Archive for Gynecology

Urinary Incontinence

urinary incontinence

Urinary incontinence is not a topic that turns up in most social conversations. In fact, it is an embarrassing affliction that affects nearly 30% of American women, and most oftentimes tends to go untreated for this very reason. Understanding incontinence is the first step in getting help and treating the problem.

There are different types of incontinence, each with easy-to-recognize symptoms:

  • Stress Incontinence – Urine leakage, either in drips or spurts, which occurs from stress on the bladder, usually from sneezing, coughing, laughing, late-term pregnancy, exercising or lifting heavy objects.
  • Urge Incontinence (also known as Overactive Bladder) – The inability to hold urine long enough to reach a toilet.
  • Overflow – The bladder often feels full, creating almost constant urgency, yet with very little output.
  • Combination – Several people suffer combinations of urinary incontinence.

The causes of urinary incontinence are many. It was once believed that age was a factor, however, according to the National Institute on Aging, this is not the case. Studies have shown that urinary incontinence can arise in anyone at any age from one or more of the afflictions listed below:

  • Damaged nerves that control the bladder
  • Urinary tract infections
  • Medications
  • Constipation
  • Tumors in or near the bladder, spinal cord or brain
  • Weak or inactive bladder muscles
  • Pregnancy (can resolve after childbirth)

Some of the problems that can be associated with a loss of bladder control are lack of sleep, social anxiety, decrease in sexual activity, urinary tract infections, rashes or sores, and depression, to name a few.

Before seeking a doctor, take this Self-Help Test to determine if there is a need for treatment. If it has been determined that there is an incontinence problem, there are medical tests that can determine the cause(s). Some are quite simple, such as urine tests, and others are more invasive, such as blood tests or tests that measure how well the bladder empties. A doctor will determine which tests are needed, based on the answers provided upon a medical history and examination of the patient.

Treatments are varied, depending on the type of incontinence that is diagnosed. Below are some of the treatments prescribed for incontinence:

  • Kegel Exercises – Used for strengthening the pelvic floor.
  • Bladder Control Training – Retraining the bladder by scheduling several visits to the bathroom each day. This type of treatment works well with the use of a Void Diary and taking careful notes of the times, urgency and amount of urine voided.
  • Medication – Doctors may prescribe medications to block the nerve receptors that receive or send signals to the bladder.
  • Surgery – When all else fails, surgery may be necessary. A surgeon may use a sling to suspend the bladder in place. The surgeon will discuss all options available to help the patient make an informed decision.

Preventing urinary incontinence is simple:

  • Fluids – Less is not more. Be sure to drink at least 8-10 glasses of water a day. This helps helps the kidneys to function properly and keeps the bladder trained to recognize the need to void. Avoid caffeine and alcohol, which promote extra urine production. Other drinks, such as acidic juices (tomato and grapefruit) can irritate the bladder. Avoid these drinks.
  • Maintain a healthy weight. Even a few extra pounds can put pressure on the bladder and create incontinence. Exercise and diet are key components to a healthy bladder.

If any of the above symptoms applies to you or someone you know, the best course of action is to contact a doctor for diagnosis and treatment. Incontinence doesn’t have to be a barrier to living a normal life.

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When to Visit the Gynecologist

gynecologist

Visiting your gynecologist is important for maintaining good reproductive health. Schedule yearly checkups as well as visits for these gynecological symptoms…

Why Visit the Gynecologist?

Visiting the gynecologist is imperative for good health. Some women aren’t fazed by it, some women find it a bit stressful, and some women are afraid and avoid the gynecologist all together. Whatever your situation may be, it is something that needs to be done on a yearly basis (preventative care), and on occasions when certain gynecological symptoms manifest.

Browse this list for the most important reasons to go:

When Teen Girls Are Sexually Active or Have Reached the Age of 18

This is the time to start seeing a gynecologist. It establishes an early relationship that will make a woman less apprehensive about the doctor and about her body. The gynecologist will find out if the menstrual cycle is regular, will do a pap smear (which checks for human papillomavirus, a contagious sexually transmitted disease), will inform about birth control, do a baseline breast exam, and answer any gynecological questions.

When a Woman Thinks She is Pregnant

Suspected pregnancy (a missed period or irregular bleeding) can be confirmed by the gynecologist. This sets the stage for early ultrasounds to determine fetal viability.

For Pelvic Pain/ Pressure/ Itching

Pelvic symptoms should be checked out by a gynecologist in order to rule out different abnormalities. Pain can be caused by fibroid tumors, ovarian cysts, or endometriosis. Pressure can also result from these abnormalities. Itching and pain can be caused by an infection. The majority of these symptoms do not indicate life-threatening problems, but proper treatment is nevertheless essential. A pelvic ultrasound might be ordered by the gynecologist for further investigation.

