neurosurgery.mgh.harvard.edu/History/ether3.htm Conquering surgical pain: Four men stake their claim]
- [http://www.hmcnet.harvard.edu/anesthesia/history/vandam.html A History of Anaesthesia at Harvard University]
- Worldwide anaesthesia associations and links
- [http://www.aagbi.org/ Association of Anaesthetists of Great Britain and Ireland]
- [http://www.aana.com/ American Association of Nurse Anesthetists]
- [http://www.asahq.org/ American Society of Anesthesiologists]
- [http://www.rcoa.ac.uk/ Royal College of Anaesthetist], UK professional body for anaesthetist
- [http://www.frca.co.uk/ FRCA UK]United Kingdom Resource for professional anaesthesist in training
- Anaesthesia resources
- [http://www.nda.ox.ac.uk/wfsa/ World Anaesthesia Online], international resource of anaesthetic articles
- [http://www.nysora.com/ New York School of Regional Anesthesia], par excellent resource for regional anesthesia
- [http://aip.kolivas.net/ A medical student's guide to anaesthesia from a patient's perspective]
- [http://www.gasnet.org/ Gasnet], a comprehensive anaesthesiology resource
- [http://www.bartleby.com/65/ac/acupunct.html Columbia Encyclopedia-Acupuncture]
- [http://www.library.ucla.edu/libraries/biomed/his/painexhibit/index.html University of California Pain Alleviation and Anesthesia Exhibit] category:anesthesia category:anesthetic equipment ja:麻酔 simple:Anesthetic

Menses

The menstrual cycle is the set of recurring physiological changes in a female's body that are under the control of the reproductive hormone system and necessary for reproduction. In women, menstrual cycles occur typically on a monthly basis between puberty and menopause. Besides humans, only other great apes exhibit menstrual cycles, in contrast to the estrus cycle of most mammalian species. During the menstrual cycle, the sexually mature female body releases one egg (or occasionally two, which might result in dizygotic, or non-identical, twins) at the time of ovulation. The lining of the uterus, the endometrium, builds up in a synchronised fashion. After ovulation, this lining changes to prepare for potential implantation of the fertilised egg to establish a pregnancy. If fertilisation and pregnancy do not ensue, the uterus sheds the lining and a new menstrual cycle begins. The process of the shedding of the lining is called menstruation. Menstruation manifests itself to the outer world in the form of the menses (also menstruum): essentially part of the endometrium and blood products that pass out of the body through the vagina. Although this is commonly referred to as blood, it differs in composition from venous blood. Common usage refers to menstruation and menses as a period. This bleeding serves as a sign that a woman has not become pregnant. (However, this cannot be taken as certainty, as sometimes there is some bleeding in early pregnancy.) During the reproductive years, failure to menstruate may provide the first indication to a woman that she may have become pregnant. A woman might say that her "period is late" when an expected menstruation has not started and she might have become pregnant. Menstruation forms a normal part of a natural cyclic process occurring in healthy women between puberty and the end of the reproductive years. The onset of menstruation, known as menarche, occurs at an average age of 12, but can occur any time between the ages of 8 and 16. The last period, menopause, usually occurs between the ages of 45 and 55. Deviations from this pattern deserve medical attention. Amenorrhea refers to a prolonged absence of menses during the reproductive years of a woman for reasons other than pregnancy. For example, women with very low body fat, such as athletes, may cease to menstruate. The presence of menstruation does not prove that ovulation took place; women who do not ovulate may have menstrual cycles. Those anovulatory cycles tend to take place less regularly and show greater variation in cycle length. In addition, the absence of menstruation also does not prove that ovulation did not take place, because hormone disruptions in non-pregnant women can suppress bleeding on occasion.

The normal menstrual cycle in humans

Women show considerable variation in the lengths of their menstrual cycles, and the length of the menstrual cycle differs in different animals (see below). While cycle length may vary, 28 days is generally taken as representative of the average ovulatory cycle in women. Convention uses the onset of menstrual bleeding to mark the beginning of the cycle, so the first day of bleeding is called "Cycle Day one". One can divide the menstrual cycle into four phases:

Menstruation

Menstruation lasts for a few days (usually 3 to 5 days, but anywhere from 2 to 7 days is considered normal) and involves the loss of about 50 millilitres of blood (including shed lining). An enzyme called plasmin — contained in the endometrium — inhibits the blood from clotting. Because of this blood loss, women have higher dietary requirements for iron than do males to prevent iron deficiency. Many women experience uterine cramps, also referred to as dysmenorrhea, during this time. A vast industry has grown to provide sanitary products to help women to manage their menses. The tampon is a common product.

Follicular phase

Through the influence of a rise in Follicle stimulating hormone (FSH), five to seven tertiary-stage ovarian follicles are recruited for entry into the menstrual cycle. These follicles, that have been growing for the better part of a year in a process known as folliculogenesis, compete with each other for dominance. In a signal cascade kicked off by luteinizing hormone (LH), the follicles secrete estradiol, a steroid that acts to inhibit pituitary secretion of FSH. With diminished FSH supply comes a slowing in growth that eventually leads to follicle death, known as atresia. The largest follicle secretes inhibin that serves as a finishing blow to less competent follicles by further suppressing FSH. This dominant follicle continues growing, forms a bulge near the surface of the ovary, and soon becomes competent to ovulate. The follicles also secrete estrogens (of which estradiol is a member). Estrogens initiate the formation of a new layer of endometrium in the uterus, histologically identified as the proliferative endometrium. If fertilised, the embryo will implant itself within this hospitable flesh.

Ovulation

embryo When the follicle has matured, it secretes enough estradiol to trigger the acute release of luteinizing hormone (LH). In the average cycle this LH surge starts around cycle day 12 and may last 48 hours. The release of LH matures the egg and weakens the wall of the follicle in the ovary. This process leads to ovulation: the release of the now mature ovum, the largest cell of the body (with a diameter of about 0.5 mm). Which of the two ovaries — left or right — ovulates appears essentially random; no known left/right co-ordination exists. The Fallopian tube needs to capture the egg and provide the site for fertilisation. A characteristic clear and stringy mucus exhibiting spinnbarkeit develops at the cervix, ready to accept sperm from intercourse. In some women, ovulation features a characteristic pain called Mittelschmerz which lasts for several hours. The sudden change in hormones at the time of ovulation also causes light mid-cycle bleeding for some women. Many women perceive the vaginal and cervical mucus changes at ovulation, particularly if they are monitoring themselves for signs of fertility. An unfertilised egg will eventually disintegrate or dissolve in the uterus. Scientific investigations have indicated that the olfactory acuity or the sense of smell is greatest during ovulation in women.

