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It is a growth of the muscular wall of uterus and it is benign > 99% of the time.
How common are the fibroids?
They are found incidentally in 25% of white women and 50% of black women. They account for 25% - 30% of all hysterectomies but 77% of women who have hysterectomies are found to have incidental myomas.
Do fibroids grow in response to oestrogen therapy?
Fibroids are sensitive to oestrogen. They contain both progesterone and oestrogen receptors. Can grow during a woman’s menstrual life and frequently shrink after menopause. Nevertheless studies suggest most fibroids do not grow during pregnancy. Fibroids also do not grow in response to oral contraceptives or HRT. If fibroids grow after menopause, the possibility of malignancy should be considered.
How common is malignancy in a fibroid?
Between 0.3% - 0.7%
What are the most common locations of fibroids?
Subserosal: just beneath the serosa
Intramural: in the uterine wall
Submucasal: protruding into the endometrial lining
What are the symptoms associated with fibroids?
Dysmenorrhoea (painful periods), menorrhagia (heavy periods), abnormal bleeding and pressure. Large fibroids may cause pelvic pressure and urinary frequency.
When do myomas require removal?
When they grow rapidly or when they grow after menopause.
Persistent abnormal bleeding unresponsive to medical therapy
Excessive pain or pressure
Consider removal where there is growth beyond 8cm in a woman who has not completed her childbearing.
Do fibroids cause infertility?
Generally fibroids are not considered a major cause of infertility. If fibroids have an impact on reproduction it may be through distortion of the uterine cavity, leading to recurrent miscarriage. When no other cause for infertility is found and myomas are removed, a 70% pregnancy rate results.
What is the therapy for fibroids?
Surgical: Hysterectomy or myomectomy depending on patients' age, reproductive status and general health.
Medical therapy: With GhRH agonists. These induce a menopausal state, reducing oestrogen levels and leading to shrinkage of the myoma. Maximum reduction in size (30% - 64%) should occur by 3 - 6 months. Medical therapy is also very useful prior to myomectomy to reduce size and blood loss. GhRH agonists are only effective for a short time. Discontinuation before menopause will cause re-growth of myomas. Low dose oestrogen replacement is usually provided. It's called “add-back” therapy and protects from symptoms of menopause.
Intervention radiology: Uterine artery embolization can be accomplished by introducing catheters into the vascular supply of the uterus. Evaluation of this technology is ongoing.
What is the incidence and differential diagnosis of vaginal bleeding in the first trimester?
Approximately 30% of women bleed during the first trimester of pregnancy. The differential diagnosis includes threatened abortion, ectopic pregnancy, abnormal pregnancy, vaginal lesions, increased friability of cervix and infections
What is the risk of miscarriage for patients who have first trimester bleeding?
About 50% of women who experience first trimester bleeding will spontaneously abort.
What percentage of pregnancies end in a miscarriage?
About 15% - 20%
When do most clinical spontaneous miscarriages occur?
The incidence of miscarriage decreases with increasing gestational age. Once embryonic cardiac activity is seen sonographically at 6 weeks gestation, the subsequent miscarriage rate is 6% - 8%. Once fetal viability is confirmed at 8 weeks gestation the miscarriage rate is only 2% - 3%
What is the utility of quantitative b-HCG measurement in a patient with threatened miscarriage?
In a normal viable pregnancy the b-HCG level should be double every 48 hours. In patients with abnormal gestation or ectopic pregnancy the b-HCG level would be slowly rising, plateauing or dropping.
What is the definition of recurrent miscarriages?
Three or more consecutive spontaneous miscarriages.
What investigations should we do for recurrent pregnancies lost?
Chromosome test for both partners, Thyroid function tests, Thyroid antibodies, Anticardiolipin antibodies, Lupus antibodies, Clotting studies, Prolactin, Pelvic scan.
How often is an identifiable cause found?
In 50% - 60% of all cases.
What is the chance of a live birth after two and three consecutive miscarriages?
70% - 75% after two miscarriages
70% after three miscarriages with a previous live birth
50% - 65% after three consecutive miscarriages without a previous live birth
What is the treatment for patients with antiphospholipid syndrome or Lupus?
Low dose aspirin (75mg). Studies show that adding corticosteroids to aspirin does not produce additional benefit.
Endometriosis & Adenomyosis
What is endometriosis? What is adenomyosis?
Endometriosis is a disorder where hormonally responsive endometrial tissue is found outside the uterus.
Ademonyosis is a disorder where endometrial tissue is found within the uterine myometrium.
How prevalent is endometriosis?
It is thought to occur in 5% - 15% of pre-menopausal women, in 50% of patients with chronic pelvic pain and in 20% - 50% of infertile women. There is an increased incidence in first degree family members of women with endometriosis.
What are the anatomic sites for endometriosis?
The Pouch of Douglas, the uterosacral ligaments, the bilateral ovarian fossa, the broad ligament, the ovarian surfaces, the fallopian tubes and even on lung, nasal mucosa, bladder, kidney, liver and spleen.
What is the etiology of endometriosis?
The etiology is not definite yet. Some theories suggest implantation following retrograde menstruation into the peritoneal cavity, lymphatic dissemination or haematogenous spread of endometrial tissue or iatrogenic dissemination due to procedures. It also appears that altered macrophage capacity to induce cytolysis of ectopic endometrial cells, along with increased ability of this tissue to survive, invade and include angiogenesis along with impaired cell apoptosis maybe the etiology.
What are the symptoms of endometriosis?
Pelvic pain: Usually cyclically just prior or with menses, located unilaterally or bilaterally. There is no relationship between the extend of the disease and the severity of the pain.