For Irregular/ Heavy Bleeding

Many women contend with irregular menstrual cycles that include bleeding between periods or heavy menstruation. A gynecologist can check for endometriosis, fibroid tumors, or problems with the endometrial lining. Again, a pelvic ultrasound is a non-invasive test that can be ordered for testing for such abnormalities.

When a Woman Has Pain During/ After Intercourse

Painful intercourse can indicate cervical/ vaginal problems such as human papillomavirus or the herpes virus, or it can also merely indicate a bacterial or yeast infection. The gynecologist can do a thorough inspection of the area and view anything abnormal. A pap smear from the cervix can also be taken.

For a Palpable Breast Lump or Pain

Upon self-examination, a breast lump or pain should be reported to the gynecologist. She or he will do a thorough breast exam and determine whether a mammogram, breast ultrasound, or both should be scheduled to view any breast abnormalities.

For Yearly Preventative Care

It is important to visit the gynecologist yearly for a preventative checkup which includes a breast exam, a pelvic exam, and a pap smear.

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Yasmin Birth Control Pills

yasmin birth control pills

Yasmin, also called Yaz, is an oral contraceptive used to prevent pregnancy. Because Yasmin is a different type of birth control pill, it is also used to treat PMDD (Premenstrual Dysphoric Disorder) and a condition known as Polycystic Ovarian Syndrome (POS). As with any medication, it is important to know how the medicine works, its side effects and drug interactions before beginning a medicine regimen.

How Yasmin Works

Yasmin primarily prevents pregnancy by preventing the ovaries from ovulating, which is the release of an egg into the fallopian tube. It also makes the cervical mucus thicker, which makes the sperm have difficulties passing to the uterus. For added protection, Yasmin changes the lining of the uterus to make the uterine wall less receptive to a fertilized egg or embryo.

Drospirenone, the form of progesterone in Yasmin, is closely related to a drug called spironolactene, which is a diuretic. This hormone has anti-androgenic activity that helps women with moderate to severe acne and other male hormone related problems. It helps work against testosterone and other male hormone overproduction. This is why Yasmin is often prescribed for women with PMDD and Polycystic Ovarian Syndrome as well as women who wish to prevent pregnancy.

Side Effects of Yasmin

As with any medication, Yasmin has its share of side effects, ranging from common side effects to rarer, more serious side effects. Even though Yasmin has been documented to have side effects, not all patients will experience side effects. In fact, Yasmin is well tolerated by most patients.

The most common side effects of Yasmin are:

  • Headache
  • Menstrual changes
  • Breast pain
  • Abdominal or stomach pain
  • Nausea and/or vomiting
  • Diarrhea
  • Vaginal discharge or yeast infection

Patients who do experience these side effects report that the symptoms normally go away after the first few weeks of taking the medication as directed.

If more serious side effects are experienced, especially any of those listed below, contact a doctor immediately and/or seek emergency medical attention. Though occurring infrequently, the following more serious side effects have been reported:

  • High blood potassium (Technical name: hyperkalemia)
  • Blood clot in the leg (Symptoms include pain in the calf, leg cramps, and swelling of the foot or leg)
  • Blood clot in the lung (Symptoms include shortness of breath, sharp chest pain, and coughing up blood)
  • Blood clot in the eye (Symptoms include loss of vision or sudden vision changes)
  • Heart attack
  • Stroke (Symptoms include vision or speech changes, weakness or numbness in the leg or arm, and severe headache)
  • Liver damage (Symptoms include jaundice, which is the yellowing of the eyes or skin, dark urine, and upper-right abdominal pain)
  • Depression or other emotional changes
  • Migraines
  • Breast lumps
  • High blood pressure (Technical name: hypertension)

If one experiences any signs of an allergic reaction, such as an unexplained rash, shortness of breath, wheezing, hives, unexplained swelling or difficulty swallowing, seek emergency medical attention immediately as an allergic reaction is potentially life threatening.

Yasmin Drug Interactions

If one is currently taking an ACE inhibitor, ARB (Angiotensin II Receptor Blocker), NSAIDs (Nonsteroidal Anti-Inflammatory Drugs) or Heparin, Yasmin can increase the risk of unsafe levels of potassium in the blood. Have a doctor check potassium levels while taking Yasmin, especially during the first cycle of the medication. Examples of these medications include Benazepril, Captopril, Enalapril, Irbesartan, and Valsartan.

