PREGNANCY AFTER WEIGHT LOSS (BARIATIC) SURGERY

 

IN the modern world obesity is one of the biggest problems. However the medical world has found a solution to it. They perform special types of surgical procedures to overcome this. These are called Bariatric surgery. There are 3 such operations, gastric banding, Ry gastric bypass, and Gastric sleeve by pass. After these women can lose up to 38 kgms. Eating decreases extra care is required to keep the nutrition good. Fertility, PCOS blood pressure, and diabetes improves .Women should wait for12 to18 months after bariatric surgery before getting pregnant. This time is necessary for them to establish their weight loss and nutrition.

During pregnancy the risk for preeclampsia, gestational diabetes, decrease. However risk of hyperemesis, intestinal obstruction, internal hernias, and cholelithiasis increases. Often an adjustment to gastric banding is required. There is risk of premature labor, lower risk of forceps delivery, caesarian section, epidural anesthesia labor dystocia, fetal distress, peripartum[Ma1]   sphincter injury , large babies ,and post-partum bleeding on the fetal side there is no  increase in fetal malformation , neonatal intensive care admissions neonatal  deaths and stillbirths increased.  

During pregnancy special care is required both for mother’s nutrition and growth of the baby. The pregnancy complications are minimized however they are not completely eliminated. Normal pregnancy tests are all performed, glucose tolerance test is modified. In women after bariatric surgery threshold for diagnosis of GDM is a fasting more than5.3mmol/L, one hour after a meal7.8mmols/L 2hours more than 6.7 mmol/L is considered as GDM.

 This subject needs to be studied a bit more by all concerned surgeons for new techniques ,nutrionalists[Ma2]  and above all obstetrician who need to manage these women .

 

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DYSMENORRHEA

 

Dysmenorrhea means painful period. Almost every woman must have experienced this to some degree in her life time. If you have never felt it, you are extremely lucky. DYSMENORRHEA (DYSM) Starts 6-12 months after menarche, it can even happen after 2 years. This is due to the fact that it happens when ovarian function matures, that is when ovaries start to make an egg. It is a very painful spasm in the lower abdomen, backache, and pain in the legs. In severe cases it even causes nausea, vomiting, diarrhea, headache, and dizziness. It can make adolescent or a woman totally incapacitated to attend school or work. It often starts one or two days before bleeding starts and can last up to 12 or 72 hours. Proves very harmful for studies or work situations. Many women can manage it easily just by paracetamol or Ibuprofen or drugs available over the counter. Why does this happen? It is due to tissue damage, resulting in the production of hormone like chemicals produced locally from fatty acids called prostaglandin, these help with inflammation and healing. Unfortunately they also cause severe uterine spasm and blood clots. There are two types of DYSM primary meaning there is no other pelvic pathology and secondary meaning there are other pelvic diseases such as, Endometriosis, pelvic infections, adenomyosis and fibroids. The last two most often happen in older age group and often associated with heavy bleeding. Endometriosis is the most common cause of very painful periods in all age groups, if a woman is sexually active sex is painful, even bowel action can be painful. Very often women need to take medical advice, about painful periods.  When you attend a clinician he will take a history, do a pelvic examination and see if there is pain or any pathology. You may require Smear test, blood tests, tests for sexually transmitted infections and an ultrasound. These are only done depending on the pathology. If Endometriosis is suspected often an operative procedure called LAPASCOPY is performed. Here the surgeon looks inside the abdomen with a telescope under anesthesia and often Endometriosis is treated at the same time with ablation by laser or electric current. For simple cases life style factors such as regular exercise, good nutrition rich in calcium, Zn, magnesium, vitamin D. Avoid constipation. Hot bathes, hot water bottle will provide heat to the abdomen. Heat packs also are a good source of portable heat to the area. Acupressure and acupuncture helps. Often the treatment to stop periods is offered such as progesterone implants injections even intra uterine hormone devices.  As it was mentioned at the start that it is the ovulatory cycles which are painful oral contraceptive pill is an excellent option if there are no contra indication to use it or having children is not an issue. In older women, when child bearing is completed with adenomyosis and fibroids often operative treatment is offered.