Infertility: The effect of scarring and adhesions distorts pelvic anatomy and affects oocyte transport from the ovary to the tube. The peritoneal environment affects the oocytes and sperm.
Dyspareunia (painful intercourse)
Abnormal uterine bleeding
How is endometriosis diagnosed?
With laparoscopy (procedure where a camera is introduced inside the abdomen from the umbilicus). Endometriotic spots look like black, blue-black, red, red-pink or yellow-brown spots. Endometriotic cysts contain “chocolate-like” fluid.
What is the medical management of endometriosis?
With Danazol, GhRH agonists, anti-inflammatory agents and progestins (such as medroxyprogesterone)
What is the surgical management of endometriosis?
Surgical procedures include excision or destruction with laser vaporization, eletrocoagulation or thermocoagulation and lysis of adhesions. It can also include total abdominal hysterectomy and bilateral salpingo-oophorectomy (removal of womb, tubes and ovaries). Laparoscopic conservative surgery in women with endometriosis-associated chronic pelvic pain provides relief > 6months in 40% - 70% of women. The success rate for surgical treatment of pain with hysterectomy, even without uterine pathology is reported to be up to 78%.
What is an ectopic pregnancy?
It’s a pregnancy that develops at any site other than inside the uterus.
What is the incidence of ectopic pregnancy?
About 2% of pregnancies. Ectopic pregnancy continues to be the most common cause of maternal death in the first half of pregnancy and the second most common overall, accounting for 10% - 15% of all maternal deaths.
Where do the majority of ectopic pregnancies occur?
Fallopian Tube: 97.7 %
Inside the abdomen: 1.4%
Ovarian or cervical: <1%.
What is the incidence of an intrauterine pregnancy co-existing with an ectopic pregnancy?
What is the likelihood that a woman with one ectopic pregnancy will have a subsequent ectopic pregnancy?
Between 7% - 15%
What are the risk factors for an ectopic pregnancy?
History of Pelvic Inflammatory Disease
Previous ectopic pregnancy
Progesterone-only contraceptive pills
What are the most common symptoms of ectopic pregnancy?
Over 90% of patients have abdominal pain, however only 35% report totally missing period.
Abnormal bleeding is not uncommon.
Some women (25%) report shoulder pain which occurs due to diaphragmatic irritation (caused by blood inside the abdomen).
Role of Human Chorionic Gonadotrophin (hCG) in the diagnosis and management of ectopic pregnancy
HCG is a glycoprotein, produced by trophoblastic tissue, and can be measured in the serum within 8-12 days after fertilization. During the first 6-7 weeks of pregnancy the hCG values approximately double every 48hours, in 90% of all intrauterine pregnancies. A subnormal rise <66% is seen in 85% of nonviable pregnancies and a rise of >20% is 100% predictive of a nonviable pregnancy.
What is the role of ultrasound?
Ultrasound in conjunction with hCG titers also helps to confirm intrauterine pregnancy. At levels of 2000 Miu/ML of hCG, a transvaginal scan should be able to detect intrauterine gestational sac.
What is the treatment of ectopic pregnancy?
If growing, an ectopic pregnancy should be removed. Nowadays this can be done via key hole surgery (laparoscopy), with minimal hospital stay. In case of confirmed ectopic pregnancy which is dissolving and is asymptomatic, an expectant management could be followed. Methotrexate, a folic acid antagonist has been used in selected cases. Patient is advised to discuss with doctor the optimal way of treatment.
Pap-Test & Cervical Cancer
What are the causes of cervical cancer?
Certain subtypes of Human Papilloma Virus (HPV) (especially 16, 18 and 31) have been found to be an important etiologic event. Increased incidence of cervical cancer is seen with: low socioeconomic status, early age of first coitus, higher number of sexual partners, cigarette smoking and in HIV disease.
How many people get cervical cancer?
In USA it is estimated around 10,500 women per year. Worldwide, the incidence approaches 500,000 cases per year and half of these patients will die of their disease, making it among the leading cases of cancer death for women in many developing nations
Can cervical cancer be diagnosed by Pap-smear?
No. Pap smear can detect cervical changes highly suggestive of cancer, but biopsy is required in order to diagnose cancer. If abnormal cells are found, in many cases they will go back to normal on their own, but sometimes they continue to develop. If left untreated, these cells may eventually develop into cancer. However, it usually takes more than ten years for this to happen, and cervical cancer can easily be prevented if abnormal changes are found and treated early.
Who should have the Pap-test? How often?
Women between 18-70 years old should have a smear test every year. Statistics have shown a woman’s risk of cervical cancer is cut by 91% if having a smear every 3 years (like in the UK), and 93% if having it annually. Women who are under 18 and are sexually active are advised to have test-Pap as well.
How is it taken?
To take the sample, your doctor will put a special instrument called a speculum into your vagina. This helps open your vagina so the sample can be taken. Your doctor will gently clean your cervix with a cotton swab and then collect a sample of cells with a small brush.
When should it be taken?
A woman should have a Pap smear when she is not menstruating. The best time for screening is between 10 and 20 days after the first day of her menstrual period. For about two days before testing, a woman should avoid intercourse or using spermicidal foams, creams, or jellies or vaginal medicines (except as directed by a physician).
What do the results mean?
Normal smear means the cervix is healthy. An abnormal Pap smear can be a sign of a number of changes in the cells on your cervix:
Inflammation (irritation). This can be caused by an infection of the cervix, including a yeast infection, infection with the human papillomavirus (HPV) the herpes virus or many other infections.
