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Questions and Answers

What is a primary risk factor for developing Ovarian Hyperstimulation Syndrome (OHSS)?

Having polycystic ovary syndrome (PCOS) is a primary risk factor for developing OHSS.

What role does vascular endothelial growth factor (VEGF) play in OHSS?

VEGF is excessively secreted and is thought to contribute to the mechanism of OHSS.

How can Clomiphene negatively affect cervical mucus?

Higher doses of Clomiphene can thicken cervical mucus, impeding sperm passage through the cervix.

What is the significance of monitoring follicle size during controlled ovarian stimulation?

Monitoring follicle size is crucial to ensure there are at least 4 follicles of 18 mm for optimal IVF success. Signup and view all the answers

What is the purpose of laparoscopic adjustable gastric banding (LAGB) in women with fertility issues?

LAGB can be adjusted to accommodate the increased demands of pregnancy while addressing obesity. Signup and view all the answers

What is a long-term sequelae of OHSS that involves cardiovascular health?

Hypertension and cardiovascular disease are potential long-term complications of OHSS. Signup and view all the answers

What is the first step in the in vitro fertilization (IVF) process?

The first step in IVF is Controlled Ovarian Stimulation. Signup and view all the answers

What is the purpose of embryo culture in the IVF process?

Embryo culture allows for monitoring fertilization and development of embryos before transfer. Signup and view all the answers

What are some surgical therapies for treating genital warts that can be used during pregnancy?

Cryotherapy, surgical excision, electrocautery, and laser vaporization. Signup and view all the answers

Which topical therapies for genital warts are contraindicated in pregnancy?

Podophyllin cream, trichloroacetic acid (TCA), bichloracetic acid (BCA), imiquimod cream, and podofilox solution or gel. Signup and view all the answers

Under what condition is cesarean delivery indicated for a patient with genital warts?

It is indicated only if there are severe vaginal warts posing a risk of neonatal laryngeal papillomatosis. Signup and view all the answers

What is a common initial symptom of primary syphilis?

A painless ulcer called a chancre at the site of bacterial entry. Signup and view all the answers

Describe one key feature of secondary syphilis.

A widespread papular rash over the trunk and extremities. Signup and view all the answers

What diagnostic methods are used for identifying syphilis?

Dark field microscopy examination of the ulcer and blood tests for antibodies like FTA and VDRL. Signup and view all the answers

What is the primary treatment for syphilis in patients who are not allergic to penicillin?

Procaine or Benzathine penicillin is the primary treatment. Signup and view all the answers

How does HIV affect the immune system, specifically regarding T-helper cells?

HIV suppresses the function of T-helper lymphocytes and macrophages. Signup and view all the answers

What is primary dysmenorrhoea and when does it typically appear in relation to menarche?

Primary dysmenorrhoea is characterized by uterine hypercontractility and typically appears 6-12 months after menarche when ovulatory cycles begin. Signup and view all the answers

Describe the typical symptoms associated with primary dysmenorrhoea.

Symptoms include lower abdominal cramps, backache, and may involve diarrhea and vomiting, lasting 8-72 hours after menstrual flow onset. Signup and view all the answers

List the mainstays of treatment for primary dysmenorrhoea.

The mainstays of treatment are NSAIDs and combined oral contraceptive pills (COCP). Signup and view all the answers

What is the role of prostaglandins and leukotrienes in primary dysmenorrhoea?

Elevated levels of prostaglandins and leukotrienes are associated with increased uterine contractions and pain during menstruation. Signup and view all the answers

When should investigations for secondary dysmenorrhoea be considered?

Investigations for secondary dysmenorrhoea should be considered if symptoms are atypical or if primary dysmenorrhoea treatment fails. Signup and view all the answers

What alternative pain management strategies can be employed for dysmenorrhoea?

Nonpharmacologic pain management options include acupuncture, transcutaneous electrical stimulation (TENS), psychotherapy, and heat patches. Signup and view all the answers

Define premenstrual syndrome (PMS) and its symptom resolution timeline.

PMS is characterized by cyclical somatic and psychological symptoms that occur in the luteal phase and resolve by the time menses begins. Signup and view all the answers

Why is it important to provide reassurance and explanation as part of managing primary dysmenorrhoea?

Reassurance and explanation help in alleviating anxiety and improve patient compliance with the treatment plan. Signup and view all the answers

What are the absolute contraindications to hormone replacement therapy (HRT)?

