ch 14. Endometriosis

Posted: May 17, 2012 in Gynocology
  • Every month, a woman’s ovaries produce hormones that tell the cells lining the uterus (womb) to swell and get thicker. The body removes these extra cells from the womb lining (endometrium) when she gets her period.
  • If these cells (called endometrial cells) implant and grow outside the uterus, endometriosis results.Women with endometriosis typically have tissue implants on the ovaries, bowel, rectum, bladder, lining of the pelvic area and other Ectopic Locations.

Etiology :

  1. The cause of endometriosis is unknown.
  2. Retrograde menstruation :One theory is that the endometrial cells shed when you get your period travel backwards through the fallopian tubes into the pelvis, where they implant and grow. This is called .
  3. Aging : Endometriosis is typically diagnosed between ages 25 – 35, the condition probably begins about the time that regular menstruation begins.
  4. Genetics : Changes in Chromosome 10 can create Endometriosis.Any past family history of Endometriosis.
  5. Biomarkers : The one biomarker that has been used in clinical practice over the last 20 years is CA-125. However, its performance in diagnosing endometriosis is low, even though it shows some promise in detecting more severe disease.

    Retrigrade Menstuation

    Can for Endometrial Cyst or Chocolate cyst as a further complication.

Stages of Endometriosis :

Stage 1 (Minimal): Just a few endometrial implant; mostly found in the cul-de-sac and pelvic area.
Stage 2 (Mild): Moderate levels of endometriosis to mild levels that not only affect the above areas but can now affect the ovaries.
Stage 3 (Moderate): Moderate amount of disease and in extensive places around the pelvic cavity, with adhesions.
Stage 4 (Severe) : Extensive endomtrial implants sprinkled all throughout the pelvic cavity with adhesions; higher probability of infertility.

Symptoms :

  1. Dysmenorrhea – painful, sometimes disabling cramps during menses; pain may get worse over time (progressive pain), also lower back pains linked to the pelvis
  2. Chronic pelvic pain – typically accompanied by lower back pain or abdominal pain
  3. Dyspareunia – painful sex
  4. Dysuria – urinary urgency, frequency, and sometimes painful voiding

Diagnosis :

  1. Laparoscopy:  A surgical procedure where a camera is used to look inside the abdominal cavity
  2. Ultrasound and magnetic resonance imaging (MRI) : Use of imaging tests may identify endometriotic cysts or larger endometriotic areas. It also may identify free fluid often within the Recto-uterine pouch.
  3.  Biopsy : The diagnosis is based if Endometrium like tissues can be found on ectopic Locations.

ch. 13 Infertility

Posted: May 17, 2012 in Gynocology

Infertility means She/He cannot make a baby (conceive).

Types :

  • Primary infertility refers to couples who have not become pregnant after at least 1 year of unprotected sex (intercourse).
  • Secondary infertility refers to couples who have been pregnant at least once, but never again.
Requirements for Normal Reproduction :
1)Release of a normal preovulatory oocyte.
2)Production of adequate spermatozoa.
3)Normal transport of the gametes to the ampullary portion of the fallopian tube (where fertilization occurs).
4)Subsequent transport of the cleaving embryo into the endometrial cavity for implantation and development.

Etiology :

Female infertility :

  1. A fertilized egg or embryo does not survive once it sticks to the lining of the womb (uterus)
  2. The fertilized egg does not attach to the lining of the uterus
  3. The eggs cannot move from the ovaries to the womb
  4. The ovaries have problems producing eggs

Female infertility may be caused by:

