Vegan Diet-2022 Blog 1

 

These days many different types of diets are available, mainly vegetarian

Low carb, Mediterranean, no sugar, fertility diet and so on. One such Diet which is very common among the younger generation is called vegan diet. This means that you do not eat any animal products, including dairy products, and eggs.  This even excludes honey.

The vegan diet mainly consists of fruits, vegetables, plant based milk alternatives, legumes, beans, lentils and peas. Again their nutrition is improved by soaking, cooking and then fermenting.  Nuts in vegan diet provides zinc magnesium selenium vitamin E, some iron and protein. 28 gms of nuts contain 5-12 gms of protein .Hemp, chia seeds and flax seeds are a rich source of omega 3. Chia seed is a great substitute for egg in baking .Hemp has been removed from controlled drugs act. Most vegans use fortified products such as vegetable milk, breakfast cereals, and fortified nutritional yeast. Nutritional yeast is a good source of nutrients, it is cheese supplement for vegans/ however it can cause a few side effects such as gastrointestinal upset, flushing of the face, and can precipitate migraine head ache.

Vegan diets are good diets but if not followed intelligently considering your personal reasons, one can suffer from severe deficiency problems due to lack protein, of calcium, vitaminB12, vitamin D, Iron and essential fatty acid. Special care is needed for, pregnant mothers, new mothers, their babies and children. Proteins are required for sports people, growing children, pregnant or nursing mothers, people recovering from an illness. Soya products are a very rich source of proteins such as tofu, soya drinks. Tempeh is made from fermented soya beans this increases its nutritional value and this contains a very small amount of B12 as well. Nutritional yeast especially if fortified is a rich source of protein and B12. For calcium green leafy vegetables, cabbage, broccoli okra are good. Calcium set tofu is also made. Sesame seeds Tahini pulses are good sources. Soya drinks fortified with calcium and vitamin D are good supplements. Fortified cereals are good supplements for many nutritional needs for iron one needs pulses, green leafy vegetables dried fruits. For B12again fortified cereal, soya drinks yeast extract or even a medical supplement. Essential fatty acids are required for many functions in the body. They come from grain, green leafy vegetables and nut, walnuts and pistachio nuts, seaweeds are rich in essential fatty acids antioxidants and iodine. Vitamin D is also available in many fortified food. One can easily get it from sunshine.

Vegan diet is excellent for animal protection, personal satiety as there is bulk in food , good to lose weight, lower cholesterol and above all saves from heart disease which in the major killer of human society. If care is taken to protect one from deficiency problems it can be excellent. When one wants to start any diet see what is your need for example if you have a family history of heart attacks it will be very good for you, but if your family has suffered from osteoporosis it is no good for you. Also you do not have to follow it the whole, one can modify according to once needs.

Asha Pahuja

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 .

 

---

 [Ma1]

 [Ma2]

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.

---

 [AP1]

 [AP2]

 [AP3]

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.

POST MENOPAUSAL ENDOMETRIOSIS

FREQUENCY, DIAGNOSIS AND MANAGEMENT

Endometriosis a common gynaecological disorder occurring in 5 to 10% of the female population. It is a disease that affects younger women during their fertile life. It is supposed to be oestrogen dependent and therefore subsides after menopause. However it still occurs in 2.5 % of post menopausal women. Now there are millions and millions of postmenopausal women, and thousands are with Endometriosis, thus the gynaecologists often come across them. In recent times management of postmenopausal endometriosis is being considered. There is no clear cut pathogenesis on endometriosis. A very old retrograde menstruation theory does not explain all situations. In some case endometriosis has been seen in some 60 to 70 year old women, without any previous history. These lesions are deep, adhesive and sometimes far off from the pelvis. Besides retrograde menstruation, the other factors can be familial predisposition, genetic and epigenetic factors. It can also happen because of coelomic metaplasia, (meaning the bowel epithelium changes into endometriotic tissue) It can also arise from foetal remnants or abnormal oestrogen production from non ovarian tissues. Perhaps immune deficiency also plays a role it is believed that a hormone called Aromatase can convert the local testosterone into oestrogens and a de novo endometriosis arises. Levels of this hormones are higher in postmenopausal women . This can happen more often in obese women. No single theory can explain endometriosis especially when it happens for the first time. It often happens away from the pelvis on non gonodal (not gonads) such as, organs, kidney, ureter (the tube that connects the kidney to the bladder), appendix and bowel. Very rarely it is even reported on the skin. HRT is often responsible for postmenopausal endometriosis especially if oestrogen only therapy is used. Phytoestrogens (oestrogens from plant sources), these are over the counter drugs and their irregular use can reactivate endometriosis in post menopausal women who had it in younger years. Previous endometriosis can even become malignant if oestrogen only therapy is used in hysterectomised post menopausal women.

