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Surgical treatment may also be preferable to women who desire an immediate end point arthritis in neck sleeping purchase online diclofenac. Suction curettage has been shown superior to sharp curettage, which adds little once complete suction evacuation of the uterus has been performed. One advantage of suction evacuation is the ability to perform the procedure in an outpatient office setting using local anesthesia. Women presenting with septic abortion should receive a complete blood count, urinalysis, blood chemistry, and electrolyte panel. Cervicouterine cultures should be taken, and a Gram stain may provide rapid analysis. Evacuation of the uterus should occur within 2 hours of the initiation of broad-spectrum, intravenous antibiotics. Hysterectomy may be warranted for patients with severe sepsis or those whose uterus cannot be evacuated through the cervix. Avoidance of excessive physical activity/ exercise and coitus may serve as comfort measures. Her feelings surrounding the pregnancy, as well as cultural preferences and past experience, may influence her decision regarding intervention. Provided there is no evidence of infection, expectant management, medical therapy, or surgical evacuation of the uterus are all viable alternatives. Up to 95% will successfully expel an incomplete abortion without intervention (Sotiriadis, 2005). Within 2 weeks, 25% to 85% of women with a missed abortion will spontaneously resolve the pregnancy, 37% doing so within 7 days (Luise, 2002). As there is no agreed-upon value, ultrasound should not be used to measure endometrial thickness for confirmation of completion of a miscarriage but rather solely to document the absence, thus presumed passage, of a previously seen gestational sac. Should expectant management be undertaken, the patient should have a short interval follow-up within 1 to 2 weeks. Medical management most often employs misoprostol, a prostaglandin E1 analogue, as a means to expedite expulsion of products of conception. The majority of women, 80% to 90%, will completely expel a first-trimester loss after one or two doses. Misoprostol is administered either orally or vaginally, with the vaginal route preferred to maintain steady serum levels and to avoid gastrointestinal side effects. Candidates for medical management include women without evidence of infection, hemorrhage, anemia or a bleeding disorder. At this time, the patient should be asked open-ended questions about her experience and thoughts. Dealing with those frustrations will improve interactions in the future and may also decrease the risk of depression after the loss. Many women experience guilt after miscarriage, believing that the loss was something that they caused by some action that they performed. In fact, one study found that 80% of women had some guilt associated with a particular act or habit that is perceived as causing the miscarriage. Some women develop physical symptomatology with grieving that may mimic symptoms of depression, such as fatigue, anorexia, sleeplessness, and sometimes somatic symptoms such as headache and back pain. A patient should be advised that if such symptoms develop, she and her family should return. Studies have also shown that couples experiencing miscarriage are at an increased risk for breaking up compared to couples with live births. Five percent to 20% of women may develop transient symptoms of thyroid disease after a pregnancy loss. The symptoms should be treated with thyroid replacement for low thyroid and antithyroid medications for hyperthyroid symptoms. Treatment is usually continued for 6 to 9 months, at which point the patient is reevaluated. Also, at the follow-up visit an assessment is given as to potential causes of miscarriage and possible explanations. The workup that is initiated for a cause of recurrent pregnancy loss is discussed next. There is no compelling evidence showing that delaying conception after an early pregnancy loss will decrease subsequent miscarriage risk. If another pregnancy is not desired, hormonal-based contraception may be initiated immediately after completion of early pregnancy loss, if appropriate. It is recommended that diagnostic evaluation be initiated after a woman has had two failed clinical pregnancies, as one early miscarriage is relatively common. Not uncommonly a history may elicit a particular line of investigation that should be initiated even after one loss. If a pregnancy loss occurs in the second trimester, the cause is more likely to recur. Thus a diagnostic evaluation should be considered after a woman has had only one second-trimester loss. Other studies should include prolactin, hemoglobin A1C, and antiphospholipid antibodies. Sonohysterography is a sensitive, specific, and accurate screening method for assessing abnormalities in the uterine cavity of women with recurrent miscarriage.