  1. Autoimmune disorders, such as antiphospholipid syndrome (APS)
  2. Cancer or tumor
  3. Clotting disorders
  4. Diabetes
  5. Growths (such as fibroids or polyps) in the uterus and cervix
  6. Birth defects that affect the reproductive tract
  7. Excessive exercising
  8. Eating disorders or poor nutrition
  9. Use of certain medications, including chemotherapy drugs
  10. Drinking too much alcohol
  11. Obesity
  12. Older age
  13. Ovarian cysts and polycystic ovary syndrome (PCOS)
  14. Pelvic infection or pelvic inflammatory disease (PID)
  15. Scarring from sexually transmitted infection or endometriosis
  16. Thyroid disease
  17. Too little or too much hormones
Male infertility :
  1. A decrease in sperm count
  2. Sperm being blocked from being released
  3. Sperm that do not work properly

Male infertility can be caused by:

  1. Environmental pollutants
  2. Being in high heat for prolonged periods
  3. Birth defects
  4. Heavy use of alcohol, marijuana, or cocaine
  5. Too little or too much hormones
  6. Impotence
  7. Infection
  8. Older age
  9. Cancer treatments, including chemotherapy and radiation
  10. Scarring from sexually transmitted diseases, injury, or surgery
  11. Retrograde ejaculation
  12. Smoking
  13. Use of certain drugs, such as cimetidine, spironolactone, and nitrofurantoin

 Tests for diagnosis Female Infertility :

  1. Transvaginal Ultrasonography (TVUS)
  2. Hysterosalpingography (HSG)
  3. Hysteroscopy
  4. Laparoscopy
  5. History of Past Diseases

Tests for diagnosis Male Infertility :

  1. Scrotal Ultrasonography
  2. Transrectal Ultrasonography (TRUS)
  3. Complete Blood Count (CBC)
  4. FSH, Testosterone
  5. GC/Chlam, UA
  6. Renal and Liver Function
  7. Semen analysis
  8. Postejaculatory urinalysis
  9. Past sexually transmitted infection (STI).
  10. Varicocele  (widening of the Varicose veins along the cord that holds up a man’s testicles)
  11. Hernia
  12. History of Past Diseases

Infertility Treatment :

  • Treatment of infertility depends on the cause, diagnosis, duration of infertility, age of the partners and many personal preferences.
  • Some causes of infertility cannot be corrected.
  • A woman can still become pregnant with assisted reproductive technology or other procedures to restore fertility.
Increase frequency of intercourse: Two to three times a week of intercourse may improve fertility.

Sperm survive in the female reproductive tract for up to 72 hours, and an egg can be fertilized for up to 24 hours after ovulation.

General sexual problems:  Addressing impotence or premature ejaculation can improve fertility.
Treatment for these problems often is with medication or behavioral approaches.

 Lack of sperm: surgery or hormones to correct the problem or use of assisted reproductive technology is sometimes possible.

Varicocele can often be surgically corrected.

Stimulating ovulation with fertility drugs: Fertility drugs are the main treatment for women who are infertile due to ovulation disorders.These medications regulate or induce ovulation, and work like natural hormones to trigger ovulation such as: Follicle-stimulating hormone (FSH) and Luteinizing hormone (LH).

Commonly used fertility drugs include:

  1.  Clomiphene citrate
  2. Human menopausal gonadotropin, or hMG (Repronex)
  3. Follicle-stimulating hormone, or FSH (Gonal-F, Follistim, Bravelle)
  4. Human chorionic gonadotropin, or HCG (Ovidrel, Pregnyl)
  5. Gonadotropin-releasing hormone (Gn-RH) analogs
  6. Letrozole (Femara)
 
In Vitro Fertilization
Normal Menses : 
  • Flow lasts 2-7 days
  • Cycle 21-35 days in length
  • Total menstrual blood loss 20-60 mL
Other Causes of Vaginal Bleeding :
  1. Pregnancy related causes
  2. Medications
  3. Anatomic causes
  4. Infectious disease
  5. Endocrine abnormalities: Thyroid, DM
  6. Bleeding disorders
  7. Endometrial hyperplasia
  8. Neoplasms

Descriptive Term

Bleeding pattern

Menorrhagia Regular cycles, prolonged duration, excessive flow
Metrorrhagia Irregular cycles
Menometorrhagia Irregular, prolonged, excessive
Hypermenorrhea Regular, normal duration, excessive flow
Polymenorrhea Frequent cycles
Oligomenorrhea Infrequent cycles

Amenorrhoea is the absence of a menstrual period in a woman of reproductive age. Physiological states of amenorrhoea are seen during pregnancy and lactation (breastfeeding) Periods.

