Monthly Archives: July 2015

Intrauterine contraceptive devices (IUCDs)

The intrauterine device have been used throughout the world. During the last couple of decades, however, there has been a significant improvement in its design and content. The idea is to obtain maximum efficacy without increasing the adverse effects. The device is classified as open, when it has got no circumscribed aperture of more than 5 mm so that a loop of intestine or omentum cannot enter and become strangulated if, accidentally, the device perforates through the uterus into the peritoneal cavity. Lippes loop, Cu T, Cu 7, Multiload and Progestasert are examples of open devices. If closed devices, like Grafenberg ring and Birnberg bow, accidentally enter the abdominal cavity, they have the potential of causing strangulation of the gut; and hence are obsolete. The device may be nonmedicated as Lippes loop or medicated (bioactive) by incorporating a metal copper, in devices like Cu T-200, Cu T-380A, Multiload-250, Multiload-375. Hormone containing IUD either releasing progesterone (progestasert) or levonorgestrel (LNGIUS) has also been introduced.

Copper T 200 — The widely used medicated device is Copper T 200 B. It carries 215 sq mm surface area of fine copper wire wounded round the vertical stem of the device. Stem of the T-shaped device is made of a polyethylene frame. It has a polyethylene monofilament tied at the end of the vertical stem. These two threads are used for detection and removal. In spite of the copper being radiopaque, additional barium sulfate is incorporated in the device. The device contains 124 mg of copper. The copper is lost at the rate of about 50 μg per 24 hours during a period of one year. It is supplied inside a sterilized sealed packet. The device is to be removed after 4 years. Cu T 200 carries 200 sq mm surface area of wire containing 120 mg of copper and is removed after 3 years.

Cu T 380A — Cu T 380A carries total 380 mm2 surface area of copper wire wound around the stem (314 mm2) and each copper sleeve on the horizontal arms (33 mm2). The frame contains barium sulfate and is radiopaque. Replacement is every 10 years.

Multiload Cu 250 — The device emits 60–100 μg of copper per day during a period of one year. The device is to be replaced every 3 years.

Multiload–375 — The device is available in a sterilized sealed packet with an applicator. There is no introducer and no plunger. It has 375 mm2 surface area of copper wire wound around its vertical stem. Replacement is every 5 years.

Levonorgestrel intrauterine system (LNG-IUS) — This is a T-shaped device, with polydimethylsiloxane membrane around the stem which acts as a steroid reservoir. Total amount of levonorgestrel is 52 mg and is released at the rate 20 μg/day. This device is to be replaced every 7 years. Its efficacy is comparable to sterilization. It has many non-contraceptive benefits also.

Contraindication for IUCD

(1) Presence o\f pelvic infection current or within 3 months;

(2) Undiagnosed genital tract bleeding;

(3) Suspected pregnancy;

 (4) Distortion of the shape of the uterine cavity as in fibroid or congenital uterine-malformation;

(5) Severe dysmenorrhea;

(6) Past history of ectopic pregnancy;

(7) Within 6 weeks following cesarean section;

(8) STIs — Current or within 3 months;

(9) Trophoblastic disease;

(10) Significant immunosuppression. Additionally for CuT are:

(11) Wilson disease

(12) Copper allergy. For LNG-IUS:

(13) Hepatic tumor or hepatocellular disease (active); 

(14) Current breast cancer and

(15) Severe arterial disease.

Adenomyosis

Adenomyosis is a condition where there is ingrowth of the endometrium, both the glandular and stromal components, directly into the myometrium.

Causes: The cause of such ingrowth is not known. It may be related to repeated childbirths, vigorous curettage or excess of estrogen effect. Pelvic endometriosis co-exists in about 40 percent.

Pathogenesis: Histologically, it is characterized by the extension of endometrial glands and stroma beneath the endometrial—myometrial interface (EMI). As the submucosa is absent, endometrial glands lie in direct contact with the underlying myometrium. It forms nests, deep within myometrium. Subsequently, threre is myometrial hyperplasia around the endometriotic foci. Myometrial zone anatomy was observed by MRI. A junctional zone (with low signal intensity on T2 weighted images) is defined at the innermost layer of myometrium. It is thought that the disturbance of normal junctional zone (JZ) predisposes to secondary infiltration of endometrial glands and stroma to inner myometrial zone. The disturbance of junctional zone (JZ) may be due to the endometrial factors, genetic predisposition or altered immune response. Trauma to the deeper endometrium (repeated curettage), causing breakdown of EMI is also taken as an important etiologic factor.

Pathology: The growth and tissue reaction in the endometrium depend on the response of the ectopic endometrial tissues to the ovarian steroids. If the basal layer is only present, the tissue reaction is much less, as it is unresponsive to hormones. But, if the functional zone is present which is responsive to hormones, the tissue reaction surrounding the endometrium is marked. There is hyperplasia of the myometrium producing diffuse enlargement of the uterus, sometimes symmetrically but at times, more on the posterior wall. The growth may be localized or may invade a polyp (adenomyomatous).

