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Thedistinctionbetweenadenomyosis and a uterine fibroid may not always be clear on ultrasonic examination herbals for kidney function generic hoodia 400 mg without a prescription. Figure 25-5 illustrates the typical gross appearance of an enlarged uterus with extensiveadenomyosis herbals medicine discount hoodia 400mg online. Exceptinextremecases herbalshopcom cheap hoodia on line, theinitialtherapyismedical lotus herbals 3 in 1 matte review cheap 400mg hoodia overnight delivery,withavarietyofhormonal and nonhormonal regimens available to control the bleeding. Surgicaltherapyisreservedforthosewomenforwhom medical management fails or for those who have obviouslysignificantpathology. Thecausesofmostcases of heavy bleeding are benign, and symptoms are often effectivelymanagedwithhormonaltreatmentalone. Up to 20% of women experience debilitating symptoms caused by heavy bleeding at some point during their reproductiveyears. Theetiologyofthebleeding irregularities includes benign or malignant growths, systemic disease, coagulation defects, and hormonal imbalance. Diagnosis Initially, abnormal vaginal bleeding is assumed to emanatefromtheuterus. Apelvicexamination,includ322 ingtheinsertionofavaginalspeculum,isessentialto eliminatethepossibilitythatthevulva,vagina,exocervix (or ectocervix), or even the rectum or bladder is actually the source of the bleeding. Table26-1outlinesthenormal andabnormalvaluesforeachofthesedimensionsand provides the newer terms to describe the abnormalities. Asanexample,theassessmentofabnormalbleeding in a woman with complaints of "irregular menstruation" can be categorized as follows: If her cyclelength(firstdayofmensestothefirstdayofthe nextmenses)is23days,shebleedsfor10daysduring eachcycle,andsheloses100mLofblood,thiswould C H A P T E R 26 Abnormal Uterine Bleeding 323 be described as "frequent, prolonged, and heavy menses. However,itisimportanttobecomefamiliar with these older terms, because they have been usedfordecadesinclinicalpracticeandinthemedical literature and are still used for diagnostic coding purposes. Rare problemssuchasimperforatehymenortransversevaginal septumaremorelikelytopresentwithprimaryamenorrhea and not with chronic bleeding problems. A "not yet classified" category completes the acronym andisavailableforacauseofbleedingthatisnotcurrentlyincludedoridiopathic. Heavy menstrual bleeding occurs in 9-14% of healthy women of reproductive age and is the reason for up to 20% of outpatient clinic visits by women. Acute Excessive Bleeding in Nonpregnant Women of Reproductive Age the etiologies, workups, and therapies of excessive bleedingcandifferforacuteheavybleedingcompared with chronic heavy bleeding, although often there is considerable overlap. A woman who presents with heavybleedingneedstobeassessedforhemodynamic stability, anemia, and always the possibility of pregnancy. Itishelpfultogetadescriptionofhercurrentbleeding episode as well as her recent and usual bleeding patterns, along with any previous evaluations or treatments. It is quite possible for a womantohavemorethanoneproblemasthecauseof her abnormal bleeding. Obvious causes requiring immediate surgeries should be ruled out, such as vaginaltraumaorbleedinglacerations,aswellasabortingfibroids(leiomyomata). Hospitalization and transfusion are generally recommended for women who have severe anemia (hemoglobin 7 g/dL) and those who are hemodynamically unstable. Baselinehemoglobinismandatory,andacomplete bloodcount(withredbloodcellindices)isperformed todeterminethechronicityoftheproblem,toruleout thrombocytopenia, and to identify possible hematologic malignancies. Many of the test results may not be available for days,buttheheavybleedingneedstobepromptlycontrolled. Surgical approaches are usually reserved for women whose condition does not respond to medical therapies and for those who are bleeding so heavily that there is insufficient time to consider medical treatments. Inthepast,itwasbelievedthathighdosesofestrogen were needed to induce cell proliferation over the denuded areas of endometrium that were thought to beactivelybleeding. Bothhigh-doseintravenousestrogen and high doses of combined oral contraceptive pills were recommended. More recently, it has been recognized that high doses of estrogen may not be necessary to control the bleeding. Furthermore,hemorrhage is known to induce a hypercoagulable state, and the addition of high-dose estrogen may increase the risk of dangerous clotting, especially in women with reactive thrombocytosis. As a result, the doses used in these estrogen-based therapies have been significantly reduced, and high-dose progestin-only therapies have been recommended as first-line treatment for acute heavy menstrual bleeding, particularly in the outpatient setting. This is true regardless of the underlying etiology of the heavy bleeding orthestatusoftheendometrium. More urgent imaging may be needed if there are other symptoms, such as significantpain. Inawomanwithsuspiciousultrasonic findings or increased risk factors for cancer, biopsy is indicated once the bleeding has been stabilized and herhemoglobinlevelisnormal.