Taking Cytadren, Emend, St. John’s Wart, Provigil or Protease Inhibitors and Yasmin together will lessen the effectiveness of Yasmin. If taking Yasmin for the prevention of pregnancy, rather than for the treatment of PMDD or POS, use a back up method of contraception.

Before having sexual intercourse while taking an antibiotic, consult a physician to see if an additional method of protection is needed. It has been shown in general oral contraceptive studies that antibiotics can interfere with the effectiveness of these drugs.

If one takes Theophylline, Cyclosporine, or Selegiline, it may be better to pursue a different method of contraception. Yasmin increases the levels of these three drugs within the blood, which increases the chances of having side effects from these drugs. In some cases, the reduction of dosage of these medications is enough to prevent the side effects of Yasmin being taking together with one of these drugs.

Lipitor increases the level of Yasmin within the blood stream, which will increase the chances of having side effects from Yasmin. Speak with a prescribing physician before taking these medications at the same time.

Barbiturates, such as Amytal or Nembutal, and certain seizure medications, such as Topomax or Dilantin, can potentially cause the body to metabolize the hormones in Yasmin too quickly, which will decrease the effectiveness of Yasmin. Speak with a physician to see if oral contraceptives can be an efficient method of birth control or if another method will be necessary.

Carefully evaluate the current medical situation with a physician before beginning Yasmin for the prevention of pregnancy or the treatment of PMDD or POS.

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Pregnancy

Millions of sperm are deposited in the vagina during intercourse but only 50-100 of these reach the ovum. Conception normally occurs in the outer 1/3 of the Fallopian tube and cell division begins immediately. The morula (cell mass) enters the uterus some 3 to 4 days later. A few days after that the blastocyst (8-16 cells) is ready to implant into the endometrium. Some of these cellls develop into the fetal portions of the placenta while the others become the embryo. A Doppler ultrasound device can detect the baby’s heart sounds around 8-10 weeks and the heart sounds can be heard with a regular stethoscope at 18-20 weeks.

The first sign of pregnancy and the reason that most women seek a physician is when they are sexually active and have missed a period. Breast enlargement and tenderness, nausea and occasional vomiting may also be noticed. Blood or urine tests are done to confirm pregnancy. Many different urine pregnancy tests are available over-the-counter at local drug stores.

By convention, pregnancies are usually dated from the first day of the last menstrual cycle. Therefore, usually two weeks after missing a period, you are considered to be six weeks pregnant. Pregnancies are considered to last 266 days (38 weeks) after conception or 280 days from the last menstrual cycle (40 weeks). “Due Dates” are calculated by subtracting 3 months from the first day of the last menstrual cycle and adding 7 days. This is an approximate calculation and only about 10% of all babies are born exactly on their due date. A baby is considered full-term if it arrives any time +/- two weeks of their projected due date or 36-42 weeks gestation.

Pregnancy causes changes in every system in the body. However, these changes generally revert back to pre-pregnancy state about 6 months after the baby is born. One of the most common and uncomfortable changes takes place in the kidneys. The hormones, particularly progesterone, which the body produces during pregnancy, cause the ureters (tubes that carry urine from the kidneys to the bladder) to dilate allowing a greater amount of urine to make its way into the bladder in a shorter amount of time. This larger amount of urine combined with the pressure the baby is putting on the bladder results in a frequent need to urinate.

Another often noticed change occurs in the stomach. As the uterus enlarges, it compresses the stomach, slowing the speed at which the stomach empties. Hormones also cause the sphincter at the base of esophagus, which keeps food in your stomach, to relax. The combined result of both of these changes is that belching and heartburn may occur.

Melasma, the “mask of pregnancy” refers to a blotchy pigmented area on the forehead and sides of the face. This is possibly due to the placenta producing a melanocyte-stimulating hormone. The mask will generally fade away over time after the pregnancy.

During the pregnancy, the mother may experience nausea and vomiting, especially in the first trimester. No medications have been approved for this. If  “morning sickness” occurs, a physician may have some suggestions as to its treatment. Eating and drinking frequently and in small amounts may help alleviate the problem.

Many other symptoms may be noticed. A physician should be consulted for questions and is the best source of information about the changes going on in the body.

Labor and Delivery
The usual beginning sign of labor is back pain or lower abdominal contractions at steady intervals. False alarms are not uncommon, but true labor with contractions occurring every 2-5 minutes, is very often abrupt in onset. Delivery occurs then in less than 24 hours. Every mother is different with regards to how fast her labor progresses. In general, the labor with a first child will be longer.