Naked eye appearance: There is diffuse symmetrical enlargement of the uterus; the posterior wall is often more thickened than the anterior one. The size usually does not increase more than a large orange (12–14 weeks pregnant uterus). On cut section, there is thickening of the uterine wall. The cut surface presents characteristic trabeculated appearances.

Unlike fibroid, there is no capsule surrounding the growth. There may be visible blood spots at places

 In about one-third, it remains asymptomatic being discovered on histological examination. The patients are usually parous with age usually above 40.

Treatment for Soft Erection

Symptoms:

Menorrhagia (70%)—The excessive bleeding is due to increased uterine cavity, associated endometrial hyperplasia and inadequate uterine contraction. During normal menstruation, there are antegrade propagation of subendometrial contractions from the fundus to the cervix. In adenomyosis with distorsion of junctional zone myometrial contractions are abnormal and inadequate (see below).

Dysmenorrhea (30%)—Progressively increased colicky pain during period is due to retrograde pattern of uterine contractions. It also depends on the number and depth of adenomyotic foci in the myometrium. When the depth of penetration is > 80% of the myometrium, the pain is severe. Other causes of pain are—local tissue edema and prostaglandins.

Dyspareunia or frequency of urination—are due to enlarged and tender uterus.

Infertility: Women with adenomyosis have a higher incidence of infertility and miscarriage.

GENITAL TUBERCULOSIS

The incidence of genital tuberculosis varies widely with the social status of the patient and her environment. The incidence is about 1 per cent amongst the gynecological patients attending the outpatient department in the developing countries. Incidence is high (5–10%) amongst the patients with infertility. With the prevalence of HIV infection incidence of genital tuberculosis is rising. About 10 per cent of women with pelvic tuberculosis, have urinary tract tuberculosis.

The causative organism is Mycobacterium tuberculosis of human type. Very rarely the bovine type may affect the vulva. Genital tuberculosis is almost always secondary to primary infection elsewhere in the extragenital sites such as lungs (50%), lymph nodes, urinary tract, bones and joints. The fallopian tubes are invariably the primary sites of pelvic tuberculosis from where secondary spread occurs to other genital organs.

From any of the primary sites, the pelvic organs are involved by hematogenous spread in about 90 per cent cases. If the post-primary hematogenous spread coincides with the growth spurt of the pelvic vessels, the genital organs, the tubes in particular, are likely to be affected. Thus, the pelvic organs are infected during puberty. If the spread precedes the growth phase, the genital organs are spared. The infection remains dormant for a variable period of time (4–6 years) until clinical manifestations appear

The commonest site of affection is the fallopian tubes (100%). Both the tubes arection is in the submucosal layer (interstitial salpingitis) of the ampullary part of the tube. The infection may spread medially along the wall causing destruction of the muscles which are replaced by fibrous tissue. The walls get thickened, become calcified or even ossified. The thickening may at time become segmented. The infection may spread inwards; the mucosa gets swollen and destroyed. The fimbria are everted and the abdominal ostium usually remains patent. The elongated and distended distal tube with the patent abdominal ostium gives the appearance of “tobacco-pouch”. Occlusion of the ostium may however occur due to adhesions.The tubercles burst pouring the caseous material inside the lumen producing tubercular pyosalpinx, which may adhere to the ovaries and the surrounding structures. Often the infection spreads outwards producing perisalpingitis with exudation, causing dense adhesions with the surrounding structures— tubercular tubo-ovarian mass. Rarely, military tubercles may be found on the serosal surface of the tubes, uterus, peritoneum or intestines. These are often associated with tubercular peritonitis

Microscopic picture of the lesion is very characteristic irrespective of the organ involved. Typical granuloma consists of infiltration of multinucleated giant cells (Langhans), chronic inflammatory cells and epithelioid cells, surrounding a central area of caseation necrosis. Caseation may not be a constant feature.

The infection is restricted mostly (80%) to childbearing period (20–40 years). There may be past history of tubercular affection of the lungs or lymph glands. Genital tuberculosis occurs in 10–20 per cent of patients who have pulmonary tuberculosis in adolescence. A family history of contact may be available. Onset is mostly insidious. A flare up of the infection may occur acutely either spontaneously or following diagnostic endometrial curettage or hysterosalpingography.

Low Sex Drive in Women

As you advance in years, your libido may decline. Sex might become a source of frustration, even pain. Sexual dysfunction and low sex drive are common problems for women over forty. Libido loss may undermine your confidence. It may damage your relationship. It may also suggest that you may have other health issues that you should address. If you notice that you are not interested in having sex, request an appointment with your doctor to get your hormone levels checked. It only takes a blood test and some simple medical tests.

Many factors may cause a decline in your sexual desire.

Reasons of Low Sex Drive in Women

  • Problems in your Relationship

Probably you have problems with your partner and you cannot find a way to tell him. You still have sexual contact with him, however, your body will show him that something is wrong.