DHEA: DIHYDROEPIANDROSTERONE

 

What is DHEA; a hormone easily available in many countries over the counter and in many countries in the nutritional section of tablets? In many countries women use it freely as a heath product often without proper advice. They think it helps their wellbeing, muscle strength, lose weight, cognition, boost immunity and sexual function. Some also feel benefitted from hot flushes and depression. It    is available as tablets, topical cream, powder, capsules, and gel. The studies on this subject are confusing. Only one study has suggested in a small number of women that helped with hot flushes, sexual dysfunction. Off course it helps with bone density. It has a few side effects such as, headaches, fatigue, insomnia, abnormal bleeding, acne, may be loss of hair and hairiness (Hirsutism).They can also interact with some important drugs such as blood thinners, anticonvulsants and drugs used for heart or liver disease. One situation it is useful in, is vaginal atrophy due to menopause. It has no systemic effect hence can be useful in women after treatment for breast cancer. It is helpful in sexual function due to prevention of pain, it is not believed that it helps in improving libido in any other way. Using DHEA women, also risk getting problems with, Thyroid, HDL, PCOD, and Clotting problems. I have come across many menopausal women taking DHEAS to prevent aging effects, wellbeing and feel better sexually; my suggestion to them is not to take this without proper advice, it does nothing for aging, may be a bit for menopausal symptoms and surely helps with vaginal atrophy and bone density.

EMERGENCY CONTRACEPTION

 Contraception is a constant bane in a women’s life, from the moment she becomes mature as a woman, until one or two years after menopause. In the scheme of life, we usually have 2-3 children and in our 40-50 years of reproductive life, we have to keep protecting ourselves from getting pregnant. There are several ways to do so, however every now and then we get mixed up. Involved in different and other stressful situations, we forget about contraception, and the problem starts for emergency contraception (EC). When do women need this, when they have forgotten to take two pills in the first week of the cycle, did not take the progesterone only pill, and did not put the vaginal ring or the skin patch on in time? Some times bigger things are forgotten such as changing IUCD on time, skin implant not renewed. Besides these the condom breaks during sex, sexually assaulted and diarrhea and vomiting disrupted the pill cycle. Sometimes women assume it is ok to have sex, soon after having had a baby, however one can get pregnant again, and 21 days after having had a baby.  So many situations when one needs emergency contraception (EC). I am sure you will be able to think of many other different situations. 

Now what are the methods of EC? These act by preventing ovulation, altering the lining of the uterus, making it unsuitable for an egg to settle down. Ordinary contraceptive pills are packed as four together to be taken as a single dose. There is also a method called YUZPE method in which two hormones are given to be taken 12 hours apart. Both these pill systems can cause vomiting due to high doses of estrogens, if this happens the dose should be repeated after 2 hours. The three best recognized methods are again two hormone tablets prepared for this purpose. They are called the morning after, however they can be taken up to 72 hours and one after 120 hours. Both these hormone tablets can be bought from a pharmacy, a family planning clinic, sexual health clinic, no script is needed. Some GP’s also can give it. 

 

There is another morning after pill which is very effective, however in some countries you need a script for this, so the cost goes up and as such it is expensive .The next method is insertion of a copper intrauterine device, it can be done up to five days. One must make sure about the sexual history of the woman, exclude the likely hood of any pelvic infection. The morning after pill or copper IUCD does not protect women from STI’s, it is important to test for STI’s. The pill can cause side effects in a small number of women, these are nausea, dizziness, headaches, breast tenderness, and lower abdominal pain. There can be spotting and the next period can be late. Please do not use the morning after method as your regular method of contraception. Always keep STI’s in mind and protect yourself from them and always have a test done for them. If an IUCD insertion is used it is good as it can continue as a regular contraception for up to five years if you wish.

To summarize, emergency  contraception  provides good service, if your regular method fails with your regular partner it is safe, do not make it a habit with new partners it cannot be used twice in the same month,  protection from STI’s is essential. In some parts of the world it can be expensive.