Leg cramps are experienced by almost half of all pregnant women bajaj herbals fze cheap hoodia 400mg overnight delivery, particularly at night and in the later months of pregnancy herbs medicinal buy cheapest hoodia and hoodia. Bothcalcium andsodiumchloridesupplementationappeartohelp reduce leg cramps in pregnancy kairali herbals malaysia order hoodia visa. Recently herbs for weight loss order hoodia 400 mg with amex, vitamin D deficiency in both men and women has been associatedwithlegcrampsandmusclepain. Backaches are common during pregnancyandare lessened by avoiding excessive weight gain. Additionally, exercise, sensible shoes, and specially shaped pillows can offer relief. In cases of muscle spasm or strain, analgesics (such as acetaminophen), rest, and heatmaylessenthesymptoms. Maternal obesity may occur over time between pregnancies because of the difficulty that some women have returning to prepregnancy body weight. Althoughweightgainisanimportantconsideration duringpregnancy,the clinician should emphasize the "right amount of nutrition" over the "right amount of weight gain. Advice regarding work shouldbeindividualizedtothenatureofthework,the health status of the woman, and the condition of the pregnancy. Work that requires prolonged standing, shiftornightwork,andhighcumulativeoccupational fatiguehasbeenassociatedwithanincreasedriskfor lowbirthweightandprematurity. Where working conditions involve occupational fatigue or stress, a change in work conditions during pregnancy should be recommended. Any type of exercise involving the potential for loss of balance or even mild abdominal trauma should be avoided. Pregnant women should beencouragedtoambulateperiodicallywhentakinga long flight or car ride. International travel that places the patient at a high risk of exposure to infectious disease should be avoided, whenever possible. Increased, unchanged, and decreased levels of sexual activity can all be normal during pregnancy. Abstinenceorcondomusemaybeadvisableifthereis an increased risk of preterm labor or repeated pregnancy loss, or in women with a history of persistent second-orthird-trimesterbleeding. Thescheduleof these follow-up visits, however, should be tailored to the needs of individual patients. Women should be screened for depression early in pregnancy, during the third trimester and again postpartum. The incidence of depression during pregnancy and the postpartum period is as high as 20%. Multiple studies have shown a significant relationship between vitamin D deficiency and depression. Duringeachregularlyscheduledvisit,theclinician shouldevaluatebloodpressure,weight,urineprotein and glucose, uterine size for progressive growth, and fetal heart rate. Between 24 and 34 weeks, women should be taught the warning symptoms of preterm labor (uterine contractions, leakageoffluid,vaginalbleeding,lowpelvicpressure, or low back pain). Patients at risk may require additional visits to assess signs and symptoms of preterm labor. Beginning in the late second trimester, they shouldalsobetaughttorecognizethewarningsymptomsofpreeclampsia(frontalheadache,visualchanges, handorfacialswelling,epigastricorrightupperquadrantpain). Beginning at 28 weeks, systematic examination of the abdomen should be carried out at each prenatal visit to identify the lie. Thefirst maneuverinvolves palpating the fundus to determine which part of the fetusoccupiesthefundus. The second maneuver involves palpating either side of the abdomen to determine on which side the fetal back lies. The third maneuver involves grasping the presenting part between the thumbandthirdfingerjustabovethepubicsymphysis todeterminethepresentingpart.
