By 1940 the medicalization of menopause became popular, they prepared drugs from the urine of pregnant women and pregnant female horse's(Premarin). These drugs were available in the USA in high doses such as 1.25mgs.
Further down the track by 1948 smaller doses were available such as 0.625 mgs and 0.3 mgs.
In 1950 Ayrest Laboratories funded a big campaign to educate women on menopause, what it is and how it can be helped. After their public relations exercise's, Premarin become the number one drug dispensed in the USA.
This got further promotion when gynaecologist Dr Robert Wilson in 1964 published an article on menopause called" Menopause" and a book called" Feminine Forever".
He did very extensive PR on the value of HRT, however by 1968 the side effects of oestrogen replacement therapy started to become obvious, such as endometrial cancer, breast cancer, deep venous thrombosis and the lack of any benefit to heart disease. There were some benefits, such as the prevention of osteoporosis and fractures.
Because of these complications several studies were set up to assess the benefit risk ratio of HRT(Oestrogen and Progesterone).
The main study was set up by the national institute of health , called Women's Health Initiative(WHI).
This was started in 1991 and to be completed in ten years on 160,000 women.
There were four arms to this study , one of them was a continuous oestrogen progesterone with an intact uterus, however this had to be stopped after 7 years due to increased risk of breast cancer , heart attacks and deep venous thrombosis.
This group had women of all ages from early menopause to late. They were more useful in younger women who took the HRT at the start of menopause.
The conclusion drawn from these controlled trials there was clear evidence of deep venous thrombosis, there was no clear benefit of cardiac disease and there was no increase in coronary disease in women less than 10 years post menopausal.
After this study and many others the oestrogen was on trial and it seemed that the benefits of oestrogen were less beneficial than the side effects, this created a fear amongst women particularly the increased risk of breast cancer.
All of a sudden the sale of HRT plummeted , the stock market fell by nearly 20% and the sale of drugs from Wyeth namely Premarin fell from 1.2Billion to 984.Million.
People started to believe that these tablets were no more the magic bullet.
One of the problems with this study was that they included women of all ages and even those who had no symptoms.
As a result of this fear, millions of women suffered from severe hot flashes and problems with their sexual life. Their husbands also suffered during this period from their wives' mood swings, bad temperament and were devoid of any sexual pleasure with each other.
We have recently worked out that Pre menopause, Peri menopause and Menopause is a continuum of the same biological problem, which is the lack of oestrogen due to the end of the biological cycle for women. This is now referred as Peri-Menopause, Menopause and Post Menopause. This has been studied under stages of reproductive aging, this makes it easier to understand women's menopause.
This period lasts for several years and that's why is was called "Climacteric". This in Greek meant seven years.
Currently we call it Menopause transition.
During this time some women have variable menstrual cycle both in duration and amount of bleeding, some of them still ovulate and can get pregnant. One of the hormones called F.S.H which comes from the brain increases. Please refer to earlier posts in relation to menstrual cycle.
Later on in menopause transition the menstrual cycles are delayed up to sixty days or more, F.S.H increases further. Its called menopause when you have not had a period for one year.
During this time of menopause transition women suffer symptoms of menopause, such as hot flashes, lack of sleep, mood swings, irregular bleeding and many others.
During this time we need to treat them and also offer contraception.
Recently the Women's Health Initiative has published a new update on women's health along with the British Menopause Society , North American Advisory Committee and Royal College of Gynaecology have all published new guidelines on HRT, so we have come full circle.
WE should not let women suffer from any fear from menopause or HRT, always consult a professional and not be guided by the media frenzy about this subject.
The original WHI created a lot of confusion, the reasons being the selection of women for the study was incorrect. 160,000 women were selected with no consideration of their age, their symptoms, their medical history, obesity, smoking, and poor lifestyle factors. They mainly focused on the long term benefits of HRT, no attention was paid to their initial symptoms such as severe hot flashes, urinary symptoms, lack of sleep, mood swings, and many other annoying problems.
The results were also analysed and expressed very poorly , for example they said that breast cancer risk increased by 26 per cent( 30-10,000 to 38-10,000 ), this frightened the life out of women and their care providers, they could have easily said, one extra patient in 1250 women who had been on HRT for 5 years was at risk.