When women suffer, with pelvic pain, dyspareunia, Dyschezia (pain on bowel movement), abnormal bleeding, and known to have had endometriosis, has had surgical treatment, even if no history of endometriosis, always keep endometriosis in mind. Now if a woman is still having hot flushes, foggy head, lack of sleep and requests treatment for her problems; what can be offered to help her? After looking at her basic previous history, tests such as, a pelvic examination, cytology basic blood tests, maybe an ultrasound, a laparoscopy, if the pain is significant. If there are any significant findings, such as cysts on the ovary and deep infiltrating endometriosis, surgical treatment is advised. If there are no surgical findings medical treatment can be offered. This can be in the form of oestrogens, progesterone, and modified oestrogens called SERMS (modified oestrogens which act differently on different organs). If she still has her uterus and has recently become postmenopausal, concerned about pregnancy, she can try an oral contraceptive pill. Use a pill that best suits her. She can also try a group of hormones called GnRH analogues (these can lower the sex hormone levels). Tibolone, a synthetic steroid which acts as oestrogen, progesterone and testosterone, is a very useful drug. It helps with hot flushes, decreased libido and is very easy to take. It is a useful HRT for postmenopausal with endometriosis. It has a slightly increase risk of DVT.

Postmenopausal endometriosis is mostly recurrence or continuation of premenopausal endometriosis however there are cases reported which seem to arise new. There pathophysiology is difficult to understand.  Beside the explanations mentioned earlier it is also believed that an inflammatory  small cell protein involved in cell signalling called interlukin  play an important role by allowing ectopic endometrial cells to implant in different places and help them to grow. It is also suggested that stem cells modify as endometrial cells.

Conclusion: - Postmenopausal endometriosis is known to occur in about 2.5% of this group of women. It should always be kept in mind when postmenopausal women present with symptoms of pain and / or abnormal bleeding.

Since the postmenopausal endometriosis can be malignant, they can be surface ovarian cancers, endometrial and clear cell cancers; surgical treatment should be the first line of approach.  Many case reports where endometriosis is seen to occur outside the pelvis, such as the ureter, appendix, and bowel loops, and vagina. In one recent case report on the liver in which after surgical treatment, a SERM (conjugated equine oestrogens/ Bazidoxifene,) was used, as a modified HRT which preventing oestrogen acting on the endometrium (preventing the risk of endomtrial cancer), was used, and endometriosis completely resolved. I wonder if in future others will try to do this. Further research is needed to manage the postmenopausal Endometriosis and guidelines for surgical treatment and different newer HRT, will also be very welcome.