During this phase herbals and glucocorticoids order hoodia paypal, there is disruption and disintegration of the endome trial glands and stroma jenith herbals generic hoodia 400 mg amex, leukocyte infiltration herbals online cheap hoodia 400 mg free shipping, and red blood cell extravasation ayur xaqti herbals order hoodia 400mg overnight delivery. Inadditiontothissloughing of the functionalis, there is a compression of the basalis due to the loss of ground substances. Because the bases of the endometrial glandsliedeepwithinthebasalis,theseepithelialcells arenotdestroyedduringmenstruation. During this phase of the cycle, the large increase in estrogen secretion causes marked cellular prolifera tion of the epithelial lining, the endometrial glands, and the connective tissue of the stroma(Figure4-7). Numerous mitoses are present in these tissues and thereisanincreaseinthelengthofthespiralarteries, whichtraversealmosttheentirethicknessoftheendometrium. Note the tortuous, saw-toothed appearance of the endometrial glands with secretions in the lumens. The stroma is edematous and necrotic during this stage, leading to sloughing of the endometrium at the time of menstruation. The spiral arteries continue to extend into the superficial layer of the endometriumandbecomeconvoluted(Figure4-8). Themarkedchangesthatoccurinendometrialhistology during the secretory phase permit relatively precisetiming(dating)ofsecretoryendometrium. If pregnancy does not occur by day 23, the corpus luteum begins to regress, secretion of progesterone and estradiol declines, and the endometrium under goes involution. About1daybeforetheonsetofmenstruation, marked constriction of the spiral arterioles takes place, causing ischemia of the endometrium followed by leukocyte infiltration and red blood cell extravasation. Itisthoughtthattheseeventsoccursecondary to prostaglandin production by the endometrium. Ironically, menstruation, which clinically marks the beginning of the menstrual cycle, is actually the terminal event of a physiologicprocessthatenablestheuterustobepreparedtoreceiveanotherconceptus. Spermatogenesis, Sperm Capacitation, and Fertilization Fertilization, or conception, is the union of male and female pronuclear elements. Together with transportation, a total of about 3 months elapses before sperm are ejaculated. Thespermachievemotility during their passage through the epididymis, but sperm capacitation, which renders them capable of fertilization in vivo, does not occur until they are removed from the seminal plasma after ejaculation. Interestingly,spermaspiratedfromtheepididymisand testis can be used to achieve fertilization in vitro employing intracytoplasmic injection techniques directlyintotheooplasm. Estrogen levels are high at the time of ovulation, resultinginanincreasedquantity,decreasedviscosity, andfavorableelectrolytecontentofthecervicalmucus. The average ejaculate contains 2 to 5 mL of semen; 40 to 300 million sperm may be deposited in the vagina, 5090% of which are morphologically normal. Inaddition,digestionof sperm by vaginal enzymes, destruction by vaginal acidity,phagocytosisofspermalongthereproductive tract,andfurtherlossfrompassagethroughthefallopian tube into the peritoneal cavity all diminish the numberofspermcapableofachievingfertilization. Thosespermthatdomigratefromthealkalineenvironmentofthesementothealkalineenvironmentof the cervical mucus exuding from the cervical os are directedalongchannelsoflower-viscositymucusinto the cervical crypts where they are stored for later ascent. Uterine contractions, probably facilitated by prosta glandin in the seminal plasma, propel sperm to the tubes within 5 minutes. Someevidenceindicatesthat these sperm may not be as capable of fertilization as those that arrive later largely under their own power. Sperm may be found within the peritoneal cavity for long periods, but it is not known whether they are capable of fertilization. Capacitation is the physiologic change that sperm must undergo in the female reproductive tract before fertilization. Humanspermcanalsoundergocapacitationafterashortincubationindefinedculturemedia without residence in the female reproductive tract, whichallowsforinvitrofertilization(seeChapter34). The acrosome, a modified lysosome,liesoverthespermheadasakindof"chemical drill-bit" designed to enable the sperm to burrow its way into the oocyte (Figure 4-9). The overlying C H A P T E R 4 Female Reproductive Physiology 47 Subacrosomal space Acrosomal contents Plasma membrane Nucleus Equatorial segment Postacrosomal sheath Inner acrosomal membrane Outer acrosomal membrane Nuclear envelope tion restores the diploid number of chromosomes and determines the sex of the zygote. Incoupleswith infertility resulting from severe sperm abnormalities, fertilization and subsequent pregnancy can be successfullyachievedaftertheinjectionofasinglesperm, withorwithoutitstail,intothecytoplasmoftheoocyte (seeChapter34). Thisconsistsof arapidsuccessionofmitoticdivisionsthatproducea mulberry-like mass known as a morula. Fluid is secreted by the outer cells of the morula, and a single fluidfilled cavity develops, known as the blastocyst cavity. An inner-cell mass can be defined, attached eccentrically to the outer layer of flattened cells; the latter becomes the trophoblast.