Luteal phase

The corpus luteum is the solid body formed in the ovaries after the egg has been released from the fallopian tube which continues to grow and divide for a while. After ovulation, the residual follicle transforms into the corpus luteum under the support of the pituitary hormones. This corpus luteum will produce progesterone in addition to estrogens for approximately the next 2 weeks. Progesterone plays a vital role in converting the proliferative endometrium into a secretory lining receptive for implantation and supportive of the early pregnancy. It raises the body temperature by half- to one degree Fahrenheit (one-quarter to one-half degree Celsius), thus women who record their temperature on a daily basis will notice that they have entered the luteal phase. If fertilisation of an egg has occurred, it will travel as an early embryo through the tube to the uterine cavity and implant itself 6 to 12 days after ovulation. Shortly after implantation, the growing embryo will signal its existence to the maternal system. One very early signal consists of human chorionic gonadotropin (hCG), a hormone that pregnancy tests can measure. This signal has an important role in maintaining the corpus luteum and enabling it to continue to produce progesterone. In the absence of a pregnancy and without hCG, the corpus luteum demises and inhibin and progesterone levels fall. This will set the stage for the next cycle. Progesterone withdrawal leads to menstrual shedding (progesterone withdrawal bleeding), and falling inhibin levels allow FSH levels to rise to raise a new crop of follicles.

Menstrual symptoms

In many women, various unpleasant symptoms caused by the involved hormones and by cramping of the uterus can precede or accompany menstruation. More severe symptoms may include significant menstrual pain (dysmenorrhea), abdominal pain, migraine headaches, depression and irritability. Some women encounter premenstrual stress syndrome (PMS or premenstrual syndrome), a cyclic clinical entity. Breast discomfort caused by premenstrual water retention is very common. The list of symptoms experienced varies from person to person. Furthermore, within an individual, the severity of the symptoms may vary from cycle to cycle.

The fertile window

The length of the follicular phase — and consequently the length of the menstrual cycle — may vary widely. The luteal phase, however, almost always takes the same number of days. Some women have a luteal phase of 10 days, others of 16 days (the average is 14 days), but for each individual woman, this length will remain constant. Sperm survive inside a woman for 3 days on average, with survival time up to five days considered normal. A pregnancy resulting from sperm life of eight days has been documented . The most fertile period (the time with the highest likelihood of sexual intercourse leading to pregnancy) covers the time from some 5 days before ovulation until 1–2 days after ovulation. In an average 28 day cycle with a 14-day luteal phase, this corresponds to the second and the beginning of the third week of the cycle. Fertility awareness methods of birth control attempt to determine the precise time of ovulation in order to find the relatively fertile and the relatively infertile days in the cycle. People who have heard about the menstrual cycle and ovulation may commonly and mistakenly assume, for contraceptive purposes, that menstrual cycles always take a regular 28 days, and that ovulation always occurs 14 days after beginning of the menses. This assumption may lead to unintended pregnancies. Note too that not every bleeding event counts as a menstruation, and this can mislead people in their calculation of the fertile window. If a woman wants to conceive, the most fertile time occurs between 19 and 10 days prior to the expected menses. Many women use ovulation detection kits that detect the presence of the LH surge in the urine to indicate the most fertile time. Other ovulation detection systems rely on observation of one or more of the three primary fertility signs (basal body temperature, cervical fluid, and cervical position). Among women living closely together, the onsets of menstruation may tend to synchronise somewhat. Researchers first described this phenomenon in 1971, and explained it by the action of pheromones in 1998 (Stern and McClintock 1998). However, subsequent research has called this conclusion into question.

Hormonal control

Extreme intricacies regulate the menstrual cycle. For many years, researchers have argued over which regulatory system has ultimate control: the hypothalamus, the pituitary, or the ovary with its growing follicle; but all three systems have to interact. In any scenario, the growing follicle has a critical role: it matures the lining, provides the appropriate feedback to the hypothalamus and pituitary, and modifies the mucus changes at the cervix. Two sex hormones play a role in the control of the menstrual cycle: estradiol and progesterone. While estrogen peaks twice, during follicular growth and during the luteal phase, progesterone remains virtually absent prior to ovulation, but becomes critical in the luteal phase and during pregnancy. Many tests for ovulation check for the presence of progesterone. These sex hormones come under the influence of the pituitary gland, and both FSH and LH play necessary roles. FSH stimulates immature follicles in the ovaries to grow. LH triggers ovulation. The gonadotropin-releasing hormone of the hypothalamus controls the pituitary, yet both the pituitary and the hypothalamus receive feedback from the follicle. After ovulation the corpus luteum — which develops from the burst follicle and remains in the ovary — secretes both estradiol and progesterone. Only if pregnancy occurs do hormones appear in order to suspend the menstrual cycle, while production of estradiol and progesterone continues. Abnormal hormonal regulation leads to disturbance in the menstrual cycle. Some women with neurological conditions experience increased activity of their conditions at about the same time every month. 80 percent of women with epilepsy have more seizures than usual in the phase of their cycle when progresterone declines and estrogen increases. Mice have been used as an experimental system to investigate possible mechanisms by which levels of sex steroid hormones might regulate nervous system function. During the part of the mouse estrous cycle when progesterone is highest, the level of nerve-cell GABA receptor subtype delta was high. Since these GABA receptors are inhibitory, nerve cells with more delta receptors are less likely to fire than cells with lower numbers of delta receptors. During the part of the mouse estrous cycle when estrogen levels are higher than progesterone levels, the number of delta receptors decrease, increasing nerve cell activity, in turn increasing anxiety and seizure susceptibility. (Maguire et al., 2005)

Hidden ovulation

Unlike other species, human women have concealed ovulation. A woman may sense her own ovulation while it may remain indiscernible to others; this is considered to have sociobiological significance. In contrast, other species often signal receptivity through heat. In this context, evidence suggests that women's preferences for men may change during their most fertile days; that is, before and shortly after ovulation. During this time, they may prefer different male scents, more masculine faces, and social presence in males considered as partners. (Gangestad 2004; debated) Women, especially young teens, have been noted to dress more provocatively, to say that they feel sexier, to flirt more, and to be more likely to initiate sexual activity around the time of ovulation than they did at other points in their menstrual cycle. Most of this, especially in younger women, appears to be subconscious.