TESTOSTERONE THERAPY FOR POST-MENOPAUSAL WOMEN(The latest help for post-menopausal women)

 

Since women are living for longer and longer they wish their lives to be happy. The desire to have a happy sex life is one such prerequisite. Many women suffer from what is called HYPOACTIVE SEXUAL DESIRE DISORDER (DYSFUNTION) (HSDD).   This is attributed to be many causes, however one such reason is supposed to be testosterone deficiency. This happens in young as well as older women.  Besides estrogens and progesterone women have small amounts of testosterone in their bodies, much less than men. One of the functions of this is to give us hairiness, muscle mass, help with fertility, menstrual cycle and last but not the least with sexual feelings (Libido).  The testosterone comes from the ovaries and adrenal glands in different chemical forms and converted to testosterone at area of need, within the body and inside the cells. As we age the testosterone levels decline causing difficulty in women’s sexual desire. This is in addition to the anatomical changes that are happening at the same time in post-menopausal women. To some extent the clinicians have improved the anatomical difficulties of genitourinary syndrome of menopause (GUS). However HSDD needed to be solved. There are many reasons for HSDD to happen such as psychosexual problems in the relationship, drugs, diseases such as Diabetes, thyroid disorders, local genital tissues damage. HSDD leads to relationship distress, depression, poor self-image and fatigue. After a fair bit of work it was decided to give testosterone therapy to these women, only for HSDD not for muscular strength, cognitive improvement or any other problems. Special suitable testosterone preparations were prepared for women. After a proper history, investigations, counselling; after it was made sure that the real cause of HSDD is lack of testosterone.  It was then offered as treatment. A testosterone preparation was offered as dose of 0.5 ml of a cream containing 5 mgm of testosterone. The women are advised to use it once a day in a measured amount and it is applied to thigh or torso as a cream. It will take 4 to 6 weeks for it to take effect. If it doesn’t help within six months it should be discontinued. Before starting the testosterone other causes of HSDD, should be excluded. The side effects of testosterone, can be acne, loss of hair, small gain in weight, deepening of the voice and increased hairiness. The women should be observed for any excess of testosterone. Hopefully along with the treatment of genitourinary syndrome of menopause (GUS) and testosterone for HSDD, post-menopausal women can have a happier time with their sex life.

HEART ATTACKS IN WOMEN

 

Heart attack is the commonest cause of death in women after sixty five. As many women die of heart attack as men at this age. 26.8% of women die of heart disease as compared to all cancers, which is 26.7 %. Sudden grief in women often results in heart attack. I have personally seen two examples of this among my friends. Women’s symptoms of a heart attack are slightly different to men.  They are often resting as opposed to men who are active at the time. They can experience unexplained anxiety, pain in the jaw, back ache, chest discomfort, abdominal pain and even mild flu like symptoms. The reason for these include conditions such as; high blood pressure, diabetes , high (bad) cholesterol(LDL), low (good) cholesterol (HDL), smoking, and high BMI. Even more important than the BMI is abdominal girth as this indicates visceral fat that is the fat inside the body organs. The abdominal girth measured at the level of belly button, should be less than 35 inches, or 89 cms. There can be fast and irregular beating of the heart. There is swelling of the feet if there is associated heart failure. Other conditions that can cause a heart attack are HIV, depression, inflammatory diseases, rheumatoid arthritis, Lupus. Cardiac arrest and aneurysm (Dilated Blood Vessel), high blood pressure during pregnancy and gestational diabetes are also risk factors for heart attacks in women. Women often ignore their symptoms if they are; having chest discomfort or pain, pain in the arm or jaw, sweating, suddenly feeling unwell or fainting. Do not ignore these symptoms. Seek urgent medical help. A dose of Aspirin can be lifesaving. Take it only after you have spoken to your medical adviser. Make sure you are not allergic to it.  For urgent diagnosis an ECG (Electronic heart monitoring) is done. Cardiac Markers are also tested in the blood, they give a good indication of what is happening. Cardiac Markers are repeated to assess the progress. An Ultrasound, chest X-ray, Coronary Angiogram or CT Coronary angiogram is performed to assess the blood vessels of the heart.  Other tests  to assess the general condition such as a full blood examination, inflammatory markers, kidney, liver, thyroid functions and blood electrolytes (Sodium, potassium) are all done. The patients are stabilized, cardiac rhythm is controlled. The final treatment depends on the findings. Either an angioplasty is performed by open heart surgery (changing the blocked blood vessels) or stents are put in the blocked blood vessels. This depends on the severity and degree of blood vessels involved. Both the procedures are very safe. Some researchers believe if early in menopausal life a women takes or given HRT, it is protective against heart attacks in later life. However one cannot be given HRT to protect repeat attacks. In summary it is good to know that, there are lots of solutions for heart attacks. Do not ignore the symptoms if they seem cardiac, as many women get heart attacks as men, after menopause. There is some protection by HRT if one has taken it at the right age, early in menopause. Improve your life style factors. Quit smoking, limited alcohol, watch weight and abdominal girth, regular exercises, cut down your stress levels and be happy. Change of life style factors will take you a long way to protect you from heart attacks.