BOY OR GIRL? IT DEPENDS ON THE MALE PARTNER

This story starts in 1962. I was a very young doctor, just started a new job at a newly opened Medical school as a lecturer. It was my very first day, at my first job after completing my training. Those days there was no ultrasound, not even an x-ray machine nearby. My registrar called me to this new admission in the labour ward a woman was in established labour, who had never seen a doctor throughout her entire pregnancy. She had an enormous belly. It was difficult to feel anything. I expected it to be a twin pregnancy with too much fluid. We had no idea about her blood count. She told us she is trying for a male child and already has six daughters .Within minutes of her arrival the first child was born, the second child was already in a big hurry to arrive in the world , her belly was still somewhat biggish, however I gave her the injections to prevent bleeding which  is given after twin birth, then suddenly I realised that there was another baby, I had never witnessed  a triplet birth and never thought of it, we rushed a bit, to save getting  this baby trapped  after the injection, but luckily this baby arrived safely. Guess what, all the babies were girls well formed all normal with good weights between 4.5 lbs to 5 lbs. I suddenly felt very sad. I did not know how to tell the parents I told them of a family who had 8 daughters hoping for a son one day they all became very successful doctors. Here with this lower middle class family I was worried about their feeding and schooling.  60 years on, since I still think of what happened to them. In some countries there is such a fanaticism about having a son to carry the family name. Sadly the women are always blamed however it is the fathers Y chromosome which is responsible for the sex of the baby. In humans there are two sex chromosomes X and Y. The females have XX and male are XY. When a baby is being formed, an X chromosome comes from the mother and Y from the father, if there is a Y chromosome then the baby will be male. There is a 50 /50 chance in nature what will happen.  There are a few theories. The sperm can be male or female depending on what a particular man has inherited. The male are divided as mm, mf, and ff, men with mm sperm will mostly have boys and ff will mostly have girls. This varies in different generations.  The female sperm is longer stronger and also lives longer so a few theories were suggested that if you want to have a female child work out your ovulation and refrain from having sex two to three days before that, by the time you ovulate your male sperms may have demised, and if you want a male child have sex as close to ovulation as possible the fast running sperm will be able to fertilize the egg. In the 21^st century ovulation can be worked out by temperature charts, and ultrasounds, even an artificial inoculation of sperm can be done on the precise day. This in my very brief experience proved excellent. In more sophisticated medical situations where sexing is required for prevention of sex linked diseases, a micro sort system is recommended in preference to per implantation biopsy and intra villous sampling. Stories also go about what position you adopt during sex for a boy or girl. Inherited billionaires have more boys. People who have more brothers have more sons and vice versa. How do we guess in modern times when everybody has only one or two siblings? To my way of thinking the ovulation technique seems more scientific. Poor King Henry the VIII was not aware of any of this, and that it was he who was responsible for the sex of his child and not his queens.

INTERSTITIAL CYSTITIS (IC) OR PAINFUL BLADDER SYNDROME

This is a poorly understood condition, which millions of people suffer from around the world. Two thirds of these are women.  Here we will focus mainly on women. They suffer from pain in the bladder area (that is why it is also called bladder pain syndrome or BPS). There is pain in the inner thighs, back ache, chronic pelvic pain, pain on passing urine, need to pass urine frequently without much urine in the bladder. There is no bladder infection. The problem must be going on from 6 weeks to 6 months. The Bladder is the bag where the urine collects from the kidneys, when it is full the brain sends a message to pass urine. Normally it is not painful; except when there is a bladder infection. However IC or BPS the frequency of going to the toilet 50 – 60 times during a 24hr period, middle of meetings or odd times makes sex life distorted, due to exaggeration of symptoms for several days following sex.  Even more pain during menstruation and any kind of stress, acidic type of food, strawberries, lemons, oranges, coffee, and chocolate.  It is commonly believed that cranberry juice helps urinary symptoms but in fact it makes IC worse all this makes life very difficult for women. There are many conditions, which cause symptoms similar to IC that women suffer with and some of these are Irritable bowel syndrome, Endometriosis, Sexually transmitted infections, kidney disease, bladder cancer or stone, chronic fatigue, fibromyalgia, multiple sclerosis, emotional behavioural and sexual dysfunction consequences.  Many of these are quite serious. What causes IC is not understood. There is some genetic predisposition, female sex, fair skin, red hair, chronic pain disorders, some kind of autoimmune problem (that is when the body attacks itself). Can it be Hormonal, as it is more common in females?  Is this a viral or unknown infection?  There are defects  seen in the bladder mucosa, it is not  clear, if it is the cause or the result of the disease, a leak  from these  areas  irritates the bladder by the substances in the urine.

Many researchers believe that a substance called, antiproliferative factor (Substance that can interfere with healing, APF) found in the urine of people, with IC hinders the healing of the damaged mucosa of the bladder. In fact these researchers are seeking to use APF as a biomarker for IC. Many other conditions need to be excluded before we start thinking of IC. Some of these are, as already mentioned others can be radiation treatment, drugs that may have caused allergy to the bladder, pelvic floor disorders, damage or entrapment of pelvic nerves, vulvodynia, (pain in the vulval area without any obvious infection or skin disease) prolapse of pelvic organs, vulval or vaginal or cervical pathology, pelvic masses such as ovarian disease, and trigger points causing pain tenderness and muscle spasm.  