Abnormal cells. These changes are called cervical dysplasia. The cells are not cancer cells, but may be precancerous (which means they could eventually turn into cancer).
More serious signs of cancer. These changes affect the top layers of the cervix but don't go beyond the cervix.
Indication of advanced cancer.
In every occasion, women are advised to discuss results with their gynaecologist.
What happens if the Pap-smear is abnormal?
Depending on the results, the doctor might decide to repeat the smear or do a colposcopy, a procedure where the cervix is examined with a camera, for better detailed view, and biopsies are also taken. Colposcopy is not a surgical procedure so the patient will not be anaesthetized.
How are abnormal cells treated?
If tissue cell changes have occurred, the woman will normally be advised to have this tissue removed. There are several ways of doing this including a diathermy loop or using a laser. Most procedures can be performed with local anaesthetic while the woman remains awake. Following these procedures there may be some slight bleeding but the cervix heals quickly. The pre-cancerous tissue has now been removed and will be replaced by new, healthier tissue.
What happens after treatment?
Depending on the severity of the pre-cancerous changes that have been removed, the woman will be advised how often she should attend for follow-up smear tests. This form of treatment is highly effective but pre-cancerous changes can return, so continued follow-up is essential.
What is the vaccine against cervical cancer?
Gardasil is a vaccine against certain types of human papillomavirus (HPV). Gardasil is designed to prevent infection with HPV types 16, 18, 6, and 11. HPV types 16 and 18 that currently cause about 70% of cervical cancer cases and also cause some vulvar, vaginal, penile, anal. HPV types 6 and 11 cause about 90% of genital warts cases.
Gardasil is only effective in preventing HPV infections, not in treating those already infected by HPV, and so the vaccine must be given before HPV infection occurs in order to be effective. For this reason it is recommended to administer the vaccine before adolescence and the onset of sexual activity It has been routinely established in 20 countries around Europe and 71 countries worldwide. 10 million doses have been given in USA.
Cervarix is another vaccine against 2 types of HPV, 16 and 18.
Polycystic Ovarian Syndrome (PCOS)
What are the polycystic ovaries? How common they are?
Polycystic ovaries contain several small cysts, which are follicles that do not grow and as a result, do not release eggs. 20% - 30% of women have polycystic ovaries.
What is the polycystic ovarian syndrome? How common is it?
Polycystic ovarian syndrome (PCOS) is a syndrome which combines polycystic structure of the ovaries with hormonal disorders and changes. It is found in 10% - 15% of women.
What are other names of PCOS?
Chronic ovarian Hyperandrogenism
What are the criteria for diagnosing PCOS?
Hyperandrogenism either clinical or biochemical, menstrual dysfunction associated with oligo-anovulation
What findings are commonly associated with PCOS?
Elevated LH:FSH ratio (>2:1)
Polycystic ovaries on ultrasound
Elevated Testosterone (total and / or free)
Adult-onset Diabetes mellitus
What are the causes of the PCOS?
The causes are not clear. Genetic and environmental factors have been associated with PCOS
What are the two mechanisms leading to excess production of androgens by ovarian theca cells in PCOS?
Increased LH pulse frequency and amplitude
Insulin acting on the ovary either directly or through mediators
Can the cysts on the PCOS be potentially malignant?
Are the cysts painful?
What are the most common clinical manifestations of PCOS? How common are they?
Subfertility: 74% of patients
Hirsutism: 69% of patients
Amenorrhoea: 51% of patients
Obesity: 41% of patients
Diabetes: 10% of patients
It is important to mention that the clinical picture of each patient could combine one or more of the above symptoms. Thus, the treatment is tailored to patients needs e.g. assisted conception for women trying to conceive, or hormonal treatment for women with period irregularities.
What therapy is useful for hirsutism associated with PCOS?
Combined Contraceptive Pill
Finasteride (5a-reductase inhibitor)
Eflornithine HCl cream
How soon is an effect on hirsutism seen once treatment has begun?
A treatment effect is not seen for 3-6 months
What are treatments for infertility due to anovulation in patients with PCOS?
What are the expected ovulation and pregnancy rates with clomiphene citrate therapy in women with PCOS?
Ovulation rate: 80%
Pregnancy rate: 50%
Lower Genital Tract Infections
What are the most common forms of vaginitis? What are the symptoms?
The most common are Candida vaginitis, bacterial vaginitis, Trichomoniasis and Atrophic vaginitis.
The usual symptoms are: discharge, increased and malodorous, pruritus, dyspareunia, burning, oedema and erethyma.
What is the treatment of candida?
Single dose of Fluconazole or a short course (1-7 days) of a vaginal preparation such as miconazole, clotrimazole etc.
How is the bacterial vaginosis treated?
With metronidazole or clindamycin.
What is the treatment of Trichomoniasis?
Trichomoniasis is a Sexual Transmitted Disease. Treatment is with a single dose of Metronidazole. Sexual partners should also be treated.
What is atrophic vaginitis?
Is a vulval irritation and inflammation secondary to atrophy of the vaginal mucosa. This occurs due to inadequate oestrogen and is associated with menopause. It is treated with supplemental oestrogen either locally inside the vagina, or systemically.
What is the cause of syphilis? How is it treated?
Is caused by exposure to Treponema pallidum. The disease progresses through stages. There is an initial ulcer at the point of infection, usually visible on the vulva. In contrast with genital herpes, the ulcer is painless. Systemic symptoms can appear within a year with rash of the palms and soles of the feet. Finally there is a late syphilis, in which systemic effects involve multiple systems including heart and the central nervous system. Treatment is with penicillin.