The next worst thing was that these results were given to the media before they were published in any medical journal and analysed by the experts.
Many experts felt that the WHI conclusions needed a complete reassessment.
It is after ten years of muddy conclusions and many research trials the cloud over HRT has cleared.
We cannot say that HRT has no side effects , but the benefit risk ratio is in favour of the benefits.
The most important thing is to remove the fear in the mind of women and their care providers, the next important thing is the timing of HRT, the sooner it is started near menopause or menopause transition the better it is.
If we start after women are over 60 or ten years after menopause, the aging effects have already influenced their bodies.
HRT should not be offered for prevention of chronic disease except for osteoporosis, it is useful in women before the age of 60 who have the risk of osteoporosis.
This fear of HRT has been fuelled by an aggressive alternative medicine industry, the media, some non clinical groups seeking publicity for funding and the Therapeutic Goods Association has not revised the inaccurate conclusions of the WHI.
In general the conclusions on HRT are:
1- Do not let the women suffer who need HRT for their symptoms.
2- Can be an appropriate treatment for women with osteopenia, or osteoporosis.
3- Local oestrogen therapy is very useful with women who have a dry vagina and associated poor sexual life, and in fact it puts the smile back on their faces, and they can enjoy sexual pleasures for further years.
4- Women who have had a hysterectomy only need oestrogen alone and this has no increased risk of breast cancer.
5- In women who have a premature menopause, HRT is very essential until at least the normal age of menopause.
6- The recent trials suggest that the lowest dose of oestrogen should be used.
7- It is useful to use transdermal oestrogen( on the skin ) as it prevents vascular complications, eg: Deep venous Thrombosis.
8- The dose and duration of HRT and safety issues should be discussed in individual circumstances.
9- The use of custom-compounded bio identical hormone therapy is not recommended.
10-Current safety data do not support the use of HRT after breast cancer. If you have to have it then you need to have a detailed consultation with your Oncologist.
The other things we will need to discuss about menopause are, Anatomy and Physiology of Menopause, Assessment of Menopausal Women and current treatments available.
Wednesday, August 20, 2014
Wednesday, July 23, 2014
MENOPAUSE? MENOPAUSE? MENOPAUSE?
The above subject" Menopause" is going to be covered in a number of posts in the coming weeks. I hope you enjoy and learn something useful from them.
Part One:-
What is it? There is even a musical on menopause and I hope some of you have seen it and enjoyed it. I often wonder along with other scientific people is it a disease or just a phase in a woman's life. Woman's sex gland the ovary which you may have read in previous posts is quite magical, and it changes the face of our lives. We are like little girls, then as we grow we become pubertal, menstruation starts, we become fertile and a few years later fertility is taken away from us and even the periods disappear, and then we are called menopausal. The time before the period stops has varying activity in our body and it is called pre, peri, post menopausal. It generally takes up to seven years for us to stop the periods completely. In the past this referred to Climacteric (A Greek word meaning seven).
It is called menopause when we have no periods for twelve months after the last period.
Each women's experience is unique in their own way during this time, hence the diagnosis is difficult to make.
Menopause has suddenly become like an epidemic, but this is probably due to our increased life expectancy and our desire to be healthy and happy during our menopausal years.
In 1900 the average life expectancy of a woman was 50 years, which is a very short life span after menopause, as Aristotle estimated the age of menopause was 40 years, so we had hardly any years left to live after menopause, however now in the world, several million women join the menopause club each year.
According to the World Health Statistics a girl born in 2014 is expected to live for an average of 73 years. Japanese women live the longest. The divide between the rich and the poor countries is still there, and in the rich countries the women live 7 years longer, and this is because they have the access to all the modern medical facilities that the women in the poorer countries do not have.
Therefore it is not surprising that wherever you go, be it a luncheon, a dinner party, a function or any gathering, middle aged women in their forties discuss menopause, what is it,can it be prevented, what we need to do about it, what is the treatment for it, medical or natural.