For making a diagnosis history is very important. It must be going on for 6 weeks to 6 months, take a family history, any radiation any drugs or any other problems. It is most important to exclude any bladder infection at present and during this time. Do a urine culture and urine cytology, this will exclude any infection or cancer cells. A clinical pelvic examination can exclude any prolapse, vaginal, vulval, uterine and often ovarian pathology.  In IC the bladder base is tender on an internal examination. Another test that is that can be performed is called Urodynamics. This can measure the bladder pressure and its capacity, women with IC start feeling the pain very soon after it starts to fill and get a desire to pass urine. The other test that is done by a few   doctors but not recommended by everyone is a Potassium solution test. In this test, water is used to fill the bladder followed by a potassium solution and in women with IC; filling with potassium solution is very painful. The other test called a Cystoscopy needs to be done by a specialist gynaecologist, urologist or urogynaecologist. In this test the bladder is instilled with fluid and then examined by a Fibroptic light with a Telescope. 

This shows petechial haemorrhages in the bladder wall (small pinpoint bleeding, also called Glomerulations) in different quadrants of the bladder, reddened mucosa, submucosal bleeding, and mucosal disruption, oedema with or without bleeding. This is diagnostic of some forms of IC. Depending on these finding IC is classified into four grades. Then, there are striking reddened patches on the bladder wall called Hunners ulcers. 

This finding also suggests another type of IC. Hunners areas, decreases the bladder capacity due to fibrosis and is more distressing than the one with minute haemorrhages.  A bladder biopsy is taken from these ulcers; this shows inflammation, mast cells that can cause severe allergic reaction, fibrosis and granulation. There is a questionnaire about pelvic pain frequency (PPF) and urgency of micturition which is filled by the client and if the score is 10 or more it is in favour of IC. It has been shown that the Clinicians under diagnose IC by a large percentage because they do not always think of IC in women suffering from chronic pelvic pain.
This  is  difficult  to  understand  what  causes  all  these  problems? The main question is; what is the solution? This depends on the age, severity, and how much stress is it causing and interfering with the quality of life.  

For a start, self help is required, stop the trigger factors, stress, foods that upset IC, smoking, meditation, yoga, planned breaks for toilet, gentle stretching exercises and restrict drinks before bed time. Physiotherapy for pelvic floor muscles, psychotherapy, proper bladder retraining.  Some drugs such as simple paracetamol, non steroidal anti inflammatory drugs (NSAIDS), antihistamines (anti allergy drugs) and antidepressants have all   been tried. Some tablets that help to relax the bladder are tried in more serious cases

There is one special tablet called, Pentosan Polysulphate Sodium which is an oral medication which is tried in many clinics. It takes 2-6 months to help.  Pain relief takes the longest time .First it is tried for 3 months and then for further 3 months. Its side effects are minimal nausea, headaches, dyspepsia and liver dysfunction, these are all reversible. They probably act by mast cell deregulation, immunological and neurological effects. These down regulate the activity of the sensory fibres that take the pain sensation to the brain. There are also drugs that are instilled into the bladder weekly for 6-8 weeks and then 2-5 weeks to relieve the pain and relax the bladder for three months. These are called Dimetylsulfoxide (DMSO). Some clinicians mix Heparin and Lidocaine( a local anaesthetic) for better relief of symptoms. Nerve stimulation technique is also tried by a Tens Machine, or Sacral Nerve Stimulation by a device similar to a Pacemaker called InterStim.

In some cases surgery is tried by electro  cautery or laser for  the bladder ulcers, resection of  the  abnormal area, Sub mucosal   injection. In rare situations enlarging the bladder size by using the gut is performed, but this does not help with pain. Extremely rare situations bladder is replaced by a bowel loop. There are many such techniques; this requires very special surgeons and special care of the urinary diverted loops or opening stoma. On a simpler front acupuncture and herbal remedies are tried.