The cervix is normally firm in the nonpregnant state and through most of pregnancy. However, near the end of the pregnancy, the cervix softens and dialates. Once labor has begun, the uterine contractions dilate the cervix more and this dilation sends signals to the brain to increase oxytocin release. The increased oxytocin acts on the uterus to increase the force of contractions and also causes the production of prostaglandins in the uterine lining and placenta. The prostaglandins further increase uterine contractions. These mechanisms aid in delivery of the baby and expulsion of the placenta. Delivery is aided by spinal reflexes and voluntary contractions of the abdominal muscles as well.

A physician will generally explain what to expect during labor and delivery. It is often helpful to attend a birthing class.

Lactation as birth control
Nursing prevents, in some women, the menstrual cycle from resuming after delivery while they are nursing. Prolactin acts to prevent the development of new follicles in the ovary by inhibiting the release of the hypothalamic releasing factor that stimulates LH and FSH release. Therefore, nursing, although not foolproof, provides a measure of birth control in addition to providing superior nutrition and immunoprotection to the infant. Only 5-10% of women become pregnant again while they are nursing. In addition, almost 50% of the cycles in the first six months after cycles return are anovulatory (no egg is released).

In the case of “unwanted pregnancy”, women should consider providing the baby to an adoption service for placement with a family desiring to nuture a new baby. By so doing, one individual’s “problem” can be turned into a blessing for another couple.

Osteoporosis

Definition
Osteoporosis is defined as an absolute decrease in the amount of bone mass such that bones become fragile and porous. Bone is constantly remodeling as a normal process over the course of a lifetime. Bone is constantly breaking down and rebuilding in both the cortical (dense, hard) bones and the trabecular (cancellous – vertebrae) bones. Osteoporosis occurs when bone breaks down much faster than new bone is being formed –break down leads to decreased bone density and a greater than normal susceptibility to fractures.

Symptoms
Osteoporosis is often asymptomatic. Early symptoms are acute pain in the middle to low back; restricted spinal movement. Vertebral compression fractures and fractures of the femur (large leg bone), hip or arm can also be seen. In severe osteoporosis a characteristic Dowager’s hump may be seen.

Risk Factors
Post menopausal, premature menopause, amennorhea (estrogen is protective)
White or Asian ancestry, positive family history
Short stature, small bones, leanness
Low Calcium intake, high protein intake
Inactivity, disuse
Nulliparity (having no children, pregnancy increases bone mass)
Hyperparathyroidsim, thyroid disease
Gastric or small bowel resection
Overuse of antacids
Long term use of glucocorticoids
Smoking, heavy alcohol use, caffeine

Physiology
Bone is the hardest tissue in the human body. It functions to:
–support the fleshy structures.
–protect vital organs.
–contain bone marrow (blood cells are made here).
–act as a system of levers that allow movement based on muscle contractions.

Bone tissue is made of an intercellular calcified matrix with embedded cells that make and breakdown bone in a continuous cycle. Each bone has an external and internal lining of connective tissue that act to nourish the bone tissue. Calcium, phosphate, bicarbonate, citrate, magnesium, potassium and sodium are all present in bone. Calcium and phosphate combine to form a strong crystalline substance called hydroxyapatite that lies along collagen fibers in the matrix. The association of hydroxyapatite with collagen is responsible for the hardness and resistance of bone. 99% of total body calcium is located in bone and teeth; most is locked in the hydroxyapatite reservoir. Some calcium within bone is freely exchangeable with that in the blood such that it is available to the tissues to maintain normal function. Calcium in the blood must be tightly controlled because it is necessary to cell function for such things as blood clotting, muscle contraction, enzyme reactions, cellular communication and skin differentiation.

Calcium is rather deficient in the environment. The body has developed special mechanisms to extract calcium from dietary sources. Normal adults adapt to decreased calcium intake by increasing the fraction of dietary calcium absorbed, but absorption is impaired by aging. Several hormones are involved in calcium metabolism. Two protein hormones, parathyroid hormone and calcitonin, and a derivative of Vitamin D act to make sure the body optimally assimilates dietary calcium. Calcitonin is available as a therapy for osteoporosis where it helps to maintain the bone that is still present.

Nutrition
Dietary sources of calcium are mostly from the dairy foods. However, meat, some beans, seafood, tofu, and green leafy vegetables contain substantial amounts of calcium. 72% of the calcium available from dietary sources is from the dairy group. All women over 35 should see that they get enough calcium, magnesium, vitamins C & D and exercise. Unless an individual has an adverse reaction to milk’s components (e.g., lactose intolerance) milk consumption is encouraged.

Dietary Sources of Calcium
The following chart gives information about the approximate calcium content in a specified serving size for the following foods. This is intended to be a representative example of foods containing calcium, not a comprehensive source. Getting calcium in a well balanced diet is an excellent way to ensure bone health.