A few years ago I went home to India where my mother's cook said to me "That she needs treatment for malaria, as she gets high temperature , and sweating, the treatment for malaria that the doctors are using is not helping me". Obviously she was menopausal having hot flashes and sweating which is the most common and distressing symptom of menopause. The modern treatment of HRT fixed her.
The attention paid to menopause is not new, as it started to be looked at in the 1930's by a French doctor who wrote one of the first books on menopause and he called it "The Problem as Menopause".
They called it the deficiency disease and they started to give extract of crushed ovaries and an extract from the amniotic fluid of cattle.
They also gave testicular extract and a product called Emmerin was prepared from pregnant women's urine and this was found to be useful.
In 1930 a German scientist Dr Zondek prepared an extract from the urine of a pregnant mare which was much cheaper than Emmerin and so it continued to be used.
Synthetic oestrogen was developed in 1938 and progesterone in 1937 and thus medicalization of menopause started.
Part One:-
What is it? There is even a musical on menopause and I hope some of you have seen it and enjoyed it. I often wonder along with other scientific people is it a disease or just a phase in a woman's life. Woman's sex gland the ovary which you may have read in previous posts is quite magical, and it changes the face of our lives. We are like little girls, then as we grow we become pubertal, menstruation starts, we become fertile and a few years later fertility is taken away from us and even the periods disappear, and then we are called menopausal. The time before the period stops has varying activity in our body and it is called pre, peri, post menopausal. It generally takes up to seven years for us to stop the periods completely. In the past this referred to Climacteric (A Greek word meaning seven).
It is called menopause when we have no periods for twelve months after the last period.
Each women's experience is unique in their own way during this time, hence the diagnosis is difficult to make.
Menopause has suddenly become like an epidemic, but this is probably due to our increased life expectancy and our desire to be healthy and happy during our menopausal years.
In 1900 the average life expectancy of a woman was 50 years, which is a very short life span after menopause, as Aristotle estimated the age of menopause was 40 years, so we had hardly any years left to live after menopause, however now in the world, several million women join the menopause club each year.
According to the World Health Statistics a girl born in 2014 is expected to live for an average of 73 years. Japanese women live the longest. The divide between the rich and the poor countries is still there, and in the rich countries the women live 7 years longer, and this is because they have the access to all the modern medical facilities that the women in the poorer countries do not have.
Therefore it is not surprising that wherever you go, be it a luncheon, a dinner party, a function or any gathering, middle aged women in their forties discuss menopause, what is it,can it be prevented, what we need to do about it, what is the treatment for it, medical or natural.
A few years ago I went home to India where my mother's cook said to me "That she needs treatment for malaria, as she gets high temperature , and sweating, the treatment for malaria that the doctors are using is not helping me". Obviously she was menopausal having hot flashes and sweating which is the most common and distressing symptom of menopause. The modern treatment of HRT fixed her.
The attention paid to menopause is not new, as it started to be looked at in the 1930's by a French doctor who wrote one of the first books on menopause and he called it "The Problem as Menopause".
They called it the deficiency disease and they started to give extract of crushed ovaries and an extract from the amniotic fluid of cattle.
They also gave testicular extract and a product called Emmerin was prepared from pregnant women's urine and this was found to be useful.
In 1930 a German scientist Dr Zondek prepared an extract from the urine of a pregnant mare which was much cheaper than Emmerin and so it continued to be used.
Synthetic oestrogen was developed in 1938 and progesterone in 1937 and thus medicalization of menopause started.
Wednesday, May 7, 2014
GESTATIONAL DIABETES MANAGEMENT GUIDELINES
In general terms gestational diabetes includes Type 1, Type 2 and Diabetes diagnosed for the first time during pregnancy. In further discussion we will focus mainly on GDM.
When women with type 1 and Type 2 want to get pregnant it is very important that their management starts pre-conception, and if by chance that this has been missed they require very vigilant pregnant management.
There is a higher risk of early pregnancy loss in diabetes therefore it is important to make sure their pregnancy is well controlled, it is good to have their weight controlled, with body mass index being between 25 and 28 (Weight divided by your height squared in meters).