  • Your Age

Age can be amongst the causes. You may have age-related health issues. Even if you are healthy, you may lose your sex drive as you are nearing your menopause years and your body produces less female hormones like estrogen. Estrogen is a compound that affects your menstruation cycle and your reproductive abilities. Your testosterone level may decrease, too. Testosterone is a male sex hormone and an anabolic steroid. It affects your sex drive, your physical strength, and it prevents osteoporosis. Your ovaries and adrenal glands produce testosterone.

Your hormone levels have an impact on your health and well-being. You may consider a hormone replacement therapy. Ask your gynecologist or a health care provider before you decide to get an HRT.

  • Health Problems

Perhaps you have health problems that affect your libido. High blood pressure, anemia, diabetes, arthritis and cardiovascular diseases like coronary artery disease cause a decrease in your sex drive. They are serious problems. Get them treated.

  • Substance Abuse

Prescription medicine, street drugs and alcohol may kill off your libido. They make you tired, they mess with your sleeping patterns and cause insomnia; tiredness alone can be a reason of low sex drive. They also mess with your hormone levels.

  • Depression

Depressed people can find no pleasure in their favorite activities, sex included. Anxiety and workplace issues may make things worse. When you feel unhappy and insecure and you worry about your future, you cannot focus on a satisfying sex life.

  • Hormonal Problems

An underactive thyroid gland may make you tired and listless. It might be the reason of libido loss. Your thyroid is a butterfly shaped gland in your neck. It produces hormones. When it produces fewer hormones than it should, you may experience symptoms like weight gain, fatigue and low sex drive. Underactive thyroid can be a congenital problem, an autoimmune disorder or a result of high iodine consumption.

  • You Feel Weary

Sex requires energy and good physical health. Active, healthy, energetic persons have good sex life. Tired, weak persons do not have the energy to make love. Hectic lifestyle or imbalanced hormone levels may wear you off. According to doctors, it is rare that tired patients have physical health problems; stress and small problems in their everyday lives add up and sap their energy. Probably you work too much, you sleep too little or you have a disrupted sleeping pattern. If you are underweight or overweight, or you live with diabetes, you may feel tired all the time.

 

Sexual dysfunction – Facts and Symptoms

It is difficult to establish the prevalence of sexual problems in the population because of the difficulties involved in carrying out surveys of people’s sexual behaviour. The commonest kinds of problems presenting to a sexual dysfunction clinic are,

Women

Low sexual desire 50%

Orgasmic dysfunction 20%

Vaginismus 20%

Dyspareunia 5%

Men

Erectile dysfunction 60%

Premature ejaculation 15%

Delayed ejaculation 5%

Low sexual desire 5%

The assessment of sexual dysfunction

Patients with sexual problems initially often complain about other symptoms because they feel too embarrassed to reveal a sexual problem directly. For example, a patient may ask for help with anxiety, depression, poor sleep, or gynaecological symptoms. It is therefore important to ask routinely a few questions about sexual functioning when assessing patients with non-specific psychological or physical symptoms.

In a full assessment, the interviewer should begin by explaining why it will be necessary to ask about intimate details of the patient’s sexual life, and should then ask questions in a sympathetic, matter-of-fact way.

Whenever possible both sexual partners should be interviewed, at first separately and then together.

The assessment should cover the following issues.

  • Has the problem been present from the first intercourse, or did it start after a period of normal sexual functioning? Each partner should be asked, separately, whether the same problem has occurred with another partner, or during masturbation.
  • The strength of sexual drive should be assessed in terms of the frequency of sexual arousal, intercourse, and masturbation. Motivation for treatment of sexual dysfunction should be assessed, starting with questions about who took the initiative in seeking treatment and for what reason.
  • Assess each partner’s social relationships with the other sex, with particular reference to shyness and social inhibition.
  • Enquiries should be made about the partners’ feelings for one another: partners who lack a mutual caring relationship are unlikely to achieve a fully satisfactory sexual relationship. Many couples say that their relationship problems result from their sexual problems, when the causal connection is really the reverse. Tactful questions should be asked about commitment to the partner and, when appropriate, about infidelity and fears of sexually transmitted disease, including HIV.
  • Assess sexual development and sexual experience, paying particular attention to experiences such as child abuse, incest, or sexual assault that may have caused lasting anxiety or disgust about sex.
  • Enquiry should be made about homosexual as well as heterosexual feelings.
  • In the medical history, the most relevant things to look for are previous and present psychiatric and chronic physical disorders and their treatment, pregnancy, childbirth, and abortion(s), and use of alcohol or drugs, such as selective serotonin reuptake inhibitors (SSRIs).
  • In the mental state examination look especially for evidence of depressive disorder. Physical examination is important because physical illness often causes sexual problems Physical examination of women may require specialist gynaecological help. Further investigations may be necessary depending on the findings from the history and examination (e.g. if diabetes is suspected as a cause of sexual disorder).