Classifications :

  1. Primary
    • Absence of menses by age 16 with normal secondary sexual characteristics.
    • Absence of menses by age 14 without secondary sexual development.
  2. Secondary (Absence of menses for 6 months in a previously menstruating female.)

Etiology Of Primary Amenorrhoea :

  1. Hypergonadotropic Hypogonadism
  2. Hypogonadotropic Hypogonadism (Gonadotropin deficiency; Secondary hypogonadism; Kallmann syndrome)
  3. Other causes of Primary Ovarian Failure
  4. Genetic Disorders :  5-Alpha-reductase deficiency (5-ARD) is an autosomal recessive intersex condition caused by a mutation of the 5-alpha reductase type 2gene.
  5. Other Hypothalamic / Pituitary Dysfunctions

Etiology Of Secondary Amenorrhoea :

Secondary Amenorrhoea is often caused by hormonal disturbances from the hypothalamus and the pituitary gland, from premature menopause or intrauterine scar formation. It is defined as the absence of menses for three months in a woman with previously normal menstruation or nine months for women with a history of oligomenorrhoea.

Bowel  :

The small intestine takes up a large part of the abdomen ironically and is likely to be damaged in penetrating injury. Gas within the abdominal cavity seen on CT is understood to be a diagnostic sign of bowel perforation; however intra-abdominal air can also be caused by pneumothorax (air in the pleural cavity outside the lungs that has escaped from the respiratory system) or pneumomediastinum (air in the mediastinum, the center of the chest cavity). Bowel injury may be associated with complications such as infection, abscess, bowel obstruction, and the formation of a fistula.

The parenchyma are the functional parts of an organ in the body. This is in contrast to the stroma, which refers to the structural tissue of organs, namely, the connective tissues.

In cancer, the parenchyma refers to the actual mutant cells of a single lineage, whereas the stroma is the surrounding connective tissue and associated cells that support it.

Liver :

The liver, the most vulnerable abdominal organ to blunt injury .Liver injuries present a serious risk for shock because the liver tissue is delicate and has a large blood supply and capacity. In children, the liver is the most commonly injured abdominal organ. The liver may be lacerated or contused, and a hematoma may develop. If severely injured, the liver may cause exsanguination (bleeding to death).

Spleen:

 Spleen is the most common damaged organ in blunt abdominal trauma. The spleen is the second most commonly injured intra-abdominal organ in children.  A laceration of the spleen may be associated with hematoma. The spleen, pancreas and kidneys do not present as much of an immediate threat of shock unless they lacerate a major blood vessel supplying the organs, such as the renal artery.

Pancreas :

 The pancreas may be injured in abdominal trauma, for example by laceration or contusion. Pancreatic injuries, most commonly caused by bicycle accidents (especially by impact with the handlebars) in children .

Kidneys :

The kidneys may also be injured; they are somewhat but not completely protected by the ribs. Kidney injury, a common finding in children with blunt abdominal trauma, may be associated with bloody urine. Kidney lacerations and contusions may also occur.

Organ Parenchyma
Brain Neurons & Glial Cells
Heart Myocytes
Kidney Nephrons
Liver Hepatocytes
Lungs Alveolar Tissue
Pancreas Islets of Langerhans & Pancreatic Acini
Spleen White & Red Pulps
Placenta placental villi, including the fetal vessels, and the maternal intervillous space
  1. Penetrating abdominal trauma (PAT)
    • Gunshot Wounds
    • Stab Wounds
  2. Blunt abdominal trauma (BAT)