It is also important to start on Folic acid .5mgm daily as it protects against neural tube defects(defects within the brain and spinal cord), confirmation of the diagnosis should be done by 75 grams oral test and described in our previous post. Around 28 weeks of pregnancy.
Patient education is very important and they should be taught what diabetes is and how to take care of it themselves.
This includes dietary therapy, exercise, and maintenance of their blood sugars.
There is some controversy among the medical fraternity as to the level of glucose. In Australia it has been confirmed that the fasting level of 5.3 mmol/L and two hour post meals maintain at 7. If this was done the results of pregnancy are very satisfactory. This means that the pregnancy can be carried full term and the delivery be normal as the baby will not be too big.
During the antepartum management a fetal surveillance is also essential, this will again help the pregnancy to be carried to term. Ultrasound for fetal well being and fetal heart monitoring on a weekly basis help to make sure that the baby is doing well and fetal weight can be assessed.
This is usually started around 32 to 34 weeks of pregnancy.
The main complications of diabetes during pregnancy are, increased risk of miscarriage, high blood pressure, toxemia of pregnancy and large babies more than 4.5 kilograms or more in weight.
This leads to difficult delivery and can cause trauma to the baby, stuck shoulder, injury to the nerves causing palsy, the most common of these is called Erbs Palsy, fractures to the babies bones, neonatal asphyxia, neonatal hypoglycemia and even still birth.
Sometimes the baby can be small due to growth retardation, this can be due to high blood pressure and this has its own problems.
Pregnancy with diabetes should always be managed by a group of professionals, including obstetrician, endocrinologist interested in pregnancy, diabetic advisers, pediatrician and other specialists as required, for example renal physician and ophthalmologist.
Renal and eye diseases can become more complicated during pregnancy if there due to diabetes.
Coming back to the management of gestational diabetes:
1 - Routine testing on all pregnant women is universally accepted in Australia
2 - Try and control GDM by altering the lifestyle factors with the help of a diabetic adviser, dietitian and physio therapy. The diabetic adviser helps them to learn how to test their blood sugars and administer insulin if required.
3 - They can continue on their oral diabeteic treatment such as metformin.
4 - In a small number of cases, about 40% need insulin. the insulin therapy is usually controlled by the endocrinologist, they usually use several doses of rapid acting insulin.
5 - If there are no other problems the delivery can be at term. It is best to induce so that the diabetes can be controlled during labour. Continuous fetal heart monitoring is done during labour. A caesarian section is performed when ever required the baby is distressed or the baby appears to be too big for the pelvis.
6 - At birth the baby is looked after by the pediatrician who monitors the baby's blood sugars are less than 2mmol/L. They are treated with intravenous glucose.
7 - The mothers with GDM do not require any treatment after 24 hours of delivery.
Impaired glucose tolerance test merits careful follow up, this includes a OGTT at 6 weeks and at least once a year. In some non European countries the incidence of diabetes can be as high as 62 percent once they were found to have GDM.
As mentioned in the earlier post , the offspring of these mothers are likely to develop chronic illnesses such as diabetes, heart disease and strokes.
One of the key points GDM has adverse affects for pregnancy outcome and long term problems to the women and children, it is debated that due to the high prevalence of GDM the universal testing is important, and the management of GDM improves maternal and fetal outcomes. The women with GDM should be tested every 12 months. The increased number of women with GDM (almost double normal) has implication for resource allocation. The other areas where research is required is the universal screening , what is the optimal criteria for diagnosis of GDM , the cost benefit of team approach, the follow up programs for mothers and their babies and are there any possible prevention of the spreading of diabetes in these mothers and their offspring.
When women with type 1 and Type 2 want to get pregnant it is very important that their management starts pre-conception, and if by chance that this has been missed they require very vigilant pregnant management.
There is a higher risk of early pregnancy loss in diabetes therefore it is important to make sure their pregnancy is well controlled, it is good to have their weight controlled, with body mass index being between 25 and 28 (Weight divided by your height squared in meters).
It is also important to start on Folic acid .5mgm daily as it protects against neural tube defects(defects within the brain and spinal cord), confirmation of the diagnosis should be done by 75 grams oral test and described in our previous post. Around 28 weeks of pregnancy.