The ovary as an egg-bank

Evidence suggests that eggs are formed from germ cells early in fetal life. The number is reduced to an estimated 400,000 to 450,000 immature eggs residing in each ovary at puberty. The menstrual cycle, as a biologic event, allows for ovulation of one egg typically each month. Thus over her lifetime a woman will ovulate approximately 400 to 450 times. All the other eggs dissolve by a process called atresia. As a woman's total egg supply is formed in fetal life, to be ovulated decades later, it has been suggested that this long lifetime may make the chromatin of eggs more vulnerable to division problems, breakage, and mutation than the chromatin of sperm, which are produced continuously during a man's reproductive life. This possibility is supported by the observation that fetuses and infants of older mothers have higher rates of chromosome abnormalities than those of older fathers.

The anovulatory menstrual cycle

Not all menstruations result from an ovulatory menstrual cycle. In some women, follicular development may start but not complete, nevertheless estrogens will form and will stimulate the uterine lining. Sooner or later the uterus will shed this lining. As no ovulation and no progesterone involvement occurs, doctors call this type of bleeding an estrogen breakthrough bleeding, and cannot always predict its duration or frequency. Anovulatory bleeding commonly occurs prior to menopause (premenopause) or in women with polycystic ovary syndrome.

Cycle abnormalities

Frequency

The "normal menstrual cycle" occurs every 28 days ± 7 days. The medical term for cycles with intervals of 21 days or fewer is polymenorrhea and, on the other hand, the term for cycles with intervals exceeding 35 days is oligomenorrhea (or amenorrhea if intervals exceed 180 days).

Flow

The normal menstrual flow amounts to 50 ml ± 30 ml. It follows a "crescendo-decrescendo" pattern; that is, it starts at a moderate level, increases somewhat, and then slowly tapers. Sudden heavy flows or amounts in excess of 80 ml (hypermenorrhea or menorrhagia) may stem from hormonal disturbance, uterine abnormalities, including uterine leiomyoma or cancer, and other causes. Doctors call the opposite phenomenon, of bleeding very little, hypomenorrhea.

Duration

The typical woman bleeds ("is on her period") for three to seven days out of each month. Prolonged bleeding (metrorrhagia, also meno-metrorrhagia) no longer shows a clear interval pattern. Dysfunctional uterine bleeding refers to hormonally caused bleeding abnormalities, typically anovulation. All these bleeding abnormalities need medical attention; they may indicate hormone imbalances, uterine fibroids, or other problems. As pregnant patients may bleed, a pregnancy test forms part of the evaluation of abnormal bleeding.

The birth control pill

Estrogens and progesterone-like hormones make up the main active ingredients of birth control pills. Typically they tend to mimic a menstrual cycle in appearance, but to suppress the critical event of the ovulatory cycle, namely ovulation. Normally, a woman takes hormone pills for 21 days, followed by 7 days of non-functional placebo sugar pills or no pills at all; then the cycle starts again. During the 7 placebo days, a withdrawal bleeding occurs; this differs from ordinary menstruation, and skipping the placebos and continuing with the next batch of hormone pills may suppress it. (Two main versions of the pill exist: monophasic and triphasic. With triphasic pills, skipping of the placebos and continuing with the next month's dose can remove the pill's pregnancy protection.) In 2003 the United States Food and Drug Administration (FDA) approved low-dose monophasic birth control pills which induce withdrawal bleedings only every 3 months.

Etymology and the lunar month

The terms "menstruation" and "menses" come from the Latin mensis (month), which in turn relates to the Greek mene (moon) and to the roots of the English words month and moon — reflecting the fact that the moon also takes close to 28 days to revolve around the Earth (actually 27.32 days). The synodical lunar month, the period between two new moons (or full moons), is 29.53 days long. Many women, after a period of not being exposed to artificial nighttime lighting, find their menstrual cycles begin to occur in rhythm with the lunar cycle.

Menstrual products

While some women allow their menses to flow freely or learn to recognise when their menses will flow, most women prefer to use some artifical means to absorb or catch their menses to prevent soiling their clothes. There are a number of different methods used:
- Sanitary towels, sanitary napkins, or pads - Rectangular pieces of material worn in the underpants to absorb menstrual flow, often with "wings," pieces that fold around the panties, or a sticky backing to hold the pad in place. Reusable cloth pads are made of cotton (often organic), terrycloth, or flannel, and may be handsewn (from material or reused old clothes and towels) or storebought. Disposable synthetic pads are made of wood pulp or synthetic products, usually with a plastic lining and bleached.
- Tampons - Disposable wads of treated rayon/cotton blends or all-cotton fleece, usually bleached, that are inserted into the vagina to absorb menstrual flow. Some women also make their own tampons from rolled up cotton strips.
- Menstrual cups - A firm, flexible cup- or bell-shaped device worn inside the vagina to catch menstrual flow. Reusable versions include rubber or silcone cups (like the Keeper, Divacup, [http://www.lunette.fi Lunette] and Mooncup). Disposable versions come in soft plastic cups (like Instead).
- Sea sponges - Reuseable soft sponges from plant-like animals that grow on the ocean floor, worn internally to absorb blood.
- Padettes - Disposable wads of treated rayon/cotton blend fleece that are placed within the inner labia to absorb menstrual flow.
- Padded panties - Reuseable cloth (usually cotton) underwear with extra absorbent layers sewn in to absorb flow.
- Blanket, towel, or "bleeding blankie" - Large reuseable piece of cloth, most often used at night, placed between legs to absorb menstrual flow. Pharmaceutical companies also provide products — commonly Non-steroidal anti-inflammatory drugs (NSAIDs) — to relieve menstrual cramps.