Confirmed VTE, neuro-ophthalmologic vascular disease, uncontrolled hypertension, endometrial carcinoma, breast cancer, undiagnosed vaginal bleeding, suspected pregnancy, and acute hepatic disease. Signup and view all the answers

List at least three relative contraindications for HRT.

Seizure disorder, high serum triglycerides, current gall bladder disease. Signup and view all the answers

What is the primary risk associated with unopposed estrogen therapy?

Increased risk of endometrial hyperplasia and cancer if used without progesterone. Signup and view all the answers

What are some common treatments for urinary stress incontinence?

Common treatments include pelvic floor rehabilitation (Kegel exercises), pessaries, and surgeries like suburethral sling procedures. Signup and view all the answers

Which drug classes are typically used as a mainstay treatment for urge incontinence?

Anti-spasmodics such as tolterodine, alpha adrenergics, and estrogen are commonly used. Signup and view all the answers

Describe the cyclic combined therapy regime for HRT.

Estrogen is administered from days 1-25 of the month, followed by progestogen for the last 12 days of the cycle. Signup and view all the answers

What are the primary causes of genital prolapse?

The primary causes include weakness of supporting structures due to childbirth trauma, congenital weakness, and postmenopausal atrophy. Signup and view all the answers

What is the role of the progestin IUD in HRT?

It protects the endometrial tissue and avoids systemic side effects of progestogen. Signup and view all the answers

What factors should be considered in a detailed history before starting HRT?

Previous menopause symptoms, family history of IHD and stroke, and any gastrointestinal or liver disease history. Signup and view all the answers

Define cystocele and urethrocele.

A cystocele is the prolapse of the upper part of the anterior vaginal wall with the bladder, while a urethrocele is the prolapse of the lower part with the urethra. Signup and view all the answers

What characterizes posterior wall prolapse?

Posterior wall prolapse, called rectocele, involves the descent of the anterior wall of the rectum along with the posterior vaginal wall. Signup and view all the answers

Identify two common agents used in estrogen therapy.

Conjugated estrogen and estrone sulfate. Signup and view all the answers

Explain the difference between enterocele and vault prolapse.

Enterocele is the hernia of the pouch of Douglas with the upper posterior vaginal wall descending, while vault prolapse involves the descent of the vaginal vault after hysterectomy. Signup and view all the answers

What concern does a history of gastrointestinal or liver disease pose regarding HRT?

Such conditions may interfere with the metabolism and effectiveness of estrogen therapy. Signup and view all the answers

What is the significance of postpartum pelvic floor injuries?

Postpartum pelvic floor injuries are significant because they can lead to weaknesses contributing to prolapse and urinary incontinence. Signup and view all the answers

What type of prolapse occurs when the uterus descends first?

Utero-vaginal prolapse occurs when the uterus descends first, typically seen in virginal and nulliparous women. Signup and view all the answers

Study Notes

Primary Dysmenorrhea

Characterized by uterine hypercontractility with excessive amplitude and frequency of contractions, and high resting tone between contractions.
Endometrial blood flow is reduced during contractions, correlating with maximal pain.
Prostaglandin and leukotriene levels are elevated.
Symptoms typically appear 6-12 months after menarche when ovulatory cycles become established.
Early cycles after menarche are usually anovular and tend to be painless.
Symptoms include lower abdominal cramps, supra-pubic pain starting at the onset of menstrual flow and lasting 8-72 hours, backache, and may be associated with diarrhea and vomiting.
Diagnosis is primarily based on exclusion of secondary causes.
For typical symptoms, treatment is started before conducting examinations and investigations, especially in adolescents.
Atypical symptoms warrant investigation.
Suspicion of secondary dysmenorrhea requires further investigation via TVUS, MRI, or laparoscopy.
If primary dysmenorrhea symptoms are not alleviated by medication, secondary causes need to be considered.
Mainstays of treatment include NSAIDs and COCP, especially when fertility control is required.
Reassurance and explanation to the patient are important.
Effective NSAIDs include mefenamic acid, naproxen, ibuprofen, and aspirin.
COCP works by inhibiting ovulation, decreasing endometrial production of prostaglandins and leukotrienes, inducing endometrial atrophy, and reducing the amount of endometrial tissue producing these mediators.
LNG-IUS may be effective for those with contraindications to NSAIDs or COCP.
Non-pharmacologic pain management options include acupuncture, transcutaneous electrical stimulation (TENS), psychotherapy, hypnosis, and heat patches.
Surgical procedures like presacral neurectomy and uterosacral ligament section may be considered.
Treatment for secondary dysmenorrhea focuses on addressing the underlying cause.
Ibuprofen is preferred due to its efficacy and safety profile.