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The 5-year cumulative risk for repeat surgery has been found to be higher after anterior prolapse surgeries that involved mesh than those that did not (15 arthritis in club feet buy diclofenac 100 mg amex. Certainly careful patient selection, detailed patient counseling, and a skilled surgeon with proper training is needed for these procedures and to manage the complications. Recurrent anterior vaginal wall prolapse remains a frustrating problem for gynecologic surgeons and patients. Because there is a risk of urinary retention immediately after surgery, a voiding trial should be performed after removing any vaginal pack and prior to discharging the patient. For the back fill, the bladder is retrograde filled with 300 mL of sterile saline, and then the catheter is removed. For auto fill, the catheter is removed, and the bladder is allowed to fill spontaneously. The voided volume is measured, and the residual volume is measured with a bladder ultrasound or straight catheterization in either type of voiding trial, or it can calculated after a back fill. The patient can be considered to have passed the voiding trial if she voids at least two thirds of the total bladder volume. Two randomized trials of the two voiding trial techniques revealed that the back fill technique was a better predictor of adequate postoperative bladder emptying than the auto fill technique, and it was also preferred by patients (Pulvino, 2010; Geller, 2011). Notably, 40% or more of patients had an unsuccessful voiding trial after prolapse or incontinence surgeries and were discharged home with a catheter. It is helpful to counsel women on this high chance of going home with a catheter, given short hospital stays after these procedures. Prophylactic antibiotics are rarely recommended; however, symptomatic lower urinary tract infections are common and should be treated as they occur. Because paravaginal repairs and mesh-reinforcement have not significantly decreased the rate of recurrence, and addition of mesh grafts increases the reoperation rate compared to native tissue repairs because of mesh complications as noted earlier, anterior colporrhaphy remains the procedure of choice for isolated anterior vaginal wall prolapse. Notably, the rate of recurrence has been found to significantly decrease with the addition of apical vaginal support (Eilber, 2013). In the setting of apical support defects associated with anterior vaginal wall prolapse, repairs such as uterosacral ligament suspension, sacrospinous ligament suspension, and sacral colpopexy may be indicated. Protrusion of the prolapse may worsen later in the day and be aggravated by prolonged standing or exertion. With a rectocele, the woman may also complain of constipation, difficulty with bowel movements, a feeling of incomplete emptying of the rectum, and the need to push on the vagina or perineum (splint) to have a bowel movement. Obstructed defecation symptoms may be reported by 9% to 60% of women with pelvic floor disorders, with 18% to 25% splinting, 27% straining, and 26% incompletely evacuating (Grimes, 2012). Although reported symptoms might be related to the rectocele, there are many other potential causes of evacuation problems that are not (constipation, sigmoidocele, rectal prolapse, rectal intussusception). Diagnosis Posterior vaginal wall prolapse is descent of the posterior vaginal wall and may include an enterocele (small bowel), a rectocele (rectum), or both. Posterior vaginal wall prolapse may be identified by retracting the anterior vaginal wall upward with one half of a Graves or Pederson speculum and asking the patient to strain. The physician should then place one finger in the rectum and one in the vagina and palpate the defect. Often the rectovaginal septum is paper thin, and the rectocele can be palpated to its upper margin. One finger in the rectum can also evaluate for the presence of a "pocket" or bulge into the vaginal canal where stool may get trapped. If an enterocele is present, it may be possible to differentiate it from the rectocele by having the patient strain. Frequently, however, the diagnosis of a small enterocele is established only at the time of operation. Management Nonoperative management of a rectocele is similar to that mentioned for a cystocele. Pessaries, Kegel exercises, and estrogen may be useful in the appropriate situations. Gastrointestinal symptoms must be thoroughly evaluated, including screening for colorectal cancer if appropriate. If constipation and straining are issues, a dietary fiber and fluid intake review should be obtained. At least 25 g of fiber, adequate hydration, regular exercise, and allowing time for defecation after meals can be recommended to regulate bowel habits as first-line therapy. Polyethylene glycol can be used as needed if these first-line therapies do not adequately normalize stool consistency. Although this may appear to be a cystocele, split speculum exam revealed a rectocele. The leading point of the prolapse is point Bp (+5), which is 5 cm beyond the hymen. Total vaginal length is 8 cm, and point C (-6), the cuff position, has descended 2 cm. The standardization of terminology of female pelvic organ prolapse and pelvic floor dysfunction. Most women with posterior vaginal wall prolapse also have a gaping genital hiatus and a defect in their perineal body. The surgeon should estimate at the time of starting the posterior repair what degree of perineorrhaphy he or she wishes to perform.

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Paley and associates have reported using a retropubic approach in a small series of six patients to achieve direct visualization of needle placement (Paley arthritis pain relief pills purchase generic diclofenac, 1998). For larger lesions, the dose of the external component of radiation therapy is increased, with a concomitant reduction in the local vaginal component of treatment of the primary tumor. Usually, a total tumor dosage of approximately 7500 cGy Obstetrics & Gynecology Books Full 31 Malignant Diseases of the Vagina Table 31. Clear cell adenocarcinoma of the vagina and cervix secondary to intrauterine exposure to diethylstilbestrol. Kucera and Vavra, in a series of 434 patients treated with irradiation, noted that results were best for low-stage tumors, those in the upper third of the vagina, and when the tumor was well-differentiated (Kucera, 1991). Kirkbride and colleagues have reported that stage, tumor size, and tumor grade are prognostic and that the tumor dose must reach at least 7000 cGy, consistent with other studies (Kirkbride, 1995). Treatment time is also important; as noted by Lee and colleagues, it is preferable to complete the radiation therapy within 9 weeks (Lee, 1994). Survival Overall 5-year survival rates for patients with primary carcinoma of the vagina have been reported to be approximately 45%. The use of concomitant chemotherapy with radiation can be expected to produce improved survival rates (Creasman, 1998). Therapeutic considerations are similar to those for squamous cell carcinoma, taking into account the young age of the patients undergoing therapy. Cervical clear cell adenocarcinomas are treated in the same manner as primary cervical carcinomas. The results of therapy for vaginal and cervical clear cell adenocarcinoma in young women are discussed together in this section. The overall results of therapy, based on the stage of the tumor at the time of treatment, are shown in Table 31. The survival rate is related directly to the stage of the tumor, similar to other gynecologic malignancies at these sites. In general, surgery is the primary treatment modality because of the young age of the patients. In addition, efforts have been made to preserve fertility in patients who have small tumors of the vagina by the use of local irradiation of the primary tumor and immediate adjacent tissues to spare the ovaries. Because metastases to regional pelvic nodes can occur, even with small stage I tumors, retroperitoneal lymph node dissections are usually performed before local therapy. Local excision of the tumor can be performed before irradiation to facilitate local application. Senekjian and associates have noted that the survival of patients with small vaginal tumors treated by local excision and then local irradiation is comparable with that obtained with conventional extensive therapy (Senekjian, 1989). The best candidates are those with tumors smaller than 2 cm in diameter, a predominant tubulocystic pattern. Patients with larger tumors, however, receive full pelvic irradiation, in addition to an intracavitary implant. This procedure is preferably applied to central recurrences that develop after primary irradiation. Local vaginal excision as the sole therapy is not usually adequate for small tumors because the tumor frequently recurs. Three predominant histologic patterns are found in patients with clear cell adenocarcinoma. Vaginal and cervical abnormalities, including clear cell adenocarcinoma, related to prenatal exposure to stilbestrol. Pathology and pathogenesis of diethylstilbestrol-related disorders of the female genital tract. This difference is associated with a more favorable outcome for those with the tubulocystic pattern of clear cell adenocarcinoma, the most frequent histologic pattern found in older patients. In addition, smaller tumor diameter and superficial depth of invasion correlate with improved patient survival. If the regional pelvic nodes are free of tumor, the prognosis is also more favorable. It is more likely that the regional pelvic lymph nodes will be free of tumor if other factors are favorable. Clear cell adenocarcinomas can spread locally, as well as via lymphatics and blood vessels. Metastases to regional pelvic nodes are found in approximately one sixth of stage I cases. Depending on the location of the tumor recurrence, therapy has consisted of additional radical surgery or extensive radiation in localized pelvic disease and systemic chemotherapy Obstetrics & Gynecology Books Full 31 Malignant Diseases of the Vagina in cases of metastatic disease. Unfortunately, no single agent or combination of chemotherapeutic agents has emerged as an effective therapy. Prolonged follow-up is necessary for these patients because recurrences have been reported as long as 20 years after primary therapy, particularly in the lungs and supraclavicular areas. Data from the Registry on Hormonal Transplacental Carcinogenesis (Herbst, 1990) indicate that ovarian preservation with concomitant estrogen stimulation does not adversely affect survival in patients with clear cell adenocarcinoma of the vagina. The most common presenting symptoms are vaginal discharge, bleeding, and a palpable mass. These lesions appear as darkly pigmented, irregular areas and may be flat, polypoid, or nodular. Vaginal melanomas tend to metastasize early, via the bloodstream and lymphatics, to the iliac or inguinal nodes, lungs, liver, brain, and bones.