Debate

Much debate centers around which menstrual products to use. The main debate can be summarized as one between the convenience, availability, and general knowledge of disposables versus the environmental, monetary, and potential health benefits of reuseables. A secondary aspect of this is commercial responsibility. Disposable menstrual products compose a large and powerful industry in the West, with a near monopoly on advertising, supermarket shelves, and menstrual education, leading many people to believe that these corporate products are their only options. Many people object to the negative portrayal of menstruation in advertising as shameful, unnatural, stinking, and hindering. In contrast, the reuseable menstrual products industry is composed mostly of small, independent, and woman-owned, woman-positive businesses. Finally, some believe that the disposable menstrual products industry is imperialist, forcing or coercing women of other cultures to leave their resueable, inexpensive or free menstrual products to become consumers of disposables. A summary of the main issues of debate: ; Environmental waste : Tampons, pads, disposable cups and their packaging generate tons of bulky waste per year, much of which is not biodegradable. ; Cost : Many disposables have a cheaper upfront cost than reuseables, but over time (a period of a few months), this cost is recouped many times over from savings on reuseables. Many reuseables can also be made for free from old clothes or scraps of cloth. ; Health concerns : 1. Bleaching - Many women object to the chlorine bleaching of disposable menstrual products, which leaves trace amounts of dioxin, a carcinogen, in them. 2. Scents and deodorizers - Chemical scents and deodorizers can cause rashes, irritation, and allergic reactions. They can upset the pH balance of the vagina and cause yeast infections. ; Health concerns specific to tampons : Toxic Shock Syndrome is caused by Staphylococcus aureus, which can thrive the environment found in tampon fibers. It is important to remember that TSS is very rare, with only approx. 40 cases per year in the UK. Tampon-associated TSS is not a staph infection. It is caused when the bacteria release a protein called toxic shock syndrome toxin (TSST). TSST is absorbed into the body where it acts as a toxin. Toxic Shock Syndrome can, and does, cause death. TSS can be avoided by using the least absorbent tampon possible for one's flow, and changing tampons at least every 8 hours, or by avoiding tampons altogether. This may apply to sea sponges also, though no cases of TSS with sea sponge use have been reported.

Culture and menstruation

Mysticism

Mystics have sometimes elaborated "equivalencies", analogising the waxing and waning of the moon with influences on human menstruation. In this spiritual, moon goddess, or astrological context some women call menstruation their "moontime". Some ancient views also regarded menstruation as a cleansing of the body: compare bloodletting as a major medical treatment of pre-modern times.

Religion

Some religions consider women "unclean" during menstruation.

Islam on menstruation

The Islamic world considers a woman "not in a state to have intercourse" during menstruation. A verse from the Qur'an (with parenthesised interpolations by Dr. Muhammed Muhsin Khan) affirms this:

"They ask you concerning menstruation. Say: that is an Adha (a harmful thing for a husband to have sexual intercourse with his wife while she is having her menses), therefore keep away from women during menses and go not unto them till they have purified (from menses and have taken a bath). And when they have purified themselves, then go in unto them as Allâh has ordained for you. Truly, Allâh loves those who turn unto Him in repentance and loves those who purify themselves (by taking a bath and cleaning and washing thoroughly their private parts, bodies, for their prayers, etc.)." (Al-Baqarah 2:222)

See [http://63.175.194.25/index.php?ln=eng&ds=qa&lv=browse&QR=43028&dgn=4 an Islamic review] on the subject.

Judaism on menstruation

A ritual exclusion applies to a woman while menstruating and for about a week thereafter, until she immerses herself in a mikvah (ritual bath).

Menstruation in other mammals

A regular menstrual cycle as described here only occurs in the great apes. Menstrual cycles vary in length from an average of 29 days in orangutans to an average of 37 days in chimpanzees. Females of other mammalian species go through certain episodes called "estrus" or "heat" in each breeding season. During these times, ovulation occurs and females become receptive to mating, a fact advertised to males in some way. If no fertilisation takes place, the uterus reabsorbs the endometrium: no menstrual bleeding occurs. Significant differences exist between the estrus and the menstrual cycle. Some animals, such as domestic cats and dogs do produce a very short and mild menstural flow, however due to its small amount (and personal cleanliness in cats) it passes pet owners largely unnoticed.

References

- K. Stern and M. K. McClintock: "[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=9515961 Regulation of ovulation by human pheromones.]" Nature, 392 (1998), pages 177 – 179.
- Gangestad et al.: "[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15016293 Women's preferences for male behavioral displays change across the menstrual cycle.]" Psychological Science, March 2004, vol. 15, no. 3, pages 203 - 207
-

Notes

# "[http://www.4woman.gov/faq/menstru.htm#6 At what age does a girl get her first period?]," from Menstruation and the Menstrual Cycle, National Women's Health Information Center (accessed June 11, 2005). # Ibid., "[http://www.4woman.gov/faq/menstru.htm#4 What is a typical menstrual period like?]" (accessed June 11, 2005). # "Lower olfactory threshold during the ovulatory phase of the menstrual cycle" by E. Navarrete-Palacios, R. Hudson, G. Reyes-Guerrero and R. Guevara-Guzman in Biol Psychol. (2003) volume 63 page 269-279 . # M. Ball, "A prospective field trial of the Ovulation Method", European Journal of Obstetrical and Gynaecological Reproductive Biology, 6/2, 63-6, 1976. (Summarized at [http://www.woomb.org/bom/trials/index.html Trials of the Billings Ovulation Method] accessed November 3, 2005) # "Medical Microbiology" 4th ed. [http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Search&db=books&doptcmdl=GenBookHL&term=toxic+shock+syndrome+AND+mmed%5Bbook%5D+AND+147524%5Buid%5D&rid=mmed.section.769#775 Online textbook] Samule Baron, editor. (1996) Published by University of Texas Medical Branch; Galveston (TX)