VEGAN DIETS

 

In our Current world it is becoming popular to try and consume non meat diets. One such diet is called Vegan. It is estimated that in America there are 6.5 million people who are Vegans as opposed to India where the majority are all Vegetarians. The difference is that Vegans do not use any animal products which include milk and milk by products, eggs, fish, or poultry. One well known person in the world who is vegan is Bill Clinton. Using Vegan food is very good for the environment. It takes 100 times more water to produce 1lb of protein from animal than 1lb of protein from plant source. It is good as in some parts of the world we are getting short of water. Vegan diets are useful for weight loss, preventing many diseases, such as heart, diabetes and cancers.  Vegan can get their supply of Vitamin B12 from fortified plant milk and cereals it is important to make sure one gets adequate vitamins from other sources that one cannot get in a Vegan diet. The other vitamin which lacks in a Vegan diet is Vitamin D. For this it is best to sit in the midday sun for about half an hour at least three times a week, to get the UVR rays, as it turns the skin cholesterol to vitamin D. Vitamin D deficiency can cause bone pain, fatigue, muscle weakness, mood changes and even depression. B12 deficiency can also cause this. The other side effects of B12 are red tongue mouth ulcers, tingling and numbness and instability in walking. The other deficiency in a vegan diet is Omega 3. This is very important for body function, cell membranes, hormone production, contraction and relaxation of arteries, blood clotting regulation, decreasing inflammation in the body and heart function.                                                                                                 This can be obtained from flaxseeds, chia seeds and walnuts. These little seeds can be eaten with salads or cereals. The protein sources for vegans are dried peas, chickpeas, kidney, fava, black, and   adzuki beans. These sometimes are hard on GIT and cause bloated feelings and dehydration, it is best to hydrate the beans well when cooking. Eat in proportion. There are some Indian spices when used with lentils and beans help in preventing bloating.

Vegan diets over all, are very useful for individuals, hip pocket and environment; please take care of missing elements such as VitaminB12, Vitamin D, and Omega 3’s.

PREGNANCY IN WOMEN WITH DIABETES

 

Diabetes currently is one of the very serious problems in the world. About 1 in 11 people suffer from diabetes. There are 3 types of diabetes, type1, type 2 and gestational diabetes. The women who are pregnant with diabetes are type 1 or 2. Gestational diabetes is what develops for the first time in pregnancy. Women with diabetes often find it difficult to get pregnant. Uncontrolled diabetes during Pregnancy causes many problems, higher risk of miscarriages, increased foetal abnormalities, macrosomia (big baby) difficult birth, shoulder dystocia, foetal death, and a few others. In view of all this it is very important to have your diabetes under control. Make sure you are taking high doses of folic acid (400mcg daily), for one to two months prior; which helps to prevent foetal abnormalities. Once you get this sorted also make sure your BMI is ok.  This often is not easy but try to exercise regularly.  Find a diabetic specialist, who specialises in pregnancy with diabetes, a dietitian and may be a Physiotherapist. Have a long term glucose test called HbA1c tested it should be 7% if you have type 1 diabetes and 6% if you have type2. In addition you should have all your systems checked that are effected by diabetes, blood pressure, eyes, nerves, and kidneys. It is important to have a pregnancy ultrasound to have precise dates and make sure the pregnancy is normal. An ultra sound is done at 12 weeks, like in any pregnancy, for any genetic abnormalities. An 18 to 20 week ultrasound needs to be done for foetal anatomy and any foetal abnormalities. Maternal blood pressure is watched in women with blood pressure, for mother’s health and adequate foetal growth. In women who have been on Metformin it is discontinued, and replaced with Insulin if required. Women with type 1 diabetes require slightly less insulin in the first trimester. The routine blood tests, full blood examination, blood group, Hepatitis B and C, Syphilis, HIV, latest cervical screening, cervical culture and any other specific tests to the situation are all done.