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Teletherapy in the form of external beam radiotherapy means that the source of radiation is at a distance from the woman arthritis relief plus limited generic 100 mg diclofenac mastercard, sometimes located at a distance 5 to 10 times more than the depth of the tumor being irradiated. Alternatively, with the use of different angles and ports of treatment, the concept of source-axis distance has been introduced; it denotes the distance from the radiation source to the central axis of machine rotation. The woman is positioned so that this axis passes through the center of the tumor, and treatment ports are arranged around this axis to optimize tumor dose. When using a source-axis distance patient treatment setup, the daily radiation dose is calculated using machine output and beam attenuation at the depth for a given treatment field size. Conventional external beam radiation is delivered with beams of uniform intensity. Advances in computer-guided planning and treatment have made the use of beams of varying intensity more commonplace. The advantage of this technique is that there may be more sparing of normal tissue, especially small bowel, and therefore hopefully decrease both short-term and long-term toxicity. Image-guided radiation therapy using this type of device is called helical tomotherapy. In conventional therapy, and in intensity-modulated radiotherapy and helical tomotherapy, Table 27. Collimators limit scatter radiation and block portions of the treatment beam from delivering an intolerant radiation dose to critical tissues. In general, the higher the energy source of the radiation, the deeper the beam can penetrate into tissue. Thus high-energy radiation has its predominant effect in deeper tissues and spares the surface of the skin of a radiation effect. An isodose curve is a line that connects points in the tissue that receive equivalent doses of irradiation. For the 6-MeV machine, the maximum dose is near the surface, with a more rapid falloff in the deeper tissues. For the 22-MeV machine, the maximum dose is deep to the surface, sparing the effects of radiation on the overlying skin. In addition to the energy of the beam, the energy of radiation absorbed at various depths is affected by the size of the field being treated. Larger fields contain more scattered radiation, which leads to a greater dose at a given depth. Thus the radiation dose delivered to the tumor is affected by the energy of the source, depth of the tumor beneath the surface, and size of the field undergoing irradiation. Tissue Tolerance and Radiation Complications Adverse radiation effects are commonly divided into two broad categories, early and late, which demonstrate markedly different patterns of response to radiation dose fractionation. It is important for the treating physician to understand critical tissues and organ systems at risk of radiation damage. Early or acute effects manifest as the result of death in a large population of cells and can occur within days to weeks after the initiation of radiation therapy. For early effects, the total dose of radiation and, to a lesser extent, the dose per fraction determine the severity of the side effect. Radiation acutely affects tissues undergoing rapid cell division to replace lost normal functioning cells. This is most pronounced in areas such as the skin, intestinal mucosa, mucosa of the vagina and bladder, and hematopoietic system, in which precursor stem cells are renewing functional mature cells. During the treatment of gynecologic malignancies, most adverse early treatment-related toxicities can be managed with medication. It is preferred practice that radiation treatment not be interrupted for treatment-related Obstetrics & Gynecology Books Full 27 Principles of Radiation Therapy and Chemotherapy in Gynecologic Cancer 643 A B Dose volume histogram 1. The red line is the 45 Gy isodose line and, as shown, everything within the red line gets 45 Gy, including all the bowel. Only rarely does a treatment program have to be temporarily discontinued for treatment-related toxicities. Late effects are often the product of parenchymal connective tissue cell loss and vascular damage. Late effects may be seen in slowly renewing tissues such as the lung, kidney, heart, and liver and in the central nervous system. In the treatment of gynecologic malignancies, late adverse effects include tissue necrosis and fibrosis, as well as fistula formation and ulceration. As the beam emerges from the treatment machine, the beam diverges and can be shaped by high-Z material leaflets of a beam collimator (top) or custom blocks. As the treatment beam hits the patient, photon interactions occur, producing ionization events (inset). Note that the higher-energy machine delivers radiation to a greater depth for the same surface dose, resulting in skin sparing. As treatment field size varies, the dose delivered at a specified depth varies (bottom right). Fractionated radiation therapy using a daily radiation dose of 180 to 200 cGy minimizes the risk of late effects. Second cancers (mostly sarcomas) induced after radiation are rare (1 in 500 to 1000 cases) and do not usually appear until 15 to 20 years after radiation exposure. Arai and associates noted an excess of rectal cancer, bladder cancer, and leukemia in women with carcinoma of the cervix treated by radiation in comparison with those treated by surgery (Arai, 1991). The skin overlying the tumor being treated visibly reveals the effects of radiation-induced normal tissue damage. Skin effects Obstetrics & Gynecology Books Full 27 Principles of Radiation Therapy and Chemotherapy in Gynecologic Cancer are manifest by reddening of the skin and loss of hair where the radiation treatment beam enters the body. Erythema may progress to dry or moist skin breakdown or desquamation caused by loss of the actively proliferating basal layer of the epidermis that renews the overlying epithelium. This is less common now than in prior years because higher energy radiation beams, which spare the surface dose, are used.