External links

- Harry Finley: Online museum of menstruation and women's health, http://mum.org/
- [http://www.powerhousemuseum.com/rags/ The rags: paraphernalia of menstruation]
- Menstral - track your periods and fertility on your cell phone: http://procod.com/menstral/
- [http://www.bloodays.com/ Bloodays - Software for tracking ovulation, natural conception and contraceptions]
- [http://www.ovusoft.com/ Ovusoft - Software for tracking ovulation and other cycle-related events, community message boards]
- Track your likely ovulatory date with this free [http://www.ovulation-calendar.net/ Ovulation Calendar]
- [http://www.perimon.com/ Free Software to watch the menstrual cycle etc.]
- Mencal - calendar software for UNIX-style operating systems with the ability to highlight repeating cycles: http://kyberdigi.cz/projects/mencal/english.html
- Leslie Botha-Williams, Women's Health Educator: A Woman's Guide to Understanding Her Hormone Cycle, http://www.holyhormones.com
- [http://63.175.194.25/index.php?ln=eng&ds=qa&lv=browse&QR=43028&dgn=4 An Islamic answer for the ruling of women menstruating]
- Menstrual Suppression With Birth Control Pills http://www.noperiod.com
- [http://www.livejournal.com/users/incendiaryfs/204904.html Love Your Blood: An info-zine on menstrual products and their alternatives]
- [http://www.seac.org/tampons/ Tampaction] and [http://bloodsisters.org/bloodsisters/ The Bloodsisters Project]- Menstrual activism against chlorine bleaching, excessive packaging, and negative attitudes toward menstruation in the West
- [http://www.scarleteen.com/body/ontherag.html On The Rag: Everything you need to know about your fertility cycles and menstruation...period] - Article on the menstrual cycle by notable sex activist and educator Heather Corinna
- [http://www.scarleteen.com/pink/washable.html Eight Myths About Washable Menstrual Pads Dispelled] Category:Reproductive system Category:Gynecology ja:月経

PCOS

Polycystic ovary syndrome (PCOS, also known clinically as Stein-Leventhal syndrome), is an endocrine disorder that affects 5–10% of women. It occurs amongst all races and nationalities, is the most common hormonal disorder among women of reproductive age, and is a leading cause of infertility. The symptoms and severity of the syndrome vary greatly between women. While the causes are unknown, insulin resistance (often secondary to obesity) is heavily correlated with PCOS.

Nomenclature

Other names for this disorder include:
- Polycystic ovary disease (although this is not correct, as PCOS is characterised as a syndrome rather than a disease)
- Functional ovarian hyperandrogenism
- Hyperandrogenic chronic anovulation
- Ovarian dysmetabolic syndrome
- Ovarian androgen excess

Definition

There are two definitions that are commonly used: #In 1990 a consensus workshop sponsored by the NIH/NICHD suggested that a patient has PCOS if she has (1) signs of androgen excess (clinical or biochemical), (2) oligoovulation, and (3) other entities are excluded that would cause polycystic ovaries. #In 2003 a consensus workshop sponsored by ESHRE/ASRM in Rotterdam indicated PCOS to be present if 2 out of 3 criteria are met: (1) oligoovulation and/or anovulation, (2) excess androgen activity, (3) polycystic ovaries (by gynecologic ultrasonography), and other causes of PCOS are excluded. The Rotterdam definition is wider, including many more patients, notably patients without androgen excess, while in the NIH/NICHD definiton androgen excess is a prerequisite. Critics maintain that findings obtained from the study of patients with androgen excess cannot be necessarily extrapolated to patients without androgen excess.

Signs and symptoms

Common symptoms of PCOS include:
- Oligomenorrhea, amenorrhea - irregular/few, or absent, menstrual periods; cycles that do occur may comprise heavy bleeding (check with a gynaecologist, since heavy bleeding is also an early warning sign of endometrial cancer, for which women with PCOS are at higher risk)
- Infertility, generally resulting from chronic anovulation (lack of ovulation)
- Elevated serum (blood) levels of androgens (male hormones), specifically testosterone, androstenedione, and dehydroepiandrosterone sulfate (DHEAS), causing hirsutism and occasionally masculinization
- Central obesity - "apple-shaped" obesity centered around the lower half of the torso
- Androgenic alopecia (male-pattern baldness)
- Acne / oily skin / seborrhea
- Acanthosis nigricans (dark patches of skin, tan to dark brown/black)
- Acrochordons (skin tags) - tiny flaps of skin
- Prolonged periods of PMS-like symptoms (bloating, mood swings, pelvic pain, backaches)
- Sleep apnea Signs are:
- Multiple cysts on the ovaries. Sonographycally they may present as a "string of pearls".
- Enlarged ovaries, generally 1.5 to 3 times larger than normal, resulting from multiple cysts
- Thickened, smooth, pearl-white outer surface of ovary
- Chronic pelvic pain, possibly due to pelvic crowding from enlarged ovaries; however, the actual cause is not yet known
- The ratio of LH (Luteinizing hormone) to FSH (Follicle stimulating hormone) is 2:1 or more, particularly in the early phase of the menstrual cycle.
- Increased levels of testosterone.
- Decreased levels of sex hormone binding globulin.
- Hyperinsulinemia.

Risks

Women with PCOS are at risk for the following:
- Endometrial hyperplasia and endometrial cancer (cancer of the uterine lining) are possible, due to overaccumulation of uterine lining, and also lack of progesterone resulting in prolonged stimulation of uterine cells by estrogen
- Insulin resistance/Type II diabetes, generally thought to be caused by hyperinsulinaemia
- High blood pressure
- Dyslipidaemia (disorders of lipid metabolism - cholesterol and triglycerides)
- Cardiovascular disease Some data suggest that women with PCOS have an increased risk of miscarriages. As well, many women with PCOS have a difficult time conceiving, due to the irregular cycles and lack of ovulation. However, it is possible for these women to have normal pregnancies with the aid of medication and diet.

Diagnosis

It is vital to note that not all women with PCOS have polycystic ovaries, nor do all women with ovarian cysts have PCOS; although a pelvic ultrasound is a major diagnostic tool, it is not the only one. Diagnosis can be difficult, particularly because of the wide range of symptoms, and the variability of how they present themselves in individuals (which is why this disorder is characterized as a syndrome rather than a disease). There is a lot of controversy about the appropriate testing:
- gynecologic ultrasonography
- testosterone: free more sensitive than total
- Fasting biochemical screen and lipid profile
- 2-hour oral glucose tolerance test (GTT) in patients with risk factors (obesity, family history, history of gestational diabetes)and may indicate impaired glucose tolerance in 15-30% of obese women with PCOS. Frank diabetes can be seen in 6-8% of women with this condition.
- For exclusion purpose:
- Prolactin
- TSH
- 17-hydroxyprogesterone The role of other tests is more controversial, including:
- fasting insulin level or GTT with insulin levels (also called IGTT). Elevated insulin levels have been helpful to predict response to medication and may indicate women who will require either higher doses of metformin or the use of a second medication to significantly lower insulin levels. Elevated blood sugar and insulin values do not predict who responds to an insulin lowering medicaiton, low glycemic diet and exercise. Many women with normal levels may benefit from combination therapy. A hypoglycemic response where the two hour insulin level is higher and the blood sugar lower than fasting, is consistent with insulin resistance.
- LH:FSH ratio
- DHEAS
- SHBG
- Androstenedione

Differential diagnosis

As well, other causes of irregular/absent menstruation and hirsutism such as congenital adrenal hyperplasia, Cushing's syndrome, hyperprolactinemia and other pituitary and/or adrenal disorders, should be investigated.