Source  Serving Size  Calcium (mg)
Yogurt 1 cup 345-452
Skim Milk 1 cup 303
2% Milk 1 cup 290
Whole Milk 1 cup 250-350
Ice Cream 1/2 cup 50-150
Frozen Yogurt 1/2 cup 50-150
Hard Cheese 1 oz 200-300
Cottage Cheese 1 cup 211
Broccoli, cooked 1 cup 135
Kale, cooked 1 cup 180
Spinach, cooked 1 cup 245
Dried Beans 1 cup 90
Salmon, canned 3 oz 167

Calcium Supplements
Calcium supplements vary widely in terms of the amount of actual elemental calcium they contain. The table below is designed to serve as a guideline on the relative percentages of the various calcium products.

Type % Calcium Content Example Brands
Calcium carbonate 40 Caltrate®, OsCal®,
Titralac®, Tums®
Calcium citrate 21 Citracal®
Calcium glubionate 6.5 Neo-Calglucon®
Tricalcium phosphate 39 Posture®

Calcium carbonate is inexpensive and provides the most elemental calcium per tablet, but it requires gastric acid for absorption so people with low gastric acid (the elderly or people taking blocking drugs for ulcer treatment) should take another form such as calcium citrate. Taking calcium supplements with food, especially acidic foods such as citrus,  increases calcium absorption.

Prevention
Things you can do to decrease your risk of osteoporosis — (Bone mass peaks at age 30-35):
Maintain a regular diet in calcium and protein.
Exercise (weight bearing exercise, gravity is our friend in this case)
Stop cigarette smoking (always an excellent health-promoting idea!)
Reduce alcohol intake
Avoid caffeine and overuse of carbonated beverages
Increase overall calcium intake to recommended levels:

RDA is at least 1100mg/day for adult women
RDA is 1600 mg/day for those age 11 to 24 and for pregnant or breastfeeding women.
U.S. – NIH recommends 1500 mg/day for women 19-24, pregnant or nursing and 1000-1500 for all other age groups.

*RDA = recommended daily allowance
**NIH = National Institutes of Health

Therapy
Drug therapy for osteoporosis is divided into three categories:
1. Agents that stimulate bone formation — none of these are approved by the FDA for treatment of osteoporosis.

a. Fluoride — increases bone mass. Mechanism still under investigation.
b. Parathyroid hormone — investigations show some potential, but not much information available on it in the treatment of osteoporosis.

2. Drugs that inhibit the breakdown of bones.

a. Bisphosphates (e.g., alendronate, Fosamax®) are absorbed onto the surface of the bone and protect the bone from being further broken down. In clinical trials, they are proven to be effective and are approved by the FDA. Side effects include gastrointestinal upset. It may also increase the incidence of esophogeal ulceration. May also experience some abdominal and muscle or bone pain. This drug tends to not be as effective if taken with food. Patients are advised to take it with a full glass of water on an empty stomach.
b. Calcitonin is normally produced in the thyroid gland and stops the breakdown of bone. It reduces the risk for new vertebral fractures and also provides some pain relief. It is approved by the FDA and is available as an injection or as a nasal spray. Minimal side effects include nausea, flushing and nasal ulcerations from the nasal spray. There is a possibility of an allergic reaction.

3. Hormone replacement therapy (HRT).

a. Estrogen has been shown to provide definite benefits against osteoporosis by stimulating the replacement of bone and inhibiting the breakdown. Estrogen regimens can be any of the following:

i. Continuous combination –estrogen + progesterone — this can cause some menstrual spotting for the first 3-6 months, then no more menstrual cycles.
ii. Continuous estrogen + cyclic progesterone
iii. Cyclic estrogen + progesterone

The FDA has recently approved an existing transdermal estrogen patch for the prevention of postmenopausal osteoporosis. The patch, delivers estradiol, is applied twice weekly, and has been available for the treatment of menopausal symptoms since1996.

b. Progesterone is used if the patient has an intact uterus — without the progesterone component, a patient with an intact uterus taking just estrogen has an increased risk of endometrial cancer.

c. Selective Estrogen Receptor Modulators (SERMs) — an option for someone who can’t or won’t take an estrogen. Has the same positive, anti-osteoporotic and cardioprotective effects as estrogen without causing the side effects associated with starting estrogen replacement therapy.