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Many patients tolerate office endometrial sampling without an analgesic agent arthritis in knuckles of fingers order diclofenac 100 mg mastercard, but paracervical block can be an effective anesthetic aid, particularly in nulliparous women. Some patients benefit from an oral nonsteroidal antiinflammatory drug taken approximately 30 minutes before biopsy. Transvaginal ultrasonography has been evaluated as an adjunct for the diagnosis of endometrial hyperplasia and cancer. These studies have been performed in different populations, including asymptomatic postmenopausal women, women taking tamoxifen, and women presenting with postmenopausal bleeding. Langer and associates, in a study of 448 asymptomatic postmenopausal women, found a threshold of 5-mm endometrial thickness had only a 9% predictive value for detecting endometrial abnormalities (Langer, 1997). Its greater use was eliminating the diagnosis of neoplasia for those with thickness less than 5 mm (negative predictive value of 99%). These findings were confirmed in a literature review by Smith-Bindman and colleagues, who found that 96% of women with carcinoma had an abnormal ultrasound scan (endometrial thickness >5 mm). Conversely, 8% of postmenopausal women with an abnormal scan had no histologic abnormality, and the percentage grew to 23% for those on hormone replacement therapy. However, both of these studies were conducted in postmenopausal asymptomatic women. One case of hyperplasia and one of carcinoma were found, and most patients had atrophic endometrium. The authors concluded that the false-positive rate of transvaginal ultrasonography in this population was too high to warrant its use as a screening modality, and they recommended using irregular vaginal bleeding as an indication for endometrial sampling (Cecchini, 1996). Similarly, Love and associates found that endometrial thickness is not necessarily a useful guide for biopsy in tamoxifen. In the study by Barakat and colleagues, routine screening with transvaginal ultrasonography was not of value, and they concluded that sampling should be done if the patient experiences bleeding. In postmenopausal women with any vaginal bleeding, Gull and colleagues found that an endometrial stripe of less than 4 mm had a 100% negative predictive value (Gull, 2000). A finding of endometrial thickness less than 4 mm is a reasonable predictor of lack of endometrial pathology, even in a postmenopausal patient with bleeding. However, persistent vaginal bleeding should lead to endometrial sampling regardless of the ultrasound findings. Endometrial ablation is sometimes undertaken to control severe uterine bleeding (see Chapter 26). However, pathologic evaluation of the endometrium should be performed before ablation in order to rule out an underlying endometrial hyperplasia or cancer. For women with simple hyperplasia or complex hyperplasia without atypia, the risk of developing endometrial cancer is low, 1% and 3%, respectively. A diagnostic D&C can also be therapeutic, and progestins or combination oral contraceptive agents will likely be effective. For complex atypical hyperplasia, the risk of developing endometrial cancer may be 29%, and, as stated previously, a concurrent endometrial cancer may be present. Women who desire preservation of childbearing function are treated with high-dose progestin therapy, usually megestrol acetate 40 mg three times daily to four times daily. The patient should have long-term follow-up and periodic sampling, the first at 3 months and at least every 6 months thereafter. In these patients, the risk factors that led to the development of complex atypical hyperplasia are likely to remain. Therefore once the complex atypical hyperplasia is cleared, consideration should be given to periodic progestin treatment or oral contraception until the patient chooses to attempt pregnancy. For older patients with complex atypical hyperplasia, the risk of carcinoma may be increased. Kurman and associates studied the uteri of patients after curettage had been performed, and atypical hyperplasia was found in the curettings. In their study, 11% of those younger than age 35, 12% of those 36 to 54, and 28% of those older than age 55 with atypical hyperplasia were found to have carcinoma in their uterus. Thus in older patients with moderate or severe atypical hyperplasia generally a hysterectomy is recommended. In addition, those who fail progestin therapy and especially those with severe cytologic atypia should also be considered for hysterectomy. If hysterectomy is not medically advisable, long-term high-dose progestin therapy can be used (megestrol acetate 160 mg/day or its equivalent depending on the endometrial response). Studies are being performed to evaluate the role of the progesterone containing intrauterine device. It is important to emphasize that the diagnoses are not distinct and these proliferative disorders are a continuum from mild abnormalities to malignant change. The diagnosis of endometrial carcinoma is established by histologic examination of the endometrium. Initial diagnosis can frequently be made on an outpatient basis, with an office endometrial biopsy. If endometrial carcinoma is found, endocervical curettage may be performed to rule out invasion of the endocervix. A routine cytologic examination (Pap smear) from the exocervix, which screens for cervical neoplasia, detects endometrial carcinoma in only approximately 50% of the cases. If adequate outpatient evaluation cannot be obtained or if the diagnosis or cause of the abnormal bleeding is not clear from the tissue obtained, a hysteroscopy and fractional D&C should be performed.