Pathogenesis

PCOS develops when the ovaries are stimulated to produce excessive amounts of male hormones (androgens), particularly testosterone - either through the release of excessive luteinizing hormone (LH) by the pituitary gland, or due to high levels of insulin in the blood (hyperinsulinaemia) in women whose ovaries are sensitive to this stimulus. This syndrome acquired its most widely-used name because a common symptom is multiple (poly) ovarian cysts. These form where egg follicles matured, but were never released from the ovary due to abnormal hormone levels. These generally take on a 'string of pearls' appearance. The condition was first described in 1935 by Dr. Stein and Dr. Leventhal, hence its original name of Stein-Leventhal syndrome. Although the cause of PCOS is not known, research to date suggests that obesity is a prime indicator. It may have a genetic predisposition and further research into this possibility is currently taking place. No specific gene has been identified, and it is thought that there are many genes that could contribute to the development of PCOS. A majority of patients with PCOS -some investigators may say all - have insulin resistance. Their increased insulin levels contribute to or cause the abnormalities seen in the hypothalamic-pituitary-ovarian axis that lead to PCOS. Specifically hyperinsulinemia increases GnRH pulse frequency, LH over FSH dominance, increased ovarian androgen production, decreased follicular maturation, and decreased SHBG binding: all these steps leading to the development of PCOS. Insulin resistance is a common finding in obese people.

Treatment

Medical treatment of PCOS used to be directed mainly at the symptoms (ovarian and adrenal suppression, and anti-androgen therapy) and restoring ovulation. Some medications used for these purposes are:
- Oral contraceptives (ovarian suppression) - since these cause regular menstruation, they reduce the risk of endometrial carcinoma
- Spironolactone or finasteride (anti-androgen therapy) - reduce the excessive hair growth by blocking the effects of male hormones
- Clomiphene citrate and/or human chorionic gonadotropin or dexamethasone (inducing ovulation) Recent research suggests that the insulin resistance and over-release of insulin may be at the root of PCOS. Many women find [http://www.ivf.com/pcostreat.html insulin-lowering medications] such as metformin hydrochloride (Glucophage®), pioglitazone hydrochloride (Actos®), and rosiglitazone maleate (Avandia®) helpful to them, and indeed ovulation may resume when using these agents. Many women report that metformin use is associated with upset stomach , diarrhea and weight-loss. Both symptoms and weight-loss appear to be less with the extended release versions. Most published studies use either generic metformin or the regular, non- extended release version. Starting with a lower dose and gradually increasing the dosage over 2-3 weeks and taking the medication towards the end of a meal may reduce side effects. The use of basal body temperature charts or BBT charts is an effective way to follow progress. It may take up to six months to see results, but when combined with exercise and a low-glycemic diet up to 85% will improve menstrual cycle regularity and ovulation. Low-carbohydrate diets and sustained regular exercise are also beneficial. As well, initial research suggests that the risk of miscarriage is significantly reduced when Metformin is taken throughout pregnancy (9% as opposed to as much as 45%); however, further research needs to be done in this area. For patients who do not respond to these and related medications/procedures, the polycystic ovaries can be treated with surgical procedures such as:
- laparoscopy electrocauterization or laser cauterization
- ovarian wedge resection (rarely done now, because it is more invasive and has a 30% risk of adhesions, sometimes very severe, which can obstruct fertility)
- ovarian drilling

Reference

- Ehrmann DA. Polycystic ovary syndrome. N Engl J Med 2005;352:1223-36. PMID 15788499.

External links

-
- [http://www.ivf.com/pcostreat.html PCOS Treatment Overview from IVF.com]
- [http://centerforpcos.bsd.uchicago.edu/default.html The University of Chicago Center for Polycystic Ovary Syndrome]
- [http://www.pcosupport.org/ The Polycystic Ovarian Syndrome Association (PCOSA)]
- [http://www.soulcysters.com/ Soulcysters.com (support site for women with PCOS)]
- [http://www.posaa.asn.au/ Polycystic Ovarian Syndrome Association of Australia]
- [http://www.inciid.org/faq/pcos.html International Council on Infertility Information Dissemination - PCOS Frequenty Asked Questions]
- [http://www.infertilityblues.com InfertilityBlues.com - Mind Body Resources to Support Coping with PCOS]
- [http://www.ovarian-cysts-pcos.com Ovarian-cysts-pcos.com: Natural therapies and self-help strategies for PCOS]
- [http://www.pcoscoach.com PCOS Coach] Category:Gynecology Category:Endocrinology Category:Medical_conditions_related_to_obesity

Uterine fibroid

A leiomyoma (plural is 'leiomyomata') is a benign smooth muscle neoplasm that is not premalignant. They can occur in any organ, but the most common forms occur in the uterus and the esophagus.

Etymology

- Greek:
- leios = smooth
- muV = (myo) mouse or muscle
- oma = tumor
- Latin:
- Fibra = fiber

Uterine leiomyomata

Uterine fibroids are leiomyomata of the uterine smooth muscle. As other leimyomata, they are benign, but may lead to excessive menstrual bleeding (menorrhagia), often cause anemia and may lead to infertility. Enucleation is removal of fibroids without removing the uterus (hysterectomy), which is also commonly performed. Laser surgery (called myolysis) is increasingly used, and provides a viable alternative to surgery. Urine leiomyomas originate in the myometrium and are classified by location:
- Submucous – lie just beneath the endometrium.
- Intramural – lie within the uterine wall.
- Subserous – lies at the serosal surface of the uterus or may bulge out from the myometrium and can become pedunculated.