Interstitial cystitis is a very stressful condition which mainly affects women causing pain, urgency and frequency of micturition in absence of any infection of the blabber or any other discernible pathology. There is no definitive treatment for IC. It cannot be cured. A combination of treatments goes a long way to relieve symptoms. Treatment is generally started in simple ways.  Progressively more and more complicated procedures are performed to help a very distressed woman.

PELVIC ORGAN PROLAPSE (POP)

Pelvic organ prolapse simply means that the pelvic organs descend into the vagina. This includes bladder (cystocele ) rectum (rectocele), uterus and bowel (enterocele ). All of these are not seen all the time in the same person, different combinations of POP is present in different women. It is also classified in degrees depending how far down it has come , when it is a bit in the vagina it is first degree , when it is at the opening of the vagina it is second degree, when it is outside it is called third degree, when it hangs totally outside it is called procendentia .

Globally one in five female suffers from it. However women do not complain about it, perhaps they are embarrassed about it and do not know that it can be treated. In developing countries almost 50% of women suffer due to difficult child birth at home. The main cause of POP is child birth, chronic cough, smoking, constipation, obesity, and hormone deficiency at during and after menopause. It can be occupational due to standing too long and heavy lifting all the time. POP in women who have never had a child is very rare; it is usually due to developmental defects either in the pelvis or the spine. Women who have POP also suffer from urinary problems such as leakage of urine (incontinence) and even faeces.

The symptoms women experience is a feeling of pressure in the vagina and with a finger they can feel a lump. Other symptoms are, pain on standing, backache, belly ache, difficult sex, urinary and bowel problems. Often in very severe cases the pelvic organs constantly hang out. Treatment can be started very soon after child birth with pelvic floor muscle exercises. In fact in many places when maternal health is taken seriously they are taught to the mother at the time of discharge. The most common is called Kegal exercise which has been going on for generations.  Perhaps some women may remember being told about it, when they had their baby. Changes in life style factors is also important,  such as avoiding constipation, smoking,  being overweight, proper eating habits, use of oestrogens if women are in the menopausal age group.  The other non surgical treatment is pessaries.

These help to keep the pelvic organs pushed inside.  They need to be changed every three to six months. Sometimes the women can do it themselves but it is best if a clinician can do it, so that they can look for any infection, ulceration and can do cervical smear when required. This treatment is ok when the women do not wish for operative treatment or are unfit for it or often too old.

Operative Treatment

This depends on several factors; how old is the women, what is the actual problem, for example a cystocele and what else, most importantly is the preservation of the uterus required or is it a nulliparous POP? (This means a woman has never had a child). The operations are cystocele and, rectocele repair or both and repair for descending cervix.  If it is a nulliparae’s prolapse the cervix is lifted up by different types of sling operation, hitching it to sacral promontory of the spine. These were invented by Indian gynaecologists as this is common in India.

Some other sling operations are also performed if there are urinary and bowel problems. I will discuss these in my next blog. Side effects of these operations are they can recur in 20-30% of women, especially after a child birth and soon after repair, or a POP can come up in another place. If the rectocele repair becomes tight it causes painful sex and bowel problems. In older women when preservation of uterus is not desired a vaginal hysterectomy with the repair for other defects is performed. Following these operations a catheter is left in the urinary bladder while the tissues heal.  Women are usually in hospital for 2-5 days.

One very last operation is the total vaginal fusion. This is done when intercourse is never desired and the uterus is absent. A slightly modified operation called La forts operation was once performed in 1877 and then it sort of died out.  Now it is coming back as women are living longer. This is a very simple operation with a success rate of 90%.  It can be performed under local anaesthesia. Hospital stay of 2 -3days, hardly any complication rate and satisfaction rate of women is very high. With changing demographic this is more often required.

POP is a big subject now so much so that it has become a separate speciality within the field of gynaecology. There should   be more public awareness so that the women are not hesitant to ask for help in early stages of POP problems.