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Conservative estimates find that endometriosis is present in 5% to 15% of laparotomies performed on reproductive-age females arthritis pain essential oils buy diclofenac 100 mg mastercard. The prevalence of active endometriosis is approximately 33% in women with chronic pelvic pain. In a compilation of eight studies encompassing 162 patients with endometriosis, the natural course of endometriosis has been reported to increase or progress 31% of the time, to remain the same 32% of the time and to regress in 38% (Taylor, 2014). The cause of endometriosis is uncertain and involves many mechanisms including retrograde menstruation, vascular dissemination, metaplasia, genetic predisposition, immunologic changes, and hormonal influences, as discussed later. In addition, there is increasing evidence that environmental factors may also play a role, including exposure to dioxin and other endocrine disruptors. Clinically, it is most difficult to predict the natural course of endometriosis in any one individual. For example, the clinician cannot know which woman with mild disease in her 20s will progress to severe disease at a later age. The typical patient with endometriosis is in her mid-30s, is nulliparous and involuntarily infertile, and has symptoms of secondary dysmenorrhea and pelvic pain, but it must be stressed that symptoms and signs may be extremely variable. Aberrant endometrial tissue grows under the cyclic influence of ovarian hormones and is particularly estrogen dependent; therefore, the disease is most commonly found during the reproductive years. Endometriosis in teenagers should be investigated for obstructive reproductive tract abnormalities that increase the amount of retrograde menstruation. Although previously thought to be rare in adolescents, in teens with pelvic pain, endometriosis has been found in approximately half the cases. Endometriosis is a disease not only of great individual variability but also of contrasting pathophysiologic processes. It is a benign disease, yet it has the characteristics of a malignancy- that is, it is locally infiltrative, invasive, and widely disseminating. Although the physiologic levels of estrogen stimulate the growth of ectopic endometrium, the use of contraceptive steroids of various doses is usually beneficial for treatment. Another contrast often noted is the inverse relationship between the extent of pelvic endometriosis and the severity of pelvic pain. Women with extensive endometriosis may be asymptomatic, whereas other patients with minimal implants may have incapacitating chronic pelvic pain. However, as would be expected, women with deep infiltrating endometriosis, especially in retroperitoneal spaces, often experience severe episodes of pain. The clinical variability in responses among women with endometriosis may relate to differences in immunologic function and variations in cytokine production. However, no single theory adequately explains all the manifestations of the disease. Most important, there is only speculation as to why some women develop endometriosis and others do not. Retrograde Menstruation the most popular theory is that endometriosis results from retrograde menstruation. Sampson suggested that pelvic endometriosis was secondary to implantation of endometrial cells shed during menstruation (Sampson, 1927). It has been suggested that the shedding of endometrial-based adult stem cells and mesenchymal cells may explain this phenomenon (Gargett, 2010). These cells attach to the pelvic peritoneum and under hormonal influence grow as homologous grafts. Indeed, reflux of menstrual blood and viable endometrial cells in the pelvis of ovulating women has been documented. Endometriosis is discovered most frequently in areas immediately adjacent to the tubal ostia or in the dependent areas of the pelvis. Endometriosis is frequently found in women with outflow obstruction of the genital tract. The attachment of the shed endometrial cells involves the expression of adhesion molecules and their receptors. Metaplasia In contrast to the theory of seeding from retrograde menstruation is the theory that endometriosis arises from metaplasia of the coelomic epithelium or proliferation of embryonic rests (Meyer, 1924). The metaplasia hypothesis postulates that the coelomic epithelium retains the ability for multipotential development. The decidual reaction of isolated areas of peritoneum during pregnancy is an example of this process. It is well known that the surface epithelium of the ovary can differentiate into several different histologic cell types. Endometriosis has been discovered in prepubertal girls, women with congenital absence of the uterus, and rarely in men. Metaplasia occurs after an "induction phenomenon" has stimulated the multipotential cell. The induction substance may be a combination of menstrual debris and the influence of estrogen and progesterone. The mesothelium is labeled with monoclonal antibody to cytokeratin and stained with diaminobenzidine (arrows).

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Hormonal replacement therapy ecotrin arthritis relief cheap diclofenac 100 mg with amex, prothrombotic mutations and the risk of venous thrombosis. Bayesian meta-analysis of hormone therapy and mortality in younger postmenopausal women. The cost-effectiveness of hormone therapy in younger and older postmenopausal women. Mortality associated with hormone replacement therapy in younger and older women: a meta-analysis. Brief report: coronary heart disease events associated with hormone therapy in younger and older women. Five-year incidence and remission rates of female urinary incontinence in a Swedish population less than 65 years old. Modeling of the growth kinetics of occult breast tumors: role in interpretation of studies of prevention and menopausal hormone therapy. Association between hormone replacement therapy and subsequent arterial and venous vascular events: a meta-analysis. Effect of hormone replacement therapy on cardiovascular events in recently postmenopausal women: randomised trial. Release of 17-beta-oestradiol from a vaginal ring in postmenopausal women: pharmacokinetic evaluation. The influence of exogenous estrogen use on survival after diagnosis of endometrial cancer. A prospective evaluation of clomiphene citrate challenge test screening of the general infertility population. Effect of estrogen on brain activation patterns in postmenopausal women during working memory task. Affective changes with estrogen and androgen replacement therapy in surgically menopausal women. The impact of different doses of estrogen and progestin on mood and sexual behavior in postmenopausal women. Hormone therapy and in-hospital survival after myocardial infarction in postmenopausal women. Effects of childhood leukemia and chemotherapy on puberty and reproductive function in girls. Hormone replacement therapy formulations and risk of epithelial ovarian carcinoma. Low molecular weight follicle-stimulating hormone receptor binding inhibitor in sera from premature ovarian failure patients. Changes in body composition in women over six years at midlife: ovarian and chronological aging. Anti-mullerian hormone and inhibin in the definition of ovarian aging and the menopause transition. Oestrogen treatment and subsequent pregnancy in two patients with severe hypergonadotropic ovarian failure. Reproductive and gonadal function in the female after therapy for childhood malignancy. A multifactorial intervention to reduce the risk of falling among elderly people living in the community. Estrogen receptors colocalize with low-affinity nerve growth factor receptors in cholinergic neurons of the basal forebrain. Effects of gender and age on the levels and circadian rhythmicity of plasma cortisol. Age at natural menopause in a population-based screening cohort: the role of menarche, fecundity, and lifestyle factors. Twenty-four hour rhythms in plasma concentrations of adenohypophyseal hormones are generated by distinct amplitude and/or frequency modulation of underlying pituitary secretory bursts. The aging musculoskeletal system and obesity-related considerations with exercise. Anti-Mullerian hormone: an ovarian reserve marker in primary ovarian insufficiency. Treatment with oral piperalzine oestrone sulphate for genuine stress incontinence in postmenopausal women. Intrauterine administration of levonorgestrel 5 and 10 mg/24 h in perimenopausal hormone replacement therapy: a randomized clinical trial during one year. Incidence of endometrial hyperplasia in postmenopausal women taking conjugated estrogens (Premarin) with medroxyprogesterone acetate or conjugated estrogens alone. Estrogen therapy in post-menopausal women: effects on cognitive function and dementia. Twenty-four hour mean plasma testosterone concentration declines with age in normal premenopausal women. Obstetrics & Gynecology Books Full 15 Breast Diseases Detection, Management, and Surveillance of Breast Disease Samith Sandadi, David T. Additionally, breast cancer is the second most common cause of cancer-related death in women, and it is the leading cause of premature mortality from cancer in women as measured by total years of life lost in the United States. Despite the high incidence and prevalence of breast disease, and the enormous personal, psychosocial, and psychosexual aspects attached to conditions of the breast, there is surprisingly little didactic and clinical teaching time devoted to the evaluation and management of breast disease during medical school and postgraduate training. Regardless, the role of the gynecologist in the management of breast disease has been addressed in a number of published clinical opinions and practice bulletins from the American College of Obstetrics and Gynecology.