Esophageal

They are also the most common benign esophageal tumour, though this accounts for less than 1% of esophageal neoplasms. The remainder consists mainly of carcinomas.

References

- [http://www.merck.com/mrkshared/mmanual/home.jsp Merck Manual]: [http://www.merck.com/mrkshared/mmanual/section18/chapter240/240a.jsp Uterine fibroids]
- [http://www.emedicine.com/med/topic738.htm Esophageal Leiomyoma]
- [http://www.pathologyatlas.ro/Leiomyoma.html Atlas of Pathology] uterine leimyoma

External links

- [http://www.gyndr.com/myomectomy.php Laser myomectomy]
- [http://www.ayubmed.edu.pk/JAMC/PAST/16-1/NazliRev.htm Laparoscopic myomectomy]. Category:Anatomical pathology

Dilation and extraction

Intact dilation and extraction (IDX or Intact D&X), is a specific type of medical procedure —wherin a late-term fetus, is removed from the womb via the cervix (this includes miscarried and in the case of abortions, viable fetuses). In the case of a miscarriage it is used to remove a deceased fetus that is developed enough to require dilation of the cervix for extraction. The practice is highly controversial, because of its limited use for the abortion of a late-term fetus —ostensibly in cases where the health of the mother is threatened by carrying it to term. The controversial term partial-birth abortion refers to only a small subsection of IDX cases, and in that sense is a particularly objectionable example of abortion —used as an illustration and point of protest in the greater context of the abortion debate. In such use, the procedure has an extremely low rate of usage.

Overview

"Intact dilation and extraction" is the medical term for a surgical technique which can be used for the removal of a dead fetus after a late-term miscarriage, in which the patient's cervix is dilated and fetus extracted in substantially one piece. The term "dilation and extraction" or "D&X" was coined in 1992 by Dr. Martin Haskell, who developed the procedure as an alternative to dilation and evacuation or D&E (described below). The term "intact D&X" was later settled upon. "Intrauterine cranial decompression" is another medical term and is descriptive of this procedure, during which the fetal skull must be crushed and the contents emptied through a vacuum tube in order to fit through the birth canal.

Intact D&X Surgery

After preliminary procedures over a period of 2-3 days, to gradually dilate the cervix, and sometimes the administering of hormones to induce the process of labor, the doctor uses an ultrasound and forceps to take hold of the fetus' leg. The fetus is turned to a breech position, if necessary, and the doctor pulls one or both legs out of the birth canal, causing what is commonly known as the 'partial-birth' of the fetus. The doctor subsequently births the rest of the baby, usually without the aid of forceps, leaving only the head still inside the birth canal. With sufficient force, the doctor inserts scissors into the base of the back of the skull. The doctor spreads the scissors to widen the opening, and then inserts a suction catheter. The brain tissue is removed, killing the fetus, and allowing the rest of the fetus to pass easily. The collapsing of the brain is the major reason cited by pro-choice advocates who say that physical deformities of the fetus' head, such as hydrocephalus, may make the procedure medically necessary for the safety of the mother. The pro-life opponents say that caesarean section or draining the fetus' excess cerebrospinal fluid before birth can permit a safe live birth even in such cases. Since the procedure is so widely disputed, below are two descriptions of it from both a pro-life and pro-choice group.

National Right to Life Description of an Intact D & X

:This section provides the description that the Right to Life advocacy group uses for the procedure. :Partial-Birth Abortion :"Abortionists sometimes refer to these or similar types of abortions using obscure, clinical-sounding euphemisms such as "Dilation and Extraction" (D&X), or "intact D&E" (IDE) which mask the realities of how the abortions are actually performed." :"This procedure is used to abort women who are 20 to 32 weeks pregnant -- or even later into pregnancy.
- Guided by ultrasound, the abortionist reaches into the uterus, grabs the unborn baby’s leg with forceps, and pulls the baby into the birth canal, except for the head, which is deliberately kept just inside the womb. (At this point in a partial-birth abortion, the baby is alive.) Then the abortionist jams scissors into the back of the baby’s skull and spreads the tips of the scissors apart to enlarge the wound. After removing the scissors, a suction catheter is inserted into the skull and the baby’s brains are sucked out. The collapsed head is then removed from the uterus."

Planned Parenthood Description of D&E (not an Intact D&X)

:This section provides the description that Planned Parenthood uses for the procedure: :Dilation and Evacuation :Dilation and evacuation (D&E) is performed in two steps. :The first step of a D&E involves cervical preparation (softening and dilation). ::The vagina is washed with an antiseptic. ::Absorbent dilators may be put into the cervix, where they remain for several hours, sometimes overnight. Misoprostol may also be used to facilitate dilation of the cervix. :During the second step of a D&E ::The woman may be given medication to ease pain and/or prevent infection. ::A local anesthetic is injected into or near the cervix. General anesthesia can also be used. ::The dilators are removed from the cervix. ::The fetus and other products of conception are removed from the uterus with surgical instruments and suction curettage. This procedure takes about 10-20 minutes.
Circumstances in which the procedure is performed
Intact D&X procedures are rare, carried out in roughly 0.2% (two-tenths of one percent) of all abortions in the USA. This calculates to between 2500 and 3000 per year, using data from the Alan Guttmacher Institute for the year 2000 (out of 1.3 million abortions annually). They are performed at any time between the fifth and ninth month of pregnancy for various reasons, such as:
- The mother and baby are healthy, but the mother wishes to terminate her pregnancy.
- The fetus is dead (in which case the procedure is not an abortion).
- Fetal abnormality or other medical complications to pregnancy. Some of the babies which fall into this later category have developed hydrocephalus, a generally untreatable condition usually leading to fatal abnormalities or permanent and severe deformity and disability. Approximately 1 in 2,000 babies develop hydrocephalus while in the womb; this is about 5,000 a year in the United States. The defect is not usually discovered until late in the second trimester of pregnancy. If a baby develops hydrocephalus, the head may expand to a size of up to 250% of the radius of a normal newborn skull, making it impossible for it to pass through the cervix. In such a case, the physician may drain the excess fluid in utero using a syringe, thereby enabling a normal, vaginal live birth. Alternately, a caesarian section can be used for the safe delivery of a hydrocephalic baby, but with a larger than usual incision. Or the fetus can be aborted by an intact D&X procedure in which suction is used to extract both the brain and the fluid, before collapsing the fetal skull and withdrawing the dead fetus. In an Intact D&X, the cervix is first gradually dilated over a 2 to 3 day period. The fetus is delivered feet-first (breech). The surgeon inserts a sharp object into the back of the fetus' head, and inserts a vacuum tube through which the brains and its fluids are extracted. The head of the fetus contracts at this point and allows the fetus to be more easily removed from the uterus. The technique was pioneered by Dr. Martin Haskell in 1992. Intact D&X procedures are not performed during the first trimester, because there are better ways to perform abortions. There is no need to follow such a procedure because the fetus' head is quite small at this stage of gestation and can be quite easily removed from the woman's uterus.
Legal and political situation in the United States