ADENOMYOSIS: ENDOMETRIOSIS OF THE UTERUS

Eva is 37 years of age has 2 children; 6 and 4. For many months she had been having very heavy and painful periods. She was unable to cope with her day to day life; her quality of life was getting progressively worse. She went to see her GP, and complained to him about all her problems. He asked her if she had any difficulty with her bowel and urination, she immediately answered yes. I have pain both on urinating and bowel action and also frequency of passing urination. When the GP examined her he noticed that she was looking pale, he could feel her enlarged uterus on abdominal examination and confirmed this on pelvic examination, that it was about the size of 12 -14 weeks of pregnancy it was hard and tender. The uterine size is expressed with reference to the size of pregnancy; however during pregnancy it is soft. He did her haemoglobin, this was low 9.6gm (Normally it is about 11-12). He was an experienced GP, and gave her a diagnosis of a uterine Fibroid or a condition called Adenomyosis.

Adenomyosis is a condition in which the endometrial cells grow within the uterine muscle layers. It can be scattered in the muscle or form a mass like effect, unlike fibroids it does not have a capsule or an outer cover. It is believed that it affects up to 65% of females in their life time. A few decades ago it was thought that it does not affect young women who have had no children. Recently with the improvement in diagnosing Adenomyosis (ADENO) with Ultrasound and MRI it is believed that 35% of women suffering from ADENO are nulliparae’s (women who have never had a pregnancy), in fact in English medical literature some cases had been reported in adolescent girls. One third of the females suffering from ADENO have no symptoms. Others suffer from heavy painful menstrual periods, lower abdominal pain, and pain on intercourse, passing urine and on bowel actions. It also causes infertility, miscarriages and even premature birth. If associated with polycystic ovarian syndrome it is even worse due to high oestrogen levels. This makes IVF difficult due to altered uterine shape, uterine peristalsis, and makes embryo implantation difficult; a toxic and altered hormonal environment makes it further worse.

One problem is that it is a long disease, which lasts for years almost up to menopause. It often becomes mild after menopause or goes away. I have removed some very enlarged painful uteri, in post menopausal women.   A patient’s medical history and a clinical pelvic examination give a good clue to its diagnosis. Blood tests can be done to assess a woman’s condition. New high resolution ultrasound and MRI give a precise diagnosis. MRI is an expensive test and not always available ultrasound is nearly as good. In recent times it has been advised to always keep AENO in mind if you have a young adolescent girl with intractable pain and painful period, please do an ultrasound.

Why does ADENO happen? It can be due to trauma to the myometrial and endometrial zone during child birth, an operation such as curettage, caesarean, this is a process of tissue injury repair. The endometrium invades into the myometrium.  The other theory is that, stem or embryonic cells change into endometrial cells and make these endometrial nests or even masses.

The treatment of ADENO initially conservative especially if the woman is young and fertility is an issue.  Antinflamatory tablets are given during periods so that they help pain and excessive bleeding, its effect are minimal to moderate. Next in the line of treatment are hormones, they are either given to make the periods milder or stop them completely.  They all have their side effects and most of them stop fertility, however the good thing is that all of them are temporary.  Let’s start from oral contraceptive pills, then progesterone tablets or injections and vaginal rings. These also give Adenomyosis time to heal, but how much it does; we do not know.  When they are stopped the problem starts again. Another treatment is a progesterone implant a small rod implanted in your upper arm under the skin it lives there for 3 years. It can cause some irregular spotting, prevents pregnancy.  One of the good hormone is Danazol tablets, or danazol loaded intrauterine device which fitted in your uterus for 6 months.  This has a great advantage that a woman can still achieve a pregnancy while she is using this.  A strong hormone treatment is Gonnadotrophin releasing Hormone (GnRH). This is given as an injection every at 1 to 3 monthly intervals. This suppresses our pituitary gland, thus our ovaries, hence no more periods. This cannot be a very long term treatment; it causes side effects like menopause. Add on treatments are given for these.  One serious side effect is the loss of bone density. In contrast to this, a group of drugs called Aromatase inhibitors which stop the formation of oestrogens in the body from other hormones that exist in the body fat. They are also found to be useful particularly in obese women where extra oestrogen is formed in the body fat. GnRH is unable to do this.