Premenstrual Syndrome (PMS)

Characterized by cyclical somatic, psychological, and emotional symptoms that occur in the luteal (premenstrual) phase of the cycle and resolve by the time of menses.
Affects 3-9% of women.
Ovarian hyperstimulation syndrome (OHSS) is a potential complication.
Women with PCOS are at increased risk of developing OHSS.
OHSS occurs when too many follicles (>10 mm) are stimulated.
Mechanism is believed to be due to activation of the ovarian renin-angiotensin pathway and excessive secretion of vascular endothelial growth factor (VEGF).
Symptoms of OHSS include nausea, vomiting, distention, discomfort, shortness of breath, ascites, effusion, hemoconcentration, and venous thromboembolism (VTE).
Symptoms worsen with hCG if pregnancy occurs.
Treatment involves fluid administration and heparin.
Long-term sequelae of OHSS can include diabetes mellitus, dyslipidemia, hypertension, cardiovascular disease, endometrial cancer, and breast cancer due to high estrogen levels.
Sibutramine is a centrally acting agent that inhibits serotonin and norepinephrine uptake.
Orlistat is a peripherally acting agent that inhibits lipase.
Laparoscopic adjustable gastric banding (LAGB) is suitable for women with fertility problems as the band tightness can be adjusted to accommodate the demands of pregnancy.
Clomiphene (50-100 mg on days 2-6 of bleeding with US monitoring) is used for ovulation induction and singleton pregnancies. Doses exceeding 100 mg rarely provide any benefit.
Parenteral gonadotropins are used for anovulatory infertility resistant to antioestrogens. Treatment starts with low doses and US monitoring of follicle development.
Laparoscopic diathermy is an alternative with no risk of twins or OHSS and no need for ultrasound monitoring.

Assisted Reproduction

In vitro fertilization (IVF) steps:
- Controlled ovarian stimulation using GnRH agonists/antagonists, FSH, and hCG. Close monitoring with TVUS (number/size of follicles and endometrial thickness) and blood estradiol levels. At least 4, ideally 15 follicles of 18 mm are needed.
- Oocyte retrieval under TVUS. Egg removal from mature follicles.
- Oocyte fertilization through insemination or ICSI.
- Embryo culture under strict conditions. Fertilization is checked on day 1.
- Embryo transfer at day 5 (blastocyst stage) is recommended for optimal uterine implantation.
- Treatment options for genital warts:
  - Surgical therapies (can be used in pregnancy): cryotherapy, surgical excision, electrocautery, laser vaporization.
  - Topical therapies (contraindicated in pregnancy): podophyllin cream, trichloroacetic acid (TCA) or bichloracetic acid (BCA), imiquimod cream, podofilox solution or gel.
Genital Warts are not an indication for Cesarean section unless severe vaginal warts present a risk of neonatal laryngeal papillomatosis.

Syphilis (Treponema pallidum)

A sexually transmitted infection that can also be vertically transmitted, leading to intrauterine fetal demise (IUFD) and congenital syphilis (deafness, keratitis, abnormal teeth).
Primary syphilis manifests as a chancre, a painless ulcer on the genitalia, typically near the entry point of the bacteria.
Chancre is distinguished from other genital ulcers by being painless.
Secondary syphilis is a disseminated form characterized by a widespread papular rash on the trunk and extremities. Fever, myalgias, lymphadenopathy, sore throat, and headache are common. It can lead to arthritis, glomerulonephritis, nephrotic syndrome, and uveitis. One common manifestation is rough, reddish-brown spots on the soles of feet and palms of hands.
Tertiary syphilis can manifest years later and affect multiple organs, including cardiosyphilis and neurosyphilis.
Latent period: asymptomatic months to years of latency.
Diagnosis:
- Examining samples from ulcers under a dark field microscope.
- Blood tests to detect antibodies, such as the fluorescent treponemal antibody (FTA) test (highly sensitive and specific) and the VDRL and rapid plasma reagin (RPR) tests (less specific).
Treatment:
- Patient and partner should be treated with procaine or benzathine penicillin.
- Doxycycline or erythromycin can be used in patients allergic to penicillin.
- Penicillin remains the primary choice due to the bacterium's sensitivity to it.

HIV

Suppresses the function of T-helper lymphocytes and macrophages.
Transmission:
- Direct contact with body fluids, most commonly semen or blood (sexual contact).
- Parenteral exposure (intravenous drug abuse and transfusions).
- Perinatal transmission (across the placenta), at delivery, or during breastfeeding.