Birth Control

There are several different, reversible methods of contraception currently available. These include spermicides, male and female condoms, diaphragm + spermicide, cervical cap, oral contraceptives, progestin-only oral contraceptives, implanted progestin contraceptive, and depo-provera (injection). All of these have risks and benefits associated with them and none of them provide 100% guaranteed contraception. Only condoms, the diaphragm + spermicide, and the cervical cap have the potential to protect against sexually transmitted diseases — but this protection is NOT 100% guaranteed — the only absolute 100% protection from STDs is abstinence. All forms of birth control have a failure rate–the only foolproof way to avoid pregnancy during childbearing reproductive years is abstinence.

Spermicide

Foams, creams, suppositories, or jellys containing chemical agents to kill the sperm may be applied within the vagina prior to sexual intercourse. Spermicide alone is 37 times less effective than oral contraceptives in preventing pregnancy.

Diaphragm

These dome shaped plastic devices act as a physical barrier to fertilization.  They are available in several sizes and are inserted into the vagina to cover the cervix. They are used most effectively with a spermicide that is applied prior to insertion of the diaphragm. The use of a diaphragm is about 6 times less effective than oral contraceptives in preventing pregnancy.

Condom

This flexible tube shaped barrier is placed over the erect penis so that the ejaculate is retained within the tube. Condoms come in various, materials, colors and styles. It should be noted that all condoms do not protect equally against STD’s. Those made of animal skin allow the passage of infectious viruses, and should be avoided.  Condoms have a breakage rate of 1-5%. The use of a condom is about 11 times less effective than oral contraceptives in preventing pregnancy.

Oral Contraceptives

Oral contraceptives  are one of the most popular forms of contraception. They do not provide protection against STDs. The majority of oral contraceptives are a combination of a progestin component and an estrogen component. The progestin component works in two ways: 1) it prevents implantation of the fertilized egg and 2) it inhibits ovulation. The estrogen component does several things. First, it suppresses the development of a mature follicle in the ovary. Estrogen also potentiates (increases) the action of the progestin component to prevent ovulation. Finally, estrogen also serves to regulate the monthly menstrual flow.

When an oral contraceptive is started, it takes three cycles (approximately 3 months) to match the oral contraceptive’s hormones with the body’s hormones. During these three months, the oral contraceptive may not provide full protection from pregnancy; therefore, a secondary form of birth control may be beneficial during the initial three months.

There are several side effects assiociated with taking an oral contraceptive. These side effects can be remembered by the following acronym: ACHES. If any of these side effects are noticed, contact a doctor immediately.
A- Severe Abdominal pain — a rare complication of the estrogen component.
C- Severe Chest pain, shortness of breath, coughing up blood
H- Headaches
E- Eye problems: blurred vision, flashing lights, blindness
S- Severe leg pain (calf or thigh)

Another little known side effect of oral contraceptives is that they can change the shape of the cornea. Therefore, oral contraceptives can affect the fit of contacts. This change is permanent for as long as the oral contraceptive is taken.

It is very important to inform all health care providers that the pill is being taken. The reason for this is that there are a number of drug interactions with that can affect how effective the oral contraceptive is in preventing pregnancy. For example, nearly all antibiotics, will increase the metabolism of  the oral contraceptive thereby decreasing protection against pregnancy.  Failure rates for combination oral contraceptives are approximately 0.3 failures per 100 woman-years. Progestin alone has a failure rate 3-4 times that of estrogen/progestin contraceptives.

Progestin Implants

These are being used increasingly in some parts of the world. They are surgically inserted under the skin and can prevent pregnancy for up to 5 years. They appear to be effective and well tolerated although they may cause ammenorrhea or irregular bleeding.

IUD

Intrauterine contraceptive devices are plastic or metal objects placed within the uterus by a clinician. It also must be removed by a clinician. Occasionally the uterus may expel the IUD spontaneously. They act by preventing the implantation of the fertilized egg, possibly by speeding the passage of the zygote through the uterus. They also cause changes in the uterine lining during the menstrual cycle. IUD’s are associated with an increased incidence of uterine infections and painful menstruation. Their effectiveness is 4-5 times less than oral contraceptives. Copper containing IUDs may also have a spermicidal effect. This method might be perceived by some as an early stage (post-zygotic) abortive measure.

Rhythm Method

Rhythm method is an alternative to medical intervention. Abstinence is practiced during the portion of the menstrual cycle closest to the expected dates of ovulation. It is only marginally effective.

Surgical Methods

Tubal Ligation (female)

This surgical procedure consists of cutting the Fallopian tubes and ligating the ends to make it impossible for the sperm and egg to meet. This procedure does not interfere with sexual intercourse or ovulation. The procedure is virtually irreversible.

Vasectomy (male)

Surgically cutting the sperm-carrying vas deferens tubes does not interfere with sexual intercourse. The procedure must be done for both testes. When two successive tests for sperm in the ejaculate have been negative the procedure can be said to be successful. Vasectomies have been reversed with some success. Vasectomies are usually performed by urologists.