Regarding the management life style changes are emphasized, regular exercise, stop smoking, no alcohol. Oral antidiabetics are not generally used as they cross the placenta. Women are supposed to maintain and manage their own blood sugars fasting 5.3mmol/L (95mg/dL), one hour 7.8/mmol/L (140mg/dL), two hours 6.7 mmol/L, (120mg/dL). AIC level to be maintained at 6to 6.5 %in type 2 and 7% in type 1 diabetes. This is done every month during pregnancy. It is more important to control blood sugars than A1c. In those women who use the pump, it is also required to test the pre-prandial blood sugar before using the bolus dose of insulin. It is best to leave the insulin management to a diabetic specialist. If the women are getting too many hypoglycaemic episodes, A1c can be relaxed to 7%. A well maintained diabetes prevents preeclampsia.

The most important decision to make in diabetic women is when and how to deliver these women. It is complex in all situations, depending on how well the diabetes is controlled, what facilities are available, what personal are there such as anaesthesiologist, neonatologist and a women’s personal situation. If it is a well controlled diabetes, there are no complications, no foetal compromise, not a big baby, favourable cervix, then it is good to induce at 39 weeks. It is good to have a neonatologist standing by, as babies often require help. Depending on the other factors, induce between 37 to 39 weeks. Never let them be overdue. If there is a situation which require a caesarean section, go ahead and do it.

In the postpartum period the need for insulin decreases so be watchful. Lactation is the best way to feed the babies, they need support as well. They can often get neonatal jaundice. It is important to watch the baby for obesity and diabetes as they grow. In fact this can be transgenerational. Advise all women about contraception.

GESTATIONAL DIABETES: SCREENING DIAGNOSIS AND MANAGEMENT

 

Diabetes mellitus an ever increasing disease in the world. It is a chronic disease causing high blood sugars. These cause changes in the big and small blood vessels finally leading to multi organ disease e.g. brain, eyes, heart and kidneys. Type 1 diabetes occurs in children who never produce insulin. Type two occurs in adults and at present it is occurring in epidemic numbers, 1 in 11 people. This increase is in adults. So much Diabetes in the world is due to our life style factors, affluence, and lack of activity even if we have to go to the local post office we take the car. Exercise physical activity transport and too much socialization. Type 3 diabetes is gestational diabetes occurring in women for the first time during pregnancy. This happens in about 7% of women. It becomes type 2 diabetes in large numbers of females depending on their life style, subsequent pregnancies, and weight gain. Pregnancy is classified as dibetogenic. With the increasing numbers of obesity in the world, diabetic pregnancy is increasing in parallel. This is referred as Gestational Diabetes Mellitus (GDM). This has its own problems, increased blood pressure causing a complication called preeclampsia of pregnancy, big babies (Macrosomia) causing need for caesarian section or difficult deliveries, shoulder dystocia (difficulty with delivery of shoulder), intrauterine fetal deaths and so on. With these happening, the World Health Organization (WHO) decided to screen all pregnant women for diabetes during pregnancy.  Those at higher risk are screened on the first visit, others at 24 -28 weeks because the need for insulin during pregnancy increases at this time. (It is also referred as Insulin resistance meaning body’s inability to use Insulin correctly.)  Blood glucose increases in blood, not being absorbed by the body cells, muscles, fat, and liver. The main cause for this is obesity and lack of activity

Why does the need for insulin increases during pregnancy. This is due to hormones produced by the placenta to help with the fetal growth and development. These hormones are estrogens, human placental lactogens, growth hormones and cortisol. These interfere with the body using insulin effectively. It collects in the blood instead of being absorbed by the cells. This is called Insulin resistance as already mentioned. Initially the placenta is able to produce more Insulin. But in the end this fails. Insulin resistance becomes high and GDM starts. The risk factor for GDM are previous GDM, BMR over 25 Kg per sqm, family history of Diabetes in the first degree relative (Mother, Father Etc.) poor obstetric history, previous fetal death, polycystic ovarian syndrome, big baby more than 4 Kg in weight, nationality: Chinese, Indian, Pacific Islander and Blacks and many others. The screening is started on the initial visit in these high risk women.