HRT (Hormone Replacement Therapy)

Contraindications:
- Absolute: Confirmed VTE, neuro-ophthalmologic vascular disease, uncontrolled hypertension, endometrial carcinoma, breast cancer, undiagnosed vaginal bleeding, suspected pregnancy, acute hepatic disease, chronically unstable liver function.
- Relative: Seizure disorder, high serum triglycerides, current gall bladder disease, migraine headache, benign breast disease, chronic stable liver disease, fibroids.
Risks:
- Endometrial cancer: estrogen therapy increases the risk of endometrial hyperplasia and cancer when used without progesterone.
- Cardiovascular disease: increased risk of heart attack, stroke, and thromboembolism.
- Breast cancer.

Regimes:

Unopposed estrogen: daily doses in women who have undergone hysterectomy.
Cyclic combined therapy: estrogen days 1-25, progestogen for the last 12 days of the cycle.
Sequential combined therapy: estrogen daily, progestogen for 12-14 days every month.
Continuous combined therapy: both estrogen and progestogen given daily.
Periodic/quarterly progestogen: given 14 days every 3 months to reduce withdrawal bleeding and progestin side effects.
Transdermal patch: estrogen alone or combined with progesterone.
Local (intravaginal): estrogen cream, tablet, patch, synthetic ring (treats urogenital atrophy and dyspareunia).
Progestin IUD protects endometrial tissue and avoids systemic side effects.

Current agents:

Estrogen:
- Conjugated estrogen
- Estrone sulfate
- Transdermal (patch) combined estrogen and progesterone
Progestogen:
- Medroxyprogesterone acetate
- Natural oral micronized progesterone

Menopause

Before starting HRT, a detailed history, physical examination, and investigations are necessary.
History includes:
- Previous menopausal symptoms and their impact on the patient's personal, domestic, and occupational life.
- Family history of IHD, stroke, skeletal diseases (especially osteoporosis), and Alzheimer's disease.
- History of gastrointestinal or liver disease that could interfere with estrogen therapy.

Urinary Incontinence

Treatment:
- Addressing exacerbating factors (cough, constipation, obesity, "stress").
- Pelvic floor rehabilitation (Kegel exercises) for "stress" and "urge" or overactive bladder).
- Pessaries for stress incontinence.
- Medications (mainstay for urge incontinence): antispasmodics (tolterodine), alpha-adrenergic agonists, estrogen (improves urgency and dysuria but not leakage). HRT does not reduce the incidence of urinary symptoms in postmenopausal women.
- Surgery (mainstay for stress incontinence):
  - Injection of bulking agent (collagen) around the urethra.
  - Retropubic urethropexy.
  - Transvaginal needle procedures.
  - Suburethral sling (TVT & TOT).

Genital Prolapse

The normal uterus is anteverted (cervix on vagina), anteflexed (uterus on cervix).
Genital prolapse is the descent of one or more pelvic organs (urethra, bladder, uterus, rectum, Douglas pouch, or rectouterine pouch) below their normal level through the fasciomuscular pelvic floor.
Vaginal prolapse can occur without uterine prolapse, but uterine prolapse always involves the vagina.
Causes and predisposing factors:
- Weakness of the pelvic floor supporting structures (utero-sacral ligament, cervical ligament, perineal muscles and fascia) due to childbirth trauma, congenital weakness, or postmenopausal atrophy.
- Injury to the pelvic floor.

Types:

Vaginal Prolapse:
- Anterior wall prolapse:
  - Cystocele: prolapse of the upper anterior vaginal wall with the bladder base.
  - Urethrocele: prolapse of the lower anterior vaginal wall with the urethra.
  - Cysto-urethrocele: complete prolapse of the anterior vaginal wall.
- Posterior wall prolapse:
  - Rectocele: prolapse of the anterior rectal wall with. the middle third of the posterior vaginal wall.
  - Enterocele: hernia of the pouch of Douglas (upper third of the posterior vaginal wall descends, lined by peritoneum of the Douglas pouch and containing loops of intestines).
- Vault prolapse: descent of the vaginal vault (top of vagina descends) or inversion of the vagina after hysterectomy. More likely to occur after subtotal hysterectomy.
Uterine Prolapse:
- Utero-vaginal prolapse: uterus descends first, followed by the vagina. Usually occurs in virgins and nulliparous women due to congenital weakness of the cervical ligaments.

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This quiz explores the characteristics, symptoms, and treatment of primary dysmenorrhea. Learn about the physiological mechanisms, diagnosis, and the importance of distinguishing between primary and secondary causes. Enhance your understanding of menstrual pain and its management.