Menopause

This phase in the life of a woman is characterized by the cessation of menstruation and is complete when the woman has experienced no menstrual periods for a year. The average age of menopause is 50 in the US. In some women, menopause occurs abruptly, while in others there is a gradual cessation of normal periods. Decreased estrogen levels and a shift from ovarian production of estrogen to other sources, i.e. adrenal, is seen.

Symptoms that may occur during menopause are hot flashes, changes in reproductive organs, cardiovascular disease, osteoporosis, nervousness, and depression. Hot flashes are the most common symptom and are associated with estrogen withdrawal. Reproductive organ changes include vaginal dryness, thinning of the vaginal lining, and a decrease in size of the uterus and cervix. These changes are also a result of estrogen withdrawal and account for complaints such as vaginal itching and stress incontinence. There is an increased incidence of high blood pressure, stroke, and heart disease following menopause probably due to the removal of the protection estrogen affords. Osteoporosis is also a risk when estrogen decreases making postmenopausal women more at risk for fractures. The breasts become less glandular and are composed of more fat tissue than in reproductive years.

Treatment includes low-dose estrogen administration with some progesterone therapy and calcium supplementation. This therapy is protective of the breasts and uterus against cancer, deters the loss of bone, and increases HDL (high density lipoproteins, the good ones) and lowers LDL (low density lipoproteins, the bad ones) in the blood. Sometimes a topical vaginal estrogen cream is used to restore the vagina and external genitalia to a premenopausal state.

Gynecology

Anatomy & Physiology

Anatomically, the female reproductive system consists of essential and accessory organs. The ovaries are essential to the production of eggs and hormones that initiate female secondary sexual characteristics and maintain normal reproductive function. The Fallopian tubes conduct the egg or (fertilized egg, the zygote) from the ovary to the uterus that is monthly changed into a habitable place for a fertilized egg. The cervix (narrowest portion of the uterus) serves as a gatekeeper to the body of the uterus. The vagina opens to the exterior in association with the external genitalia. Accessory glands participate in normal reproductive function. These include glands that produce mucus to lubricate the vagina and urethral opening.

Ovaries

These small oval-shaped glands are located on either side of the uterus supported by several ligaments. The ovary consists of 3 areas: 1) cortex, 2) medulla, 3) hilum. The cortex contains supportive cells, blood vessels, and developing follicles. The medulla contains connective tissue, smooth muscle, blood and lymph vessels and nerves. Nerves, blood vessels and connective tissue are found in the innermost portion, the hilum. The ovaries produce eggs(ova) and hormones.

Uterus

The pear-shaped uterus opens to the vagina at the cervix and then widens toward the top where the Fallopian tubes enter the uterus. The uterus is a very muscular organ containing 3 layers of tissues. The interior layer, the endometrium, changes in thickness and secretory capability due to the influence of ovarian hormones over the course of the menstrual cycle. The myometrium, or muscle, is composed of 4 poorly defined layers of smooth muscle that is thickest at the top of the uterus. This makes for greater force during labor and delivery. The exterior of the uterus is covered with connective tissue. During pregnancy the baby (fetus) develops inside the uterus causing it to expand tremendously.

Fallopian Tubes

These narrow muscular tubes are attached to the upper outer angles of the uterus and serve as tunnels for the egg (ova) to travel from the ovaries to the uterus. Ova are captured by the infundibulum which has a wide webbed finger-like appearance, called fimbriae, near the ovary. Wave-like contractions create a current that moves the ovulated egg towards the tubular opening. Conception normally occurs in the tubes, with the fertilized egg then propelled to the uterus by the peristaltic contractions of the tubes and ciliary beating of the tubular epithlium to the uterus for implantation. Sometimes implantation will occur in the Fallopian tubes. Such an ectopic pregnancy is undesirable and must be treated immediately before the growing embryo causes rupture of the tube.

Vagina

This muscular canal extends from the midpoint of the cervix to its opening located between the urethra and rectum. The mucous membrane lining the vagina and musculature are continuous with the uterus. The epithelium lining the vagina thickens and produces lubricating substances in response to estrogen. These secretions aid in sexual intercourse.