About the terminology
When used to abort a live fetus, this procedure is referred to as "partial-birth abortion" in the media and among pro-life groups. In the medical field intact dilation and extraction is sometimes referred to as a D&X procedure (not to be confused with the D&E procedure dilation and evacuation, in which the fetus is dismembered before being removed from the womb).
Efforts to ban the procedure
dilation and evacuation Since 1995, led by Congressional Republicans, the United States House of Representatives and U.S. Senate have moved several times to pass measures banning the procedure. Congress passed two such measures by wide margins during Bill Clinton's presidency, but Clinton vetoed those bills in April 1996 and October 1997 on the grounds that they did not include health exceptions. Subsequent Congressional attempts at overriding the veto were unsuccessful. In 2003, however, opponents of the procedure succeeded in getting the Partial-Birth Abortion Ban Act (HR 760, S 3) signed into law; the House passed it on October 2 with a vote of 281-142, the Senate passed it on October 21 with a vote of 64-34, and President George W. Bush signed it into law on November 5. Through this legislation, a doctor could face up to two years in prison and face civil lawsuits for performing such an abortion. A woman who undergoes the procedure, however, cannot be prosecuted under the measure. The Act's particular definition of a partial-birth abortion is: : ... an abortion in which -- (A) the person performing the abortion deliberately and intentionally vaginally delivers a living fetus until, in the case of a head-first presentation, the entire fetal head is outside the body of the mother, or, in the case of breech presentation, any part of the fetal trunk past the navel is outside the body of the mother for the purpose of performing an overt act that the person knows will kill the partially delivered living fetus; and (B) performs the overt act, other than completion of delivery, that kills the partially delivered living fetus. Note that this definition of "partial-birth abortion" is not equivalent to "intact dilation & extraction," and covers a different range of procedures. The bill does not ban intact D&X when the fetus is already dead, making it clear that it is not a medical technique that is the issue, but the purposeful abortion of a fetus that is unacceptable, as it is perceived by many to be only inches away from classic infanticide. This infanticide protection enhancement was also addressed in the Born-Alive Infants Protection Act which protects babies who are born as the results of faulty abortions. The law contains an exception when the woman's life is at stake, the relevant text reading: :Sec. 1531. Partial-birth abortions prohibited :(a) ... This subsection does not apply to a partial-birth abortion that is necessary to save the life of a mother whose life is endangered by a physical disorder, physical illness, or physical injury, including a life-endangering physical condition caused by or arising from the pregnancy itself. Opponents of the law believe that this exception is far too narrow, arguing, among other things, that an abortion may be justified if a woman's health, and not just her life, is in danger. On November 6, 2003(?), through efforts of the American Civil Liberties Union and the National Abortion Federation, three United States district court judges issued temporary restraining orders against enforcement of the ban.
Legal and political situation in the United Kingdom
Questioned about UK government policy on the issue in Parliament, Baroness Andrews stated that "We are not aware of the procedure referred to as 'partial-birth abortion' being used in Great Britain. It is the Royal College of Obstetricians and Gynaecologist's (RCOG) belief that this method of abortion is never used as a primary or pro-active technique and is only ever likely to be performed in unforeseen circumstances in order to reduce maternal mortality or severe morbidity."

Partial-birth abortion

Partial birth abortion (PBA) refers to most intact dilation and extraction (IDX) procedures where the fetus is alive at the time of the procedure — thus resulting in an abortion of the fetus. IDX procedures are also called dilation and extraction (D&X), intact dilation & evacuation (Intact D&E, or IDE), and Intrauterine Cranial Decompression (for the purposes of this article, IDX will be the term of choice). While the term "Partial Birth Abortion" largely refers to IDX procedures, in broader contexts the term is sometimes applied to dilation and evacuation (D&E) procedures. Though often performed during the same developmental stage wherein most D&X procedures are done, D&E is a separate and distinct procedure from IDX. A D&E procedure differs in that the fetus is killed during the process of dismemberment before leaving the womb, rather than being extracted intact. The IDX procedure can also be used in late-term miscarriage cases. Two of the most well-known abortion practitioners who perform the IDX procedure, Dr. Martin Haskell and Dr. Leroy Carhart, have confirmed that in most cases the fetus is alive when the abortion procedure begins. Although accurate statistics detailing the number of partial birth abortions performed annually in the United States are not available, the number is usually estimated in the low thousands, comprising a small fraction of annual abortion procedures in the United States. Although not a proper medical term, partial-birth abortion is commonly used in public discussion of the procedure. Partial-birth abortion has been a central issue in the greater abortion debate.

Etymology

The procedure was first described as "Dilation and Extraction" by Cincinnati physician W. Martin Haskell, MD in a monograph that was distributed by the National Abortion Federation in September of 1992. [http://www.vanderbilt.edu/SFL/partial-birth_abortion.htm]. The term partial-birth abortion did not appear until several years later, when the Partial-Birth Abortion Ban Act of 1995 was introduced in the House of Representative on 14 June 1995. The law defined partial-birth abortion as "an abortion in which the person performing the abortion partially vaginally delivers a living fetus before killing the fetus and completing the delivery." That same year; however, Ohio enacted a law which referred to the procedure as dilation and extraction. In 2000, Ohio amended the law [http://onlinedocs.andersonpublishing.com/oh/lpExt.dll/PORC/13316/13a49/13a6f/13a9a?fn=document-frame.htm&f=templates&2.0#] to use the term partial birth feticide, as well as to overcome the unconstitution

Dilation and curettage

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