Different centers around the world perform the diagnosis by different technical details and consider slightly different normal values. Generally a glucose tolerance test (OGTT) is done. Blood is taken while fasting, then 75 mg of glucose solution is given to drink in 5 minutes. After this 3 samples of blood are taken for glucose in I hour, 2 hours and 3 hours .These values should be

1, 5.1mmol/L (92mg/dl)

2,10mmol/L (180mg/dl)

3, 8.5mmol/L (53mg/dl)

If any value is above the normal, a diagnosis of GDM is made. This differs in different centers in different places which creates confusion. In the past and in some places these values were slightly different fasting 5.3 mm/l. 2 hours 8.6 moll/L.  One has to go by what the local value and criteria are. Some places recommend two abnormal values, WHO recommends universal screening of all women at 24-28 weeks of pregnancy as currently GDM is increasing in tandem with obesity in the world. This is due to our prosperity and poor life style factors. GDM causes Diabetes type 2, in future years of life. It is recommended to screen for GDM on first antenatal visit if there are risk factors for diabetes These are obesity, BMI more than 25kg per sq. mtrs, family history of first degree relative with diabetes, previous stillbirth, shoulder dystocia, macrosomia baby bigger than 4000gm, ethnicity (Chinese, Indians, African Americans, Hispanic), age older than 35, weight gain of 11lbs since age 18 years.

GDM effects Pregnancy by maternal complications such as high blood pressure, preeclampsia, difficult delivery, need for induction, and caesarian section. It also causes big babies (MACROSOMIA), fetal abnormalities, still birth, shoulder dystocia (difficulty with the delivery of the shoulder) nerve palsies, fractures. These babies have hypoglycemia at birth and hyperbilirubinemia (neonatal Jaundice) these babies grow to be obese and hyperglycemic, develop diabetes later in life.

HOW to deal with GDM

Good management results in good results.  It is worthwhile to involve a diabetic physician a dietitian and may be a midwife. Proper care may, prevents preeclampsia, macrosomia, shoulder dystocia, any fetal injuries, need for induction or caesarian section. One basic rule in women with GDM is never let them go over due dates.

Glucose monitoring

Women should start monitoring fasting and 1- 2hours post prandial blood glucose the values accepted differ, 5.3 mmol/L(latest 5.1). 2hours 6.7 mmole/L.

The simplest treatment starts with life style changes, diet on the advice of a dietitian. Low GI carbohydrates are advised. Regular exercise, walking is best.

One recent  research has suggest that an  active exercise program in  the first trimester of pregnancy including walking, low impact aerobics, stationary bicycle and swimming can reduce the risk of GDM. If life style changes and diet alone cannot change the  blood sugars as desired, then some pharmacological drugs are added. Metformin is one such oral drug .  It is only used in some countries not in most. Insulin is the preferred drug treatment. Insulin is used when diet and exercise does not control diabetes as desired. 0.7 to 1, unit of Insulin is started per kg body weight of the women in question. Half of this dose is given as long acting Insulin last thing at night. The other half is given in three divided dosage as short acting Insulin with three meals, sometimes they can have some hypoglycemia in the middle of the night but it is not frequent or very severe. These dosages are adjusted as need be in each individual woman until the blood sugars are at the desired level as mentioned.

Special fetal care is provided for mothers who have GDM.  This can involve regular fundal height assessment fluid around the baby and fetal heart. This can be assessed by the clinician particularly an experienced one. This is often done by ultrasound as well twice weekly or weekly by biophysical profile from 32-34 weeks on wards. Depending on how well is your GDM is controlled. And if you are on Insulin. This includes fetal heart monitoring as well.  Fetal weight is estimated by ultrasound these days.