Mammary Glands

The breasts are milk producing glands located over the pectoral muscles consisting of a nipple, lobes, ducts and fibrous and fatty tissue. The nipple is surrounded by a pigmented, circular area (areola) and contains ductal openings. Nipple erection is produced with stimulation. The 15 to 25 lobes of each breast are further divided in lobules that are separated and supported by fibrous tissue. Each lobule contains small saclike aveoli surrounded by milk producing cells and small muscular cells. The muscular cells contract to express the milk during lactation. The lobules are drained by ducts that empty into a larger reservoir that lies just below the nipple. Reproductive hormones are important in the development of the breast in puberty and in lactation. Estrogen promotes the growth of the gland and ducts while progesterone stimulates the development of milk producing cells. Prolactin, released from the anterior pituitary, stimulates milk production. Oxytocin, released from the posterior pituitary in response to suckling, causes milk ejection from the lactating breast.

Puberty

The first change to herald the coming of reproductive capability in females is the development of breasts. This is followed by the growth of axillary (underarm) and pubic (groin) hair and finally by the first menstrual period. Intitial periods are usually anovulatory (i.e. no egg released) with regular ovulation occurring within a year. The age at the time of puberty is variable. In the U.S. puberty occurs in girls around the age of 8 to age 13. Because of the individual variability in the onset of puberty, a delay cannot be considered pathological until menstruation has not begun sometime before the age of 17.  Sometimes the delay is called primary amenorrhea and can be due to emotional stress, poor nutrition, weight loss or intensive athletic training.

Hormones & The Cycle

Females have four major hormones involved in the menstrual cycle: follicle-stimulating hormone (FSH), luteinizing hormone (LH), estrogen (estradiol) and progesterone. FSH and LH are protein hormones produced by cells of the anterior pituitary within the brain, in response to small peptide hormones from the hypothalamus (hypothalamic releasing factors). These pituitary hormones travel in the blood to the ovary where they stimulate the development of one or more eggs, each within a follicle. A follicle consists of an ovum surrounded by cells responsible for the growth and nurturing of the ovum. As the cycle progresses, one follicle becomes dominant and all others regress. Estrogen, and progesterone to a lesser degree, are steroid hormones produced by cells of the developing follicle. Estrogen causes the endometrium to increase in thickness and vascularization (i.e.blood supply).

After ovulation (at the midpoint of the cycle), under the influence of LH, these same follicular cells shift to the production of progesterone. Progesterone causes the endometrial lining to become secretory and nutritive in anticipation of implantation of a fertilized egg. These four hormones are in a constant balance that shifts during progress through the menstrual cycle. The average menstrual cycle is 28 days, however only a very small percentage of cycles are exactly 28 days, most cycles range from 25-36 days.

The menstrual cycle can be divided into three phases: the follicular phase, the ovulatory phase, and the luteal phase. The follicular phase begins with the first day of menses (menstrual flow) and continues to approximately day 13 or 14 when ovulation takes place. During the follicular phase, FSH and LH are slowly rising in preparation for the LH surge (very high level of LH) at the time of ovulation. FSH is stimulating the growth of follicles in the ovary. Estrogen and progesterone are relatively low throughout this time but slowly begin to rise toward the end of this phase.

LH surges and peaks during the ovulatory phase (around day 14) and estrogen peaks at the same time. These peaks trigger ovulation. The ovum lives about 72 hours after ovulation, but it is fertilizable for only about 36 hours. Just before ovulation, progesterone levels begin to rise rapidly. Changes in cervical mucus accompany ovulation. The amount of mucus increases and it becomes clear and thin. This facilitates conception by aiding the passage of sperm through the cervical canal. Sperm can live for up to 72 hours in the female reproductive system. Therefore, the fertile period during a 28-day cycle is only about 4-5 days.

After the egg is released, the remainder of the follicle stays intact in the ovary and produces both estrogen and progesterone. This is called the corpus luteum (hence the luteal phase). The corpus luteum remains intact for the remainder of the cycle. The breast swelling, tenderness and pain experience by some is most likely due to the effects of progesterone on breast tissue.

Right after ovulation, the luteal phase begins and during this phase, progesterone levels are very high–progesterone is important during this phase because if the egg is fertilized, and implanted in the uterus, progesterone keeps the uterus intact so that the pregnancy is maintained. The continued health of the corpus luteum (progesterone secretion) is assured by the production of human chorionic gonadotropin (hCG) by the implanted embryo, until the placenta develops and can take over. The detection of hCG in urine is the basis of laboratory and home pregnancy tests.

If fertilization and implantation have occurred, than the corpus luteum will be stimulated by hCG to continue its production of estrogen and progesterone to maintain the pregnancy. This is important because the corpus luteum dies 14-22 days after ovulation if fertilization and implantation do not occur. With no progesterone to keep it intact, the lining of the uterus (the endometrium) is then shed, resulting in the monthly menstrual flow that normally lasts about 5 days. A variety of feminine products are available to help women during menses, including absorptive pads and tampons, deoderants, and vaginal cleansers.