How is chlamydial infection treated?
With azithromycin, doxycycline or with one of several quinolones. If untreated can cause pelvic inflammatory disease (PID).
How does genital herpes presents?
Herpes typically causes small vesicles that rapidly progress to characteristic shallow, painful ulcers on the labia, vagina mucosa, cervix and/or perineum. Inguinal adenopathy frequently is present, as well as vaginal discharge. The most common complaint is pain. Women can also experience urinary retention requiring bladder catheterization, as urine is extremely irritating to the ulcers. Fever and malaise may also be present.
A primary herpes is typically more severe and lasts longer (12-21 days). Recurrent outbreaks typically last 2-5 days and the symptoms are usually milder. Some women experience a single outbreak and others have recurrences many times a year.
The disease spreads by direct contact with the virus at the site of an outbreak. Therefore the virus can only be spread when woman has a secondary outbreak or in the days prior to the eruption of an ulcer. If a woman has no active lesions and is not experiencing a prodrome, she is generally not infectious. Once ulcers are completely healed, they are no longer infectious.
How is genital herpes treated?
Although cannot be cured, the symptoms and duration of both initial and secondary outbreaks can be reduced with antiviral treatment, including acyclovir, valacyclovir and famciclovir. Initial treatment is for 7 days.
What is Pelvic Inflammatory Disease (PID)?
The term PID describes a spectrum of infection and inflammation involving the upper genital tract (endometrium, tubes and ovaries) as well as the surrounding peritoneum.
What is the cause of PID?
Usually Neisseria Gonorrhoeae and Chlamydia trachomatis.
What are the potential long term consequences of PID?
Infertility (incidence of infertility 20% with one episode of PID)
Chronic pelvic pain (20% in women with a history of PID)
Increased risk of ectopic pregnancy (risk 6-10 times greater than the risk in women without PID)
Potential passing of sexually transmitted diseases to other sexual partners.
What is the treatment of PID?
Ofloxacin plus Metronidazole.
Clindamycin plus Gentamycin.
Ciprofloxacin plus Metronidazole plus Doxycycline.
Treatment is usually for 14 days.
Menopause & Hormone Replacement Therapy (HRT)
What is Hormone Replacement Therapy (HRT)?
It’s a therapy commonly used to help with symptoms of menopause.
What are the symptoms of menopause? When does it occur?
The average age that menopause occurs is around 52 years. The most common symptoms include: irritability, lethargy, hot flushes and night sweats, depression, headaches, forgetfulness, weight gain, less need for sleep, palpitations, crying, constipation, heavy periods, period pain and feelings of being more feminine.
How common is osteoporosis?
Osteoporosis affects 25 million women in USA and results in 1.5 million fractures annually. Approximately 15% of women over the age of 50 have osteoporosis and up to 50% osteopenia. 50% of women over the age of 65 years will have a fracture. Up to 25% of fractures (particularly hip fractures) lead to death within 1 year.
When should I start taking HRT?
If you are perimenopausal you will probably be advised to start a combined HRT because you still have periods (although irregular). This contains Progesterone as well as Oestrogen in the first 12-14 of the 28 tablets and therefore causes a regular monthly bleed every 28 days, similar to that of the contraceptive pill. The reason for having a combined hormone preparation is because Oestrogen alone increases the risk of uterine cancer, but when paired with Progesterone the risk is substantially reduced.
When you are definitely menopausal (no periods for a whole year) you will be advised to take a continuous combined preparation which has a balanced dose of Oestrogen and Progesterone. This should not cause a monthly bleed as the hormones are kept at the same levels in each tablet.
If you have had a hysterectomy, you will need Oestrogen only HRT, as uterine cancer is no more a concern.
How long should I take it for?
No longer than 5 years for the treatment of hot flushes and mood swings. If you are aged over 50, then HRT should be taken only until the worst of the symptoms have passed (generally 1-3 years). However younger women who have experienced an early menopause, either naturally or via surgery may be advised to continue for slightly longer.
For the treatment of osteoporosis it has been assumed that 5-10 years of HRT after the menopause would delay the peak hip fracture incidence. Thus if the median age for hip fracture is 79 years, and if it is delayed by 5-10 years through the use of HRT, most women might not have any hip fracture during their life.
What are the benefits of HRT?
70% - 80% improvement in hot flushes and night sweats. They stop in approximately 3-4 weeks.
25% - 50% decreased risk of vertebral and hip fractures.
20% decrease in risk of colorectal cancer and possible decreased risk of Alzheimer’s disease.
25% reduction in tooth loss
Lifting mood and improving condition of skin, hair and nails.
Effect on cardiovascular disease is unclear.
Are there any side effects?
Not everybody will experience side effects. Side effects will disappear when HRT is discontinued. Side effects may include:
Nausea, breast discomfort, leg cramps, commonly due to water retention and usually disappear within a few months.
Headaches, migraines, dizziness
Vaginal spotting for the first few months (due to change of hormones)
Skin irritation (patches)
What are the possible complications?
Blood clotting (Deep Vein Thrombosis): In women who DO NOT use HRT the risk of DVT is 1/10,000 women per year. In women who DO use HRT this risk is 3/10,000 women per year.
Breast cancer: 8/10,000 women per year present more breast cancers after a six year use. The risk drops to the same levels of every other woman, five years after stopping HRT.
For these reasons, HRT should be used for menopausal symptoms for as short a duration as possible.
What other treatments are available for osteoporosis?
Cut down on sugar, caffeine and alcohol especially late at night as these increase night sweats
Ensure bed linen and bed wear are cotton.