Job Name: - /381449t negative disease (by microscopic evaluation of their draining lymph nodes) have improved survival (substaged as A) compared to those who are only evaluated clinically (substaged as B) herbs denver order hoodia 400 mg mastercard. Merkel cell carcinoma in organ-transplant recipients: report of two cases with unusual histological features and literature review herbals dictionary buy genuine hoodia on-line. Multimodality treatment of Merkel cell carcinoma: case series and literature review of 1024 cases herbals safe during pregnancy buy hoodia 400mg on line. Merkel cell carcinoma: prognosis and treatment of patients from a single institution lotus herbals effective 400 mg hoodia. Sentinel lymph node biopsy for evaluation and treatment of patients with Merkel cell carcinoma: the Dana-Farber experience and meta-analysis of the literature. Chemotherapy for patients with locally advanced or metastatic Merkel cell carcinoma. General Notes (continued): y prefix indicates those cases in which classification is performed during or following initial multimodality therapy. A mitotic rate equal to or greater than 1/mm2 denotes a melanoma at higher risk for metastasis. It should now be used as one defining criteria of T1b melanomas Melanoma thickness and tumor ulceration continue to be used in defining strata in the T category. For T1 melanomas, in addition to tumor ulceration, mitotic rate replaces level of invasion as a primary criterion for defining the subcategory of T1b the presence of nodal micrometastases can be defined using either H&E or immunohistochemical staining (previously, only the H&E could be used) There is no lower threshold of tumor burden defining the presence of regional nodal metastasis. A lower threshold of clinically insignificant nodal metastases has not been defined based on evidence the site of distant metastases [nonvisceral. By convention, it should be used after complete excision of the primary melanoma with clinical assessment for regional and distant metastases. An analysis of prognostic factors involving almost 60,000 patients from these 14 cancer centers and organizations was performed to validate the staging categories and groupings for the seventh edition. Differences between the sixth edition version and the seventh edition version of the melanoma staging system are listed in Table 31. Within each stage grouping and subgroups, there is a uniform risk for survival (Figure 31. It occurs most commonly on the extremities in female subjects and on the trunk in male subjects. The widespread use of cutaneous lymphoscintigraphy followed by lymphatic mapping and sentinel lymph node biopsy has greatly enhanced the ability to identify nodal micrometastases and to define the stage of clinically node-negative melanoma patients. Job Name: - /381449t and/or subcutaneous metastases found on pathologic examination adjacent to a primary melanoma; or (3) in transit metastases (defined arbitrarily as clinically evident cutaneous and/or subcutaneous metastases identified at a distance greater than 2 cm from the primary melanoma in the region between the primary and the first echelon of regional lymph nodes). These manifestations of melanoma constitute a small but clinically significant and distinctive category of patients, with considerable risk of both additional locoregional and distant metastases. Distant metastases most commonly occur in the skin or soft tissues, the lung, liver, brain, bone, or gastrointestinal tract. Changes in the melanoma staging system comparing the sixth edition (2002) version with the current version (2009) Factor Thickness 6th Edition criteria Primary determinant of T staging; thresholds of 1. Job Name: - /381449t are those with clinical or radiographic evidence of regional metastases, either in the regional lymph nodes or intralymphatic metastases manifesting as either satellite or in transit metastases. The Melanoma Task Force therefore made no subgroup definitions of clinically staged patients with nodal or intralymphatic regional metastases. In contrast to clinical staging, there is greater accuracy (both qualitatively and quantitatively) in defining distinctive prognostic subgroups when combining pathologic information from the primary melanoma and from pathologic examination of the regional lymph nodes after sentinel or complete lymphadenectomy. The quantitative classification for pathologic nodal status requires careful pathologic examination of the surgically resected nodal basin and documentation of number of lymph nodes examined and the number of nodes that contain metastases. With the widespread use of sentinel lymph node biopsy, it is clear that there is considerable stage migration of patients previously staged as "node negative," but who in fact have undetected nodal metastases. Specifically, the procedure should be recommended for (or at least discussed with) patients who have T1b, T2, T3, or T4 melanomas, and clinically or radiographically uninvolved regional lymph nodes. In all prospective studies performed to date involving such patients, sentinel node status was one of the most powerful independent prognostic factors examined. By convention, clinical staging should be performed after complete excision of the primary melanoma (including microstaging) with clinical assessment of regional lymph nodes.
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