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After diverticulectomy rheumatoid arthritis weight gain discount diclofenac 100 mg amex, recurrence that requires repeat excision occurs about 10% of the time. Risk factors for recurrence included proximal diverticulum, multiple diverticula, and previous pelvic or vaginal surgery, excluding previous diverticulectomy. Some with recurrent diverticulum will have persistent pain or discomfort with urination and even with complete excision those symptoms can remain. Stress incontinence development may be related to the dissection of the bladder neck and proximal urethra with injury to the urethral sphincter mechanism. If intrinsic sphincter deficiency results, the incontinence can be difficult to treat because of tissue compromise from repair. One study compared risk factors and determinants of urodynamic stress incontinence between smokers and nonsmokers using a case-control method (Bump, 1994). In this study, 71 smokers and 118 nonsmokers were compared following a complete urogynecologic evaluation. Smokers were found to have stronger urethral sphincters and generated a greater increase in bladder pressure with coughing, but similar findings with respect to urethral mobility and pressure transmission ratios were found when compared with nonsmokers. Approximately 5% of women will develop a symptomatic stone by the age of 70 years. These may be related to metabolic abnormalities, such as gout or errors of calcium metabolism, but usually relate to chronic infection and stasis of urine. Other risk factors for calculi in women include pregnancy, during which time the urinary tract becomes dilated and stasis is more common, a history of kidney stones or family history, certain medications, excessive vitamin C intake, low calcium intake, chronic diarrhea, and dehydration. Pain occurs on the side of the stone and varies from a dull ache to severe paroxysms of pain, called renal colic. Flank pain, lower abdominal pain, and groin pain can occur; the location can vary as the stone moves down the ureter with radiation of pain to the groin. Ultrasound misses small stones but is recommended for pregnant women and is increasingly recommended for initial screening as no radiation is used. Various treatment modalities are available, including observation with pain medications and fluids awaiting spontaneous passage, endoscopic removal, surgical removal, and destruction of the stone with laser or shockwave lithotripsy. The principal consideration, however, should be correction of the basic problem that caused the stone. Urgent intervention is necessary if the woman has fever, chills, nausea and vomiting, and pain uncontrolled by narcotics. Another area of interest involves racial and ethnic differences with respect to the presence of urinary incontinence. Black women with urinary incontinence have a different distribution of symptoms and different reasons for their incontinence than white women. Black women had a significantly lower prevalence of pure urodynamic stress incontinence than white women. The findings may possibly relate to differences in collagen and connective tissue. Several other studies have found a higher prevalence of urinary incontinence in nonHispanic white women and Mexican-Americen woman compared with rates in Asian and black women, although at least two studies have found no difference between racial or ethnic groups. Obesity has a strong association with incontinence and, for every five-unit increase in body mass index, the risk increases. These women reported a higher number of weekly incontinence episodes than women without depressive symptoms, as well as more bothersome symptoms and poorer quality of life (Melville, 2009). Epidemiologic studies have suggested increased risk with hysterectomy but short-term clinical studies have not, so more research is needed to clarify this issue. Vaginal childbirth and higher fetal weight are risk factors in younger women, but the effect diminishes in older women, possibly because the neuromuscular decline with aging becomes a more important factor. The prevalence of incontinence is significantly higher for women in nursing homes and women with cognitive impairment and poor mobility. When urine leakage is observed during a urodynamic study, with an increase in intraabdominal pressure and without a detrusor contraction, it is called urodynamic stress incontinence (Haylen, 2010). Stress urinary incontinence is a common condition for which nearly 14% of women in the United States will undergo surgery at some point (Wu, 2014). Injury, particularly trauma from obstetric delivery, has been implicated in stress incontinence. The odds ratio of stress urinary incontinence in parous compared with nulliparous women is threefold (Hansen, 2012); the odds ratio after vaginal compared with cesarean delivery is twofold (Lukacz, 2006). Meyer and colleagues studied 149 patients during pregnancy and 9 weeks postpartum. They found that 36% of women who were delivered by forceps and 21% who delivered spontaneously suffered from urinary incontinence (Meyer, 1998). Bladder neck mobility was significantly increased after all vaginal births, but bladder neck position at rest was only lowered in the forceps group. These injuries may lead to later pelvic floor dysfunction and incontinence, although long-term follow-up studies are needed. Considering other forms of pelvic floor trauma, Nygaard studied female American Olympic athletes and could not find a difference between the low-impact (swimmers) and high-impact (gymnasts, track and field performers) athletes with respect to the development of stress incontinence later in life (Nygaard, 1997). Because that support layer is attached to the pelvic wall via the arcus tendineus fascia pelvis and levator ani, the urethra is compressed by increases in abdominal pressure. This maintains urethral pressure above bladder pressure and prevents urinary leakage. Urethral hypermobility, which can be measured using a "Q-tip test," corresponds to the loss of the backstop support at the bladder neck. The Q-tip test involves placing a cotton swab into the urethra to the bladder neck and observing the angle that the urethra makes with the horizontal during a strain maneuver. A large excursion from the horizontal suggests defects in the supports of the urethra but not a specific urologic diagnosis.