Avoid spicy foods
Carry a water spray or hand held fan to help you cool down
Carry moist tissues to freshen up after a hot flush.
Keep yourself hydrated by drinking at least 2 litres of water per day.
What is the failure rate in one year’s use per 100 women for different methods of contraception?
Combined contraceptive pill (COP): 0.2% - 3%
Progesterone-only pill (POP): 0.3% - 4%
Levonorgestrel Intrauterine System (LNG-IUS): 0% - 0.6%
Male condom: 2% - 15%
Coitus interruptus: 6% - 17%
Fertility awareness: 2% - 25%
Injectable (DMPA): 0% - 1%
Sterilization Female: 0% - 0.05%
What is the mechanism of action of COP?
Inhibits ovulation by suppressing FSH and LH, hampers sperm transport by thickening the cervical mucosa, possible inhibition of sperm capacity, altered mobility of the uterus and fallopian tubes.
What are the non-contraceptive benefits of COP?
Reduction of menstrual cycle disorders (less heavy and less painful periods), controlled period upon request.
Fewer functional ovarian cysts
Fewer extrauterine pregnancies because normal ovulation is inhibited.
Reduction in Pelvic Inflammatory Disease
Increase in bone mineral density
Probable reduction in thyroid disease (both overactive and underactive syndromes)
Probably reduction in risk of Rheumatoid arthritis
Reduction in Trichomonas vaginalis infections
Reduced risk of cancers of ovary (40%). The protective effect lasts for at least 15 years after COP discontinuation.
Reduced risk of cancers of endometrium: Risk 20% down with 1 year use, 40% with 2 years use and 60% with 4 or more years of use. This reduction in risks persists for at least 15 years after discontinuation.
No toxicity in overdose.
What is the risk of breast cancer?
The cumulative incidence of breast cancer in 1000 women by the age of 45 years is 10 in 1000 for women who never used the COP and 11 in 1000 in women who have used the COP. The increased risk of developing breast cancer is dropping to zero 10 years after stopping the COP. The cancers diagnosed in women who use or ever used COP are clinically less advanced then in women who never used COP and less likely to spread beyond the breast.
What is the risk of Deep Vein Thrombosis?
The incidence in healthy non-pregnant women not taking the pill is 5 / 100.000 women per year
The incidence in users of COP containing Norethisterone or Levonorgestrel is 15 / 100.000 per year
The incidence in users of COP containing Desogestrel or Gestodene is 25 / 100.000 per year
What are the contraindications for COP use?
Known presence or history of Deep Vein Thrombosis or Pulmonary Embolism
History of Coronary artery disease or Ischemic Heart Attack
Diabetes with neuropathy, retinopathy or duration greater than 20 years
History of estrogen dependent cancer, like breast cancer
Migraines with neurologic symptoms
Age > 35 and smoking >15 cigarettes daily
Active liver disease
BMI >39 (absolute contraindication)
BMI 30 - 39 (relative contraindication)
Known coagulation disorder, thrombophilia
4 weeks before and/or until 2 weeks after full immobilization after major surgery
Allergy to COP.
When can the pill be started?
Menstruation: on day 1. When on day 3 or later, extra precautions are needed
Postpartum: When lactation the POP is recommended. When no lactation, on day 21
After Termination of pregnancy or miscarriage: Same day
Switching from POP to COP: any day (end of packet)
What happens if you miss a pill?
The management is different depending which days pill you have missed and you are advised to contact you doctor.
What happens with vomiting?
If vomiting began over 3 hours after one pill was taken it can be assumed to have been absorbed.
What drug usage demands specific advice?
Some of the drugs include: Rifampicin, Griseofulvin, Barbiturates, Phenytoin, Carbamazepine, Pirimidone, Topiramate, Modafinil. The general advice is to contact your doctor.
What happens with broad spectrum antibiotics?
Ampicillin, Amoxycillin, Augmentin, Tetracyclines and Cephalosporines could alter COP action. Although the risk of pregnancy is small the advice is to use condom contraception for as long as the duration of the antibiotics use, plus extra 7 days after finishing the antibiotics and also to eliminate the pill free period and start next pack.
When does the fertility return after stopping the COP?
Within one month approximately.
What is the benefit of the POP?
It is harmless during lactation. The POP is as effective as the COP. Broad spectrum antibiotics do not interfere with the effectiveness of POP. It may be used in women with past history of Venus Thromboembolism, to smokers above 35 years of age, to women with hypertension, migraine and obesity.
When does the bleeding come with the POP?
Irregular bleeding remains a very real problem. The bleeding time cannot be controlled as well as with the COP use. The trend is any prolonged bleeding episodes to lessen with continued use and at one year around 50% had either amenorrhoea or only one or two bleeds in 90 days.
What is the Levonorgestrel Releasing intrauterine system: (LNG-IUS)
It is a coil which releases 20 μg of Levonorgestrel per 24 hours.
How long it lasts for?
How does it act?
Alters sperm motility, alters tubal fluids thus egg and sperm transport and interaction and alters the uterine lining so it becomes unfavourable for implantation.
How effective is it?
The failure rate is very low, much lower than COP and POP.
What are the benefits of use?
Easy to use (no need to remember taking pills every day)
Dramatic reduction in amount and duration of blood loss
Dysmenorrhoea (painful period) is improved
Return of fertility directly after removal.
Easy to insert/ remove
Even if women become amenorrhoic (no bleeding at all) sufficient estrogen is produced from the ovaries for health.
What are the unwanted effects of LNG IUS?