An present an intrauterine device containing Levonorgestal is found to be the best reversible treatment of Adeno. It prevents fertility and can be used repeatedly, after every 3-5 years.  The failure rate of treating symptoms is only 20 percent. There is a smaller IUD now available and can be tried in adolescents. Local excision of adenomyosis has been tried, but it is not easy and long term results are a bit questionable and unsatisfactory. The treatment of ADENO depends on, if fertility is to be preserved. Hysterectomy is the best treatment, although uterine artery embolization and endometrial ablation is also tried with some success.  As long as a patient agrees to surgery, a hysterectomy can be performed abdominally, vaginally or laparascopically and now even robotically.

Generally ovaries do not need to be removed.  In some very difficult cases it is found to spread into the bladder and bowel.

Adenomyosis is a difficult and painful condition from which women used to suffer a lot in the past, but the new techniques of diagnosis and treatment have helped the gynaecologist in its management.  

CAUSES OF HOT FLUSHES AND NIGHT SWEATS

Most women in their life time experience hot flushes and sweating at night or even during the day. When peri menopausal, menopausal and post menopausal; it is estimated that this happens in about 15% of women throughout their lives. This can be very uncomfortable and very embarrassing depending on where you are and what you are doing at the time. The simple answer is to wear light clothing, give up smoking if you are a smoker, try HRT if it is ok for you, or natural remedies.

There are many other endocrine conditions which cause hot flushes and sweating, overactive Thyroid (this controls our body function and is located in the neck). If the hot flushes are not controlled by menopausal treatment, have your thyroid tested. It is common to have thyroid disorders during menopausal years, and the treatments are simple.

There are few other endocrine causes which can cause these symptoms, these are 1) Pheochromocytoma, this is a tumour of the Adrenal gland, 2) Carcinoid syndrome, is a complex syndrome arising from the appendix. This can occur at any age and will have many other symptoms associated with it. Often if someone is diabetic and is on insulin or diabetic drugs, sweating can happen due to low blood sugar, this is a serious problem and can be life threatening. Treatment is simple, sugar drinks or a glass of fruit juice with some food.

Various infections also cause sweating; some of these are very serious, such as Tuberculosis, Osteomylitis (bone infection), Endocarditis (infection of heart valves), HIV, Abscesses formation, Malaria and other infections.

Cancer also causes sweating and fever. Lymphomas are more common to do so.

Certain drugs particularly antidepressants are known to cause sweating.

Stroke and Heart Attacks can cause severe sweating.

Many disorders of the nervous system also cause sweating

My idea of giving women this list is to make them aware of the many causes of sweating. Most of these can happen suddenly and at different age groups, along with many other symptoms, so take notice and do not ignore them.

URINARY TRACT INFECTIONS IN FEMALES

Urinary tract infections (UTI’s) are a very common problem in women and young female children. What is a urinary tract in humans? It consists of two kidneys on either side of our spine in our abdomen. Two tubes called the ureters run one from each kidney into a bag called the urinary bladder. In the female a small tube called the urethra opens to the outside from where females pass urine. In men it is different, it is long and on the way it is connected to other tubes. 

Of all the urinary tract infections that happen 80% happen in women. According to one study almost 50% of women have had at least one UTI in their lives by the time they are 50. UTI’s when simple are confined to the urinary bladder  this is called cystitis.  In some women and children it happens repeatedly than it becomes more significant. It can even travel to the kidney, and it is called pyelonephritis, it can become more serious. In even more neglected cases it can cause serious infection in parts of the body, so do not ignore UTI’s or simple bladder infections. What causes UTI’s so commonly in women. It is because our urethra is small, it is close to the rectum, and bacteria easily travel to the urethra and causes infection. It is also possible that local hygiene is not so good. Women often need a catheter after an operation, during labour, or other times if they are unable to pass urine. Other causes can be obesity, unprotected sex with an infected person. Some diseases such as Diabetes, Multiple Sclerosis, Parkinson’s Disease and some local abdominal diseases such as  Fibroids (a benign uterine tumour ), Endometriosis, Ovarian Cysts, Vaginal Infections, Kidney or Bladder Stones and using local contraceptives such as Vaginal Foam and a Diaphragm. Menopausal and post menopausal women are also very prone to UTI’s due to lack of protection from Oestrogens. Chemotherapy and commercial personal hygiene products. Malformations of the UT may be a cause of UTI’s. This will show in childhood and often recurrent.

What are the symptoms of UTI’S?