The other very important decisions are when and how to deliver this woman. If the GDM is well controlled by diet and exercise they can have a normal birth at term. Do not allow them to go past the due dates. Women are induced between 37-39 weeks if any other complications are present or DGM is not greatly controlled. If the fetal weight assessment is 4500g a caesarean section is advised[AP1] [AP2] [AP3]  they are made aware of limitation of weight assessment, particularly if they have a high BMI themselves.

During labor fetal heart monitoring is done continuously. Mother’s blood sugar is maintained by intravenous glucose and Insulin as required.  A pediatrician is invited to be present for delivery to look after the baby as they can have hypoglycemia or acidosis. Mother’s insulin is often not required after delivery. An OGTT is performed for the mother 6-12 week’s post-partum. Women are advised to breast feed as this is best both for the mother and the baby as it helps with minimizing weight gain. It is best to avoid weight gain and be active as this helps not getting Diabetes in future. An OGTT needs to be performed every year, some say every 3 years which I think is not enough. It is best to avoid too many pregnancies but that is individual choice.

We have very good news for the future, worked out by some great research scientists. They have found that the Tymus gland in our body involved with our immune system has a big role in pregnancy by producing cells called  TREGS via Rank are deficient in women who suffer repeated miscarriages and GDM . They also been trying to use them in clinical trials, so we can get rid of two very big problems in women. Great news.

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CASUSES OF PAIN DURING MENOPAUSAL YEARS

 

Once the periods finish in our later years of life women generally feel very happy. Once you have not had a period for one   year it is called menopause. It is a normal phase in our life cycle, it does mean that we cannot have a pregnancy any more. We feel excited that the menstrual aches and pains will go away, but different types of problems raise their hands, just before the periods completely stop.

In the peri menopausal years, i.e. just before menopause, our periods become erratic due to lack of regular ovulation. When this happens the period that starts after a long cycle is often very heavy and painful. For the control of these irregular periods woman are often given the normal oral contraceptive pill or some special pill which regulates the cycle, stops too much bleeding, stops hot flushes and are also contraceptive, so it is great for relief of this particular situation. The other pain you may continue to have is pain due to migraine. This may be the same as you used to have. It is variable, sometimes it goes away with menopause, or it can start for the first time after menopause. Your GP or Endocrinologist will be able to help. The other important cause of pain is ovarian pains. These could be due to preexisting problems such as residual ovary syndrome after hysterectomy or less often endometriosis, adenomyosis (this is the endometriosis of the uterus) polycystic ovaries. It is nor rare for a cyst to appear de novo in the ovary. The clinicians have to be very careful about these as they can often be cancerous and need proper work up to exclude or confirm this diagnosis.  The extent of treatment will depend on the nature of the cyst.  One very common cause of pain during menopause is what is called fibro myalgia which signifies pain all over our bodies, why we do not know or understand. We live on pain killers, maybe massage and whatever variable treatments. More common causes of pain like in both sexes are different types of arthritis. Women also get some different types of pain due to osteoporosis. This does not cause serious pain except for stress fracture of the spine, or  fractures of the bones, such as hip, and wrist or and  anywhere else such as an ankle. More serious causes of pain are cardiac.   Pain due to cardiovascular disease, venous thrombosis. Never ignore them. One of the commonest cause of death in post-menopausal women is cardiovascular disease. Cardiovascular pain can also imitate shoulder, jaw pain and often stomach pain like an ulcer pain. Please seek medical advice should you feel any of these pains as this requires special investigation. During menopause the immunity decreases that results in infections, these surely cause pain. One such infection at this time is shingles. This is caused if a woman has suffered chickenpox in the past. It appear in the torso like a vesicular rash and is very painful. This is infectious in the air and by symptoms touching.  Until a crust forms on the rash women need to be isolated for ten to fourteen days. Treatment involves pain relief and antiviral such as acyclovir.  If left untreated it can cause fatal complications, such as a stroke, pneumonia, encephalitis (inflammation of the brain). It can also cause blindness if it occurs near the eye.

Management of these pain problems is self-care, exercise, correct diet, humor, group activities, fun, and regular clinical advice.