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However what helps arthritis in the knee order diclofenac on line, it is associated with deep vein thrombophlebitis in approximately 5% of cases. Superficial thrombophlebitis is frequently overlooked or disregarded as a cause of postoperative fever. Women with established superficial varicosities in the lower extremities are especially susceptible because of localized stasis or pressure during the operative procedure and inactivity during the first 24 hours after operation. Patients with superficial thrombophlebitis of the legs may also have concomitant deep venous disease. Some series have documented the association of inherited thrombophilias with superficial phlebitis, increasing the risk by 4- to 13-fold, with the more potent thrombophilias contributing to the higher risk. Recurrent superficial phlebitis, in varying anatomic sites, may be a sign of occult malignant disease. Venography studies have found that these clots and fibrin sheaths do not break up on catheter removal but initially remain in situ. The classic symptom of phlebitis is inflammation of the subcutaneous tissue along the course of a vein or over the area of merging varicosities. The duration of phlebitis is prolonged if the catheter is not immediately removed when the diagnosis of superficial phlebitis is made. However, a Cochrane review in 2013 showed no evidence to support routine catheter exchange without evidence of inflammation, infiltration, or blockage (Webster, 2013). Although routine exchange is not indicated, venous catheters should be removed at the first sign of induration, erythema, or edema. Superficial phlebitis is a common cause of an enigmatic postoperative fever during the first postoperative week. The clinical management of mild superficial thrombophlebitis Obstetrics & Gynecology Books Full 25 Perioperative Management of Complications includes rest, elevation, and local heat. Deep Vein Thrombosis Fifty percent of thromboembolic complications occur within the first 24 hours and 75% occur within 72 hours. Because women often die within a few hours of the appearance of initial symptoms, emphasis must be placed on prevention rather than treatment of this complication. Many women develop chronic venous insufficiency or postphlebitic syndrome of the legs as a major sequela following thrombophlebitis. The resulting damage to valves of the deep veins produces shunting of blood to superficial veins, chronic edema, pain on exercise, and skin ulceration. The incidence of thrombosis is directly dependent on risk factors such as the type and duration of operation, age of the woman, history of thrombophilia, or deep vein thrombosis, peripheral edema, surgical blood loss, restrictions in preoperative ambulation, obesity, immobility, malignancy, sepsis, diabetes, current oral contraceptive or hormone use, and conditions that produce venous stasis, such as ascites and heart failure (Box 25. Older and obese women have an increased incidence of thrombosis because of dilation of their deep venous system. There is a two- to fourfold increased risk for venous thrombosis in women taking postmenopausal estrogen therapy. The length of the surgical procedure also has an important influence on the development of thrombosis. If the operation is 1 to 2 hours in duration, approximately 15% of women develop the disease; if the surgery is longer than 3 hours, the risk is greater (Table 25. It is estimated that 75% of pulmonary emboli originate from a thrombus that began in the leg veins. If one leg is involved, the contralateral leg will have a thrombus in approximately 33% of women. Usually, the thrombus remains localized, it lyses spontaneously, and the local symptoms resolve. In approximately 1 in 20 cases the process extends centrally to the veins of the upper leg and pelvis. Involvement of the femoral vein often results in swelling caused by obstruction of this large vein. Pulmonary emboli from calf veins alone are rare, with only 4% to 10% of pulmonary emboli originating from this area. In 1854, Virchow described the three key predisposing or precipitating factors in the production of thrombi: an increase in coagulation factors, damage to the vessel wall, and venous stasis. Subsequent studies have documented that all three events occur with gynecologic operations. Kakkar has described the cascade of events leading to the development of thrombosis. Stasis leads to localized anoxia with subsequent generation of thrombi at the anoxic site. This produces changes in the lining of the vessel, with exposure of the basement membrane, platelet adhesion, and local coagulation. Thus the most important event in thrombosis is the generation of thrombi in the presence of venous stasis. A thrombus may generate in an area of stasis or it may generate wherever a vessel wall is damaged, with resultant exposure of the subendothelial collagen, to which platelets will adhere. The thrombus propagates and grows by repetitive layers of platelet aggregation and deposition of fibrin from fibrinogen. The most recently formed portion of the propagating thrombi are free-floating (not attached to the vein) and are most likely to become pulmonary emboli. The body attempts to repair the area of thrombosis through an invasion of fibroblasts from the vein wall to encompass the base of the thrombus. Eventually, the thrombus is attached to the vein wall, the area is reepithelialized, organization occurs, and symptoms resolve. The signs and symptoms of deep vein thrombosis depend directly on the severity and extent of the process.