Patient education is very important and they should be taught what diabetes is and how to take care of it themselves.
This includes dietary therapy, exercise, and maintenance of their blood sugars.
There is some controversy among the medical fraternity as to the level of glucose. In Australia it has been confirmed that the fasting level of 5.3 mmol/L and two hour post meals maintain at 7. If this was done the results of pregnancy are very satisfactory. This means that the pregnancy can be carried full term and the delivery be normal as the baby will not be too big.
During the antepartum management a fetal surveillance is also essential, this will again help the pregnancy to be carried to term. Ultrasound for fetal well being and fetal heart monitoring on a weekly basis help to make sure that the baby is doing well and fetal weight can be assessed.
This is usually started around 32 to 34 weeks of pregnancy.
The main complications of diabetes during pregnancy are, increased risk of miscarriage, high blood pressure, toxemia of pregnancy and large babies more than 4.5 kilograms or more in weight.
This leads to difficult delivery and can cause trauma to the baby, stuck shoulder, injury to the nerves causing palsy, the most common of these is called Erbs Palsy, fractures to the babies bones, neonatal asphyxia, neonatal hypoglycemia and even still birth.
Sometimes the baby can be small due to growth retardation, this can be due to high blood pressure and this has its own problems.
Pregnancy with diabetes should always be managed by a group of professionals, including obstetrician, endocrinologist interested in pregnancy, diabetic advisers, pediatrician and other specialists as required, for example renal physician and ophthalmologist.
Renal and eye diseases can become more complicated during pregnancy if there due to diabetes.
Coming back to the management of gestational diabetes:
1 - Routine testing on all pregnant women is universally accepted in Australia
2 - Try and control GDM by altering the lifestyle factors with the help of a diabetic adviser, dietitian and physio therapy. The diabetic adviser helps them to learn how to test their blood sugars and administer insulin if required.
3 - They can continue on their oral diabeteic treatment such as metformin.
4 - In a small number of cases, about 40% need insulin. the insulin therapy is usually controlled by the endocrinologist, they usually use several doses of rapid acting insulin.
5 - If there are no other problems the delivery can be at term. It is best to induce so that the diabetes can be controlled during labour. Continuous fetal heart monitoring is done during labour. A caesarian section is performed when ever required the baby is distressed or the baby appears to be too big for the pelvis.
6 - At birth the baby is looked after by the pediatrician who monitors the baby's blood sugars are less than 2mmol/L. They are treated with intravenous glucose.
7 - The mothers with GDM do not require any treatment after 24 hours of delivery.
Impaired glucose tolerance test merits careful follow up, this includes a OGTT at 6 weeks and at least once a year. In some non European countries the incidence of diabetes can be as high as 62 percent once they were found to have GDM.
As mentioned in the earlier post , the offspring of these mothers are likely to develop chronic illnesses such as diabetes, heart disease and strokes.
One of the key points GDM has adverse affects for pregnancy outcome and long term problems to the women and children, it is debated that due to the high prevalence of GDM the universal testing is important, and the management of GDM improves maternal and fetal outcomes. The women with GDM should be tested every 12 months. The increased number of women with GDM (almost double normal) has implication for resource allocation. The other areas where research is required is the universal screening , what is the optimal criteria for diagnosis of GDM , the cost benefit of team approach, the follow up programs for mothers and their babies and are there any possible prevention of the spreading of diabetes in these mothers and their offspring.
Monday, April 28, 2014
GESTATIONAL DIABETES
In this post I am drifting from gynecological topics to a common obstetrical problem known as Gestational Diabetes Mellitus, (GDM). I am sure that you are all familiar with the diabetic epidemic going around the world. Twenty years ago there were 20 Million diabetics in the world and now there are 240 million and if we do nothing there will be 340 million diabetics within the next 20 years. Diabetes is a long term multiorgan disease,can you imagine so many sick people wandering around the world.
What is the cause of diabetes being so popular? It is our lifestyle factors like sugary drinks and bad take away food, no activity or exercise.