There is a small incidence of irregular bleeding the first few months in some women. There is also small incidence of bloatedness, acne and depression, which usually improve often within 2 months.
What are the absolute contraindications for LNG IUS use?
Liver tumor and liver disease, breast cancer, throphoblastic disease, pregnancy, acute pelvic infection and allergy to levonorgestrel.
What is the mechanism of action of emergency contraception (morning after pill)?
Inhibits or delays ovulation, alters endometrial receptivity, interferes with corpus luteum action, thickens the cervical mucus and alters the tubal transport of egg and sperm.
How effective is it? When should it be taken?
Should be taken as soon as possible. The efficacy is dependent on the time that the treatment begins. If the treatment begins less than 24 hours after intercourse, the efficacy is around 97% - 99%. Every 12 hours delay in treatment increases the failure rate by 50%.
When should you expect your period to come?
The bleeding should occur as usual. However due to emotional stress some days delay have also been reported.
Are there any contraindications to use?
Acute liver disease, or porphyria, pregnancy or severe allergy to the pill.
Is there any upper age limit to use?
What happens if emergency contraception is needed during breastfeeding?
The conception risk is of course lower but if emergency contraception is needed the infant should be bottle-fed for 24 hours with expression of the breast milk.
What is the birth control patch? How often should it be changed?
The birth control patch is a patch placed directly on the skin of the woman. It can be attached on the buttocks, stomach, torso or arms. It has to be replaced every week, on the same day for 3 weeks in a row. The patch is not worn on the 4th week, allowing period bleeding to occur.
What is the weight limit that the provider advices for the patch use?
The provider suggests not to be used by women who are weighting> 90 kg, because the effectiveness it only 92%.
How does it work?
The patch prevents eggs from being released from the ovaries.
Second, it thickens the cervical mucus preventing the sperm from reaching the egg.
Third, it changes the lining of the uterus preventing implantation.
How effective is it?
The failure rate is as low as the rest of the contraceptive methods, and is around < 1%.
It might not cover from pregnancy when on antibiotics. It is not covering from sexual transmitted diseases.
What are the possible side effects?
They are rare and include:
Irregular vaginal bleeding
Moderate gain weight.
What are the contraindications of using the patch?
History of heart attack or stroke
Unexplained vaginal bleeding
Severe high blood pressure
Diabetes with kidney, eye, nerve or blood vessel complications
Known or suspected cancer
Known or suspected pregnancy
Liver tumors or liver disease
Headaches with neurological symptoms
Hepatitis or jaundice
Disease of the heart valves with complications
Require long bed rest following surgery
Allergic reaction to the Patch
When should I start using the patch?
It is usually advisable at the first day of your period and to use 7 days of extra contraception (e.g. condoms). It starts working immediately.
What do I do if the patch comes off?
You have to put another one on straight away. If you replace the patch within 24 hours no extra contraception is needed. Otherwise you need emergency contraception. The patch might come off during swimming, bathing, exercising.
Can I make it smaller or change it place?
The answer is no. This could alter the patch’s efficacy. You should not remove it once you apply it on the skin.
Should I wear it on the same place each week?
It is advisable to change places each time, to avoid skin irritation.
Fertility & Infertility
What is the chance of becoming pregnant per cycle in a normal fertile couple?
About 20%. Success rate is related to woman’s age. Infertility has been noted in 10% in women under age 30, 15% in women 30-35, 30% in women 35-40 and 60% in women over the age of 40.
When does ovulation happen?
A woman's monthly cycle is measured from the first day of her menstrual period until the first day of her next period. It is usually between 28 – 32 days, but some women may have much shorter cycles or much longer ones. Ovulation happens 14 days before the next expected period, (e.g. the 14th day of a 28 days cycle, the 16th day of a 30 days cycle). Because not all of the women have stable cycles it is difficult to know the exact day of ovulation.
Facts about ovulation and sperm
An egg lives 12 - 24 hours after leaving the ovary
Normally only one egg is released each time of ovulation
Ovulation can be affected by stress, illness or disruption of normal routines
Implantation of a fertilized egg normally takes place 6 - 12 days after ovulation
Each woman is born with millions of immature eggs that are awaiting ovulation to begin
A menstrual period can occur even if ovulation has not occurred
Ovulation can occur even if a menstrual period has not occurred
Some women can feel a bit of pain or aching near the ovaries during ovulation.
If an egg is not fertilized, it disintegrates and is absorbed into the uterine lining
Sperm can live inside the womb between 3 - 5 days.
How many days during my cycle am I fertile?
An egg lives about 12 - 24 hours. But since sperm can live in the body for 3 - 5 days and then the egg is available for one day, your most fertile time is considered to be about 5 - 7 days.
Can I ovulate during my period? Can I get pregnant if I have sex during or straight after my period?
Usually women who have regular cycle do not ovulate during the period. However some women have very irregular cycles, and have sometimes 2 or 3 periods during a month (or what it seems to be a period). Some women have very short cycles, and since the sperm can live up to 5 days you could get pregnant from having sex during your period if you were about to ovulate soon after your period. For example if you have a cycle of 21 days, you would ovulate around day 7, and if you have bleeding for 7 days (some women do) you could get pregnant.
Can I get pregnant from pre-ejaculation?
The answer is yes. This fluid comes out before actual ejaculation. Although low, this fluid does contain some sperm, and in theory could cause fertilization.
Can sperm travel through clothing?
It is very unlikely but in theory if the clothing was completely saturated with sperm and in direct contact with the vagina, fertilization could happen.
Can pregnancy occur from having intercourse inside water?