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Studies have demonstrated that patient-delivered partner therapy results in lower rates of chlamydial persistence or recurrence arthritis pain while sleeping order line diclofenac. One study has demonstrated significant reduction in abnormal bleeding, cervicitis, uterine tenderness, and histologic endometritis following treatment with cefixime, 400 mg orally, azithromycin, 1000 mg, with or without metronidazole, 500 mg orally twice daily for 7 days. A small subset of those with endometritis had a repeat endometrial biopsy following antimicrobial therapy, and 50% of the endometritis had resolved histologically. The sequelae of endometritis distinct from salpingitis are difficult to determine. Although endometritis commonly coexists with salpingitis, several studies have supported endometritis as a distinct clinical syndrome. In severe cases, diffuse lymphocytes and plasma cells in the endometrial stroma or stromal necrosis may be present. Several large crosssectional studies in various geographic regions have studied women with no symptoms or signs of acute salpingitis (no cervical motion or adnexal or uterine tenderness) to define subclinical endometritis further. Because many of the symptoms and signs associated with endometritis are subtle, a clinician needs to have a low threshold for performing an endometrial biopsy to aid in the diagnosis. Thus it may include infection of any or all of the following anatomic locations: endometrium (endometritis; see the previous section), oviducts (salpingitis), ovary (oophoritis), uterine wall (myometritis), uterine serosa and broad ligaments (parametritis), and pelvic peritoneum. In most clinical situations, the terms acute salpingitis and pelvic inflammatory disease are used synonymously to describe an acute infection. This includes teaching adolescents safe sex practices and promoting the use of condoms and chemical barrier methods. This ascending infection occurs along the mucosal surface, resulting in bacterial colonization and infection of the endometrium and fallopian tubes. The process sometimes extends to the surface of the ovaries and nearby peritoneum, and rarely into the adjacent soft tissues, such as the broad ligament and pelvic blood vessels. Hematogenous and lymphatic spread to the tubes or ovaries is another remote possibility. More than 20 species of microorganisms have been cultured from direct tubal aspiration of purulent material. Therapeutic strategies and regimens are of a broad range, seeking to suppress aerobic and anaerobic organisms. The other 15% of infections develop following procedures that break the cervical mucus barrier, allowing the vaginal flora the opportunity to colonize the upper genital tract. It is difficult to distinguish whether this tendency is related primarily to mucosal damage or to reinfection by a potentially infected mate. Importantly, some patients may have very little symptomatology, a condition called silent, or asymptomatic pelvic inflammatory disease. These women may have tubal infertility without a prior history of symptoms or signs consistent with an acute infection (see "Endometritis," presented earlier in the chapter). Ideally, laparoscopy with direct visualization of the internal female organs not only improves the diagnostic accuracy but also affords the opportunity for direct culture of purulent material, which might help establish optimum therapy. However, most women do not undergo this procedure because of the expense and risk. Endogenous aerobic and anaerobic bacteria that originate from the normal vaginal flora are cultured from tubal fluid in approximately 50% of cases. Direct cultures have shown that tubal infections are usually polymicrobial throughout the active infectious process. One investigator found an average of seven different species in intraabdominal cultures obtained via the laparoscope. Laparoscopic studies have demonstrated a correlation of no more than 50% between endocervical and tubal cultures. Thus endocervical cultures are, at best, a crude index of the specific cause of upper genital tract infection. Immunologic studies have demonstrated that an antibody against the outer membrane protein of the gonococcus develops in approximately 70% of women following severe pelvic infection. The lack of significant antibody titers may help explain why teenagers are more likely to develop upper genital tract disease than women in their late 20s. Once the gonococcus ascends to the fallopian tube, it selectively adheres to nonciliated mucus-secreting cells. The process of repair with removal of dead cells and fibroblast presence results in scarring and tubal adhesions. Studies have shown that upper tract chlamydial infection increases the risk of an ectopic pregnancy by three to six times compared with women without chlamydial infection. Whether this represents persistent or recurrent infection of the upper genital tract is unknown. Cell-mediated immune mechanisms appear to be important in tissue destruction associated with C. Primary infection appears to be self-limited, with mild symptoms and little permanent damage. Because chlamydial 57-kDa protein and human 60-kDa heat shock protein have homologous regions, repeat exposures to Chlamydia, such as may occur in asymptomatic untreated C.

Bozep, 63 years: Anovulatory bleeding occurs most commonly during the extremes of reproductive life-in the first few years after menarche and during perimenopause.

Thorus, 55 years: The woman should remain adequately hydrated and be encouraged to continue treatment, even though symptoms generally disappear within 48 hours.

Aila, 42 years: The office sampling instruments, such as a thin plastic Pipelle, are introduced through the cervical os into the endometrial cavity and can provide very accurate information (see Chapter 10).

Tamkosch, 51 years: However, during the postoperative period, when narcotics are given, the goal should be to keep the oxygen saturation in the 94% range.

Kent, 45 years: Within each stage, survival statistics are similar in pregnant and nonpregnant women.

Khabir, 60 years: However, after antibiotic treatment and disruption of normal enteric flora, up to 25% of hospitalized adults will become colonized with C.

Jorn, 26 years: The management of persistent menopausal symptoms with oestradiol-testosterone implants: clinical, lipid and hormonal results.

Nerusul, 35 years: There may be individual predilections and comorbidities in addition to the thrombophilias that lead to recurrent pregnancy loss in certain women.

Oelk, 23 years: Complications from vestibulectomy include occlusion of the Bartholin gland leading to development of cysts.

Porgan, 21 years: The benefits of hysteroscopic septoplasty have not yet been assessed by a randomized trial.

Gunock, 22 years: This stimulates muscarinic (primarily M3) receptors in the bladder wall, which then activate detrusor contraction.

Uruk, 64 years: Food and Drug Administration has approved anastrozole, an oral nonsteroidal aromatase inhibitor, for postmenopausal women with progressive breast cancer following tamoxifen therapy.

Hjalte, 25 years: Primary mass closure of midline incisions with a continuous polyglyconate monofilament absorbable suture.

Sinikar, 31 years: Using anticholinergics to treat overactive bladder: the issue of treatment tolerability.

Sulfock, 33 years: The subsequent fertility rate is significantly Obstetrics & Gynecology Books Full 17 Ectopic Pregnancy 367 1.

Trompok, 46 years: The most compelling reason for surgical staging in a woman with borderline tumor on frozen-section examination is the risk of invasive carcinoma on final pathology.

Charles, 41 years: In a large trial from Thailand, patients were randomized into four arms: radiation therapy alone, radiation therapy with concurrent mitomycin and oral fluorouracil, radiation therapy with adjuvant fluorouracil, or radiation with concurrent and adjuvant chemotherapy (Lorvidhaya, 2003).

Ayitos, 54 years: Although these numbers are promising, at this time, lymphatic mapping and sentinel lymph node biopsy are considered experimental, with the standard of care remaining full inguinofemoral node dissection.

Lisk, 57 years: Radiation resistance is associated with (1) enhanced cell-mediated repair of radiation-induced damage, (2) active concentration of chemical radioprotectors, or (3) cellular hypoxia or nutritional deficiency.

Taklar, 29 years: In this study, there was a modest survival advantage in those patients who received the combination regimen.