Rarely there are any symptoms, mostly women have frequent moments of passing urine and it is painful to do so. There is back ache (where kidneys are located), pain in the stomach and on the side of the abdomen. There can be nausea, vomiting, fever and even diarrhoea. The urine can be smelly and may contain blood. A young child will have all these problems. She may refuse to eat. The best thing is to go to the doctor. They can do a dip test with a strip in urine to confirm  infection and send a urine sample collected after wiping the vagina called the mid stream urine, for culture and appropriate antibiotics are started immediately. The symptoms improve within two days. If this does not happen the ABS are changed as the urine culture report will tell the doctor about the infecting bacteria and the suitable Antibiotic. A urine culture is also done after treatment to ensure that the infection has cleared. If a woman or children have recurrent infections, many other tests are done. These are an ultrasound, tests for STD’s,  a Cystoscopy meaning there by looking with a telescopic light inside the urinary bladder. Also make sure that the child is not being molested by anyone. Children sometimes have a problem that when they pass urine some urine goes back into their ureter. (The tube connecting kidney to the bladder) This requires surgical treatment. If this is not done the kidneys maybe damaged.

Women and girls who get repeated UTI’s should address their life style factors. Drink plenty of water, do not wear tight clothing, and do not wear anybody else’s clothes. Avoid grapefruit and cranberry juice that is recommended on social media for UTI’s. Use correct and safe contraceptives. Always have safe sex. Keep good hygiene for external parts of the body, when wiping bottom, wipe from top to the bottom.

         For women who get recurrent UTI’s meaning they have 2 episodes in 6 months or 3 in a year, Prophylactic treatments are required; with Postcoital Antibiotics, Continuous Low Dose Antibiotics and treatment for any voiding problems such as prolapse management of serious infections such as Aids, Antibiotics with UT instrumentation such as catheters.   

        

         Pregnancy and UTI’S

         In pregnancy UTI’s are important. In fact in all pregnant mothers a urine test is done and if there is bacteria even in absence of infection this is treated. UTI’s in pregnancy an cause premature  labour and due to  abdominal pressure, the infection can quickly go into the kidney causing pylonephritis. The women become very sick, symptoms become more severe, they are given intravenous antibiotics. They need to be hospitalized. If UTI’s happen again during pregnancy a woman is given prophylactic ABS for the rest of her pregnancy.

In UTI’s in addition to ABS we use urinary antiseptics they help and prevent bacteria, if the infection is simple and in the bladder alone for prophylaxis. In these situations we need to watch the sensitivity of bacteria so that the resistance bacteria do not develop,which will be impossible to treat. This is one big disadvantage of using prophylaxis.

Besides UTI’s there are a few other common problems with URINARY TRACT which are not strictly infection. One of them is called Interstitial Cystitis (IC) or Bladder Pressure Pain. This is a painful condition without infection. It is poorly understood, difficult to diagnose and treat. It is believed that there is some defect in the bladder lining which is irritated by food, sex and some vulval hygiene products. Diagnosis is made by using a cystoscopy in which they use a potassium solution for bladder wash this causes pain in women with IC. Treat is not very effective, women need a lot of psychological help, nonsteroidal anti inflammatory tablets, antihistamines and tricyclic anti depressants. In USA, FDI has allowed one oral drug Pontosan polysulfate to a maximum of six months. Change of life style factor is also recommended. Other urinary problem often in the elderly is over sensitive bladder when you need to go to the toilet frequently but there is no UTI. For this, one has to do pelvic floor exercises, bladder training, scheduled toilet trips, absorbent pads or underwear. Local oestrogen cream may help and intermittent catheterisation which in itself can be risky.  Usually the bacteria in UTI’s is ECOLI, which comes from our bowel but in unusual circumstances and in nursing homes they can be more serious and  difficult to treat, these are Proteus , Pseudomonas , Klebsella and bacteria from STD’s

Urinary tract system in our body is very important, as it gets rid of all the waste products from our body. If kidneys fail humans are on death bed. Special attention should be paid to all our Urinary tract problems particularly in children, women, pregnancy and the elderly. Never ignore blood in the urine, rarely can it be due to UTI’s but it can be a sign of cancer. Women do die from UT cancers.