The answer is yes. If ejaculation happens inside water, sperm could survive for some minutes and in theory could travel inside vagina.
Can pregnancy occur from anal intercourse?
The answer is no. However, because the anus and the vagina are very close, if sperm leaks out inside the vagina could cause fertilization.
How is infertility defined?
Failure to conceive after 1 year unprotected intercourse.
How often is it happening?
Infertility affects 10% - 15% of couples of reproductive age.
What are the general causes of infertility? How common is each?
Ovulatory dysfunction 10% - 25%
Pelvic Factors (tubal disease or endometriosis) 30% - 50%
Male factor 30% - 40%
Cervical factors 5% - 10%
What are the characteristics of a normal sperm analysis?
Volume > 2ml
Sperm motility >50% (category A+B)
PH 7.2 - 7.8
Normal sperm morphology >30%
Sperm count > 20 million/ml (the most important factor)
What causes infertility in men?
Heavy alcohol use
Environmental toxins, including pesticides and lead
Health problems such as mumps, serious conditions like kidney disease, or hormone problems
Radiation treatment and chemotherapy for cancer
What causes infertility in women?
Most cases of female infertility are caused by problems with ovulation. Without ovulation, there are no eggs to be fertilized. Ovulation problems are often caused by polycystic ovarian syndrome (PCOS). Primary ovarian insufficiency (POI) is another cause of ovulation problems. POI occurs when a woman’s ovaries stop working normally before she is 40. POI is not the same as early menopause. Less common causes of fertility problems in women include:
Blocked fallopian tubes due to pelvic inflammatory disease, endometriosis, or surgery for an ectopic pregnancy as well as physical problems with the uterus.
Are there any factors to increase a woman’s infertility?
Excess alcohol use
Being overweight or underweight
Sexually transmitted infections (STIs)
Health problems that cause hormonal changes, such as polycystic ovarian syndrome and primary ovarian insufficiency
How is infertility treated?
Depending on results of diagnostic investigations and causes of infertility the following treatments might be used?
Clomiphene citrate (Clomid): This medicine causes ovulation by acting on the pituitary gland. It is often used in women who have polycystic ovarian syndrome (PCOS) or other problems with ovulation. This medicine is taken by mouth.
Intrauterine insemination of sperm (IUI): Intrauterine insemination (IUI) is an infertility treatment that is often called artificial insemination. In this procedure, the woman is injected with specially prepared sperm. Sometimes the woman is also treated with medicines that stimulate ovulation before IUI.
In vitro fertilization (IVF) (fertilization outside of the body): IVF is the most effective ART. It is often used when a woman's fallopian tubes are blocked or when a man produces too few sperm. Doctors treat the woman with a drug that causes the ovaries to produce multiple eggs. Once mature, the eggs are removed from the woman. They are put in a dish in the lab along with the man's sperm for fertilization. After 3 to 5 days, healthy embryos are implanted in the woman's uterus.
Intracytoplasmic sperm injection (ICSI): is often used for couples in which there are serious problems with the sperm. Sometimes it is also used for older couples or for those with failed IVF attempts. In ICSI, a single sperm is injected into a mature egg. Then the embryo is transferred to the uterus or fallopian tube.
What are ovarian cysts?
A cyst is a fluid-filled sac located in or on the ovaries. The most common type of ovarian cyst is a functional cyst.
Functional cysts often form during the menstrual cycle. The two types are:
Follicle cysts. These cysts form when the sac doesn't break open to release the egg. Then the sac keeps growing. This type of cyst most often goes away in 1 to 3 months.
Corpus luteum cysts. These cysts form if the sac doesn't dissolve. Instead, the sac seals off after the egg is released. Then fluid builds up inside. Most of these cysts go away after a few weeks. They can grow to almost 8 cm. They may bleed or twist the ovary and cause pain. Some drugs used to cause ovulation, such as Clomiphene, can raise the risk of getting these cysts.
Other types of ovarian cysts are:
Endometriomas. These cysts form in women who have endometriosis. This problem occurs when tissue that looks and acts like the lining of the uterus grows outside the uterus. The tissue may attach to the ovary and form a growth. These cysts can be painful during sex and during your period.
Cystadenomas. These cysts form from cells on the outer surface of the ovary. They are often filled with a watery fluid or thick, sticky gel. They can become large and cause pain.
Dermoid cysts. These cysts contain many types of cells. They may be filled with hair, teeth, and other tissues that become part of the cyst. They can become large and cause pain.
Polycystic ovaries. These cysts are caused when eggs mature within the sacs but are not released. The cycle then repeats. The sacs continue to grow and many cysts form.
What are the symptoms of ovarian cysts?
Many ovarian cysts don't cause symptoms. Others can cause:
pressure, swelling, or pain in the abdomen
dull ache in the lower back and thighs
problems passing urine completely
pain during sex
pain during your period
nausea or vomiting
If you have these symptoms, get help right away:
pain with fever and vomiting
sudden, severe abdominal pain
faintness, dizziness, or weakness
How are ovarian cysts found?
Doctors most often find ovarian cysts during routine pelvic exams. The doctor may feel the swelling of a cyst on the ovary. Once a cyst is found, tests are done to help plan treatment. Tests include:
An ultrasound: With an ultrasound, the doctor can see the cyst's shape, size, location and if it is fluid-filled, solid, or mixed.
Pregnancy test: To rule out pregnancy.
Hormone level tests: Hormone levels may be checked to see if there are hormone-related problems.