Recently a Doctor David Baker from University of South Hampton ,UK has postulated a theory that the imprints of chronic diseases such as heart disease, diabetes and stroke are laid in utero they are born with this imprint. These babies are usually small in weight and premature. They generally become fat by two years of age with the wrong type of nutrition.
This theory appears to me, that During World Wars 1 and 2 young women were neglected nutritionally and so now the baby boomers are suffering with these chronic diseases. Modern society has to pay more attention to nutrition and activity, to prevent the spread of these chronic diseases.
Now going back to diabetes there are several types of diabetes such Type1, Type2, Gestational Diabetes Mellitus and they happen for different reasons. A pregnant mother can have any of these.
Diabetes Mellitus usually means that our body is unable to maintain a healthy blood glucose level.
A hormone in the body called insulin helps to make a balance in our blood sugar. The blood sugar goes high if there is not enough insulin for the body's health or the body doesn't utilize this insulin properly.
The insulin is produced by cells called Beta Cells which are located in the pancreas. In Type 1 diabetes it usually happens in childhood the beta cells are destroyed so they do not have insulin. These individuals require artificial insulin to maintain there blood glucose throughout their life.
They need careful management and can live a normal life and women can have a safe pregnancy if looked after properly.
The other diabetes is called Type 2 which starts later on in life, but these days young adults are starting to get these problems due to obesity and lifestyle. The beta cells still secrete insulin but usually it may not be enough or the body becomes resistant to insulin, however young women suffering from Type 2 diabetes can be looked after during pregnancy by strict medical management before, after and during the pregnancy.
Some women who are quite normal before getting pregnant develop diabetes during pregnancy, this is addressed as Gestational Diabetes. During pregnancy hormonal changes can make you less responsive to insulin. The increasing levels of placental lactogens and oestregens interfere with insulin function.
This increases until 28 weeks of pregnancy and generally the need for insulin is at its highest.
Recent studies show that diagnosis or management of GDM is beneficial for the mother and the baby and the next generation.
There is still some controversy about this screening program, many countries including Australia do screening for all pregnant women during pregnancy, there is some conflict if this should only be done in high risk women and secondly at what stage that this should be done.
I feel that it is worthwhile doing a fasting glucose of all women at the initial visit with their other blood tests, and if it is more than 5.5 then they can have the full test for diabetes called oral glucose tolerance test.(OGTT)
Some people like to do a full OGTT in high risks groups and these are:
1- Age over 40 plus
2- Obesity BMI more than 35
3- Family history of diabetes mellitus or GDM
4- Women from some countries ie: India, China, South Asia and Pacific Islanders (In Nauru 1/3 of the population is diabetic)
5- Poor obstetric history eg: previous still birth, repeated miscarriages, previous GDM
6- Previous birth of a baby weighing 4.5 Kilograms or more
7- Other genetic factors
8- Polycystic Ovarian Syndrome
9- Any medications like Cortisone
10-Anyone who has given birth to more than 5 children
Although there is no international agreement as yet on screening for GDM universally, however in Australia this is done on every pregnant patient at 24-28 weeks. The patients at high risk are often investigated early.
Initially we did a glucose challenge test which involved one hour blood glucose level after seventy five grams of glucose solution and if one hour glucose was more than 10 a full OGTT was done.
This glucose challenge test is no longer carried out or required.
OGTT is done after the patient has been fasting for 10 hours, a fasting glucose is done and then the patient is given 75 grams of glucose and two further blood samples are taken at 1 hour and 2 hours.
There is some controversy about these blood levels as well;
1-The fasting should be more or same as 5.1mml/litre (Some labs take this figure up to 5.8)
2-One hour 10mml/litre (Some labs do not take this sample)
3-Two Hours 8.5mml/litre ( Some labs take it less than 7.9)
You have to take into consideration the area you live in, the ethnic groups and the laboratories practice.
The risk and management of GDM will be discussed in the next post.
What is the cause of diabetes being so popular? It is our lifestyle factors like sugary drinks and bad take away food, no activity or exercise.
Recently a Doctor David Baker from University of South Hampton ,UK has postulated a theory that the imprints of chronic diseases such as heart disease