A blood test: This test is done to find out if the cyst may be cancerous. The test measures a substance in the blood called cancer-antigen 125 (CA-125). The amount of CA-125 is higher with ovarian cancer. Some noncancerous diseases also raise CA-125 levels, like uterine fibroids, endometriosis, pregnancy, pelvic infection and menstruation. Noncancerous causes of higher CA-125 are more common in women younger than 35. Ovarian cancer is very rare in this age group.
How are cysts treated?
Watchful waiting: If you have a cyst, you may be told to wait and have a second exam in 1 to 3 months. The doctor will check to see if the cyst has changed in size. This is a common treatment option for women who:
are in their childbearing years
have no symptoms
have a fluid-filled cyst
Surgery: The cyst might have to be removed if you are postmenopausal, or if it:
doesn't go away after several menstrual cycles
looks odd on the ultrasound
Birth control pills: If you keep forming functional cysts, you may be prescribed contraceptive pills to stop you from ovulating. If you don’t ovulate, you are less likely to form new cysts. You can use the COP or even the Depo-Provera injection. It is a hormone that is injected into muscle. It prevents ovulation for 3 months at a time.
As a rule any patient with an adnexal mass >10 cm requires surgery, because functional cysts rarely exceed 7 - 8 cm.
Women in reproductive age and cysts <10cm can be followed up clinically in 1 - 2months if there are no symptoms.
Postmenopausal women with complex adnexal masses or masses >5cm require surgical removal of the cyst due to increased risk of malignancy.
Can ovarian cysts be prevented?
No, ovarian cysts cannot be prevented. The good news is that most cysts don't cause symptoms, are not cancerous and go away on their own
When are women most likely to have ovarian cysts?
Most functional ovarian cysts occur during childbearing years. And most of those cysts are not cancerous. Women who are past menopause (ages: 50 – 70) with ovarian cysts have a higher risk of ovarian cancer. At any age, if you think you have a cyst, see your doctor for a pelvic exam.
What is PMS?
It has been described first in 1931. Defined as "constellation of symptoms that occurs in a cycling pattern, always in the same phase of menstrual cycle, interfering with work or lifestyle and followed by a period entirely free of symptoms"
What are the symptoms of PMS?
Symptoms may be both physical and emotional. Physical symptoms include:
Breast swelling and tenderness
Skin changes as acne
Cravings of sweets
Emotional symptoms include:
Confusion or forgetfulness
Feeling of being “out of control”
Do we know what causes PMS?
The short answer is no, but we do know that PMS is real. Several theories have been proposed, all of which have to do with various hormonal alterations: ovarian hormones (oestrogen and progesterone), fluids and electrolytes (prolactin, aldosterone, rennin/angiotensin and vasopressin), neurotransmitters (monoamines, acetylocholine) and other hormones (endorphins, androgens, glucocorticoids, melatonin and insulin). Recent research suggests that serotonin may play significant role in the disease.
Will changes in diet help?
Carbohydrate craving, especially for chocolates and sweets is a common symptom in PMS. This is thought to be related to serotonin. By ingesting sugars the body attempts to increase serotonin, which in turn increases levels of L-tryptophan in the brain. In normal metabolism the serotonin levels rise and fall throughout the day. A rise in serotonin levels accompanies the ingestion of proteins, which then lowers serotonin to begin a new cycle. In PMS serotonin levels do not reach a level high to trigger protein ingestion, even after ingestion of carbohydrates. Therefore the PMS patient continues to crave and over-eat chocolates. Thus, a healthy diet, which is low in fat, salt and sugar, but more moderate in proteins and complex carbohydrates (whole grains, vegetables and fruits) is most beneficial to the patients of PMS. Vitamin and mineral supplements have been studied without definite results.
Can sterilization reduce PMS?
How is PMS treated?
First the doctor must reassure that patient’s symptoms are real and encourage the woman to chart her symptoms for several cycles. In between changing diet habits, exercise and sleep may be very beneficial. The plan of management should be tailored to woman’s symptoms. Specific simple medical treatments include Fluoxetine, Spironolactone and Prostaglandin inhibitors (NSAID’s like Ibuprofen). If the patient needs contraception, the Combined Pill may be a good option. The vast majority of women who suffer with PMS can be helped.
What therapy is suggested for the breast tenderness associated with PMS?
Bromocriptine: 5mg/day, during the luteal phase of the cycle.
What is dysmenorrhoea?
Is pelvic pain associated with menstrual periods. Women usually complain of headache, backache, pelvic pain, light irritation, insomnia, nausea, vomiting, even diarrhoea.
How common is it?
Very high percentage of women, as high as 72% experience some discomfort associated with their menses. A smaller but still significant percentage experiences dysmenorrhoea to a point that it interferes with their activities or causes them to miss work or school. Dysmenorrhoea is less common and less severe in women who have given birth.
What is the mechanism that causes pain in primary dysmenorrhoea?
Primary dysmenorrhoea is not associated with any identifiable pathology, like fibroids, adenomyosis, endometriosis and pelvic infection. The principal cause seems to be increased production of prostaglandin F2a. This substance causes uterine cramping and is the mechanism for the systemic symptoms (nausea, diarrhoea, headache).
How is dysmenorrhoea managed?
Initially with COP and NSAID’s. The latter reduce the production of prostaglandins. The COP causes atrophy of the endometrium, which is the principal site of prostaglandin production. They can also reduce the amount and the duration of bleeding, which can improve woman’s experience.
The COX-2 inhibitors (rofecoxib and others) are new class of oral analgesics, originally used to treat arthritis. They have been shown effective in the management of dysmenorrhoea. In secondary dysmenorrhoea (where an underlying cause has been identified) the treatment is directed at the causing factor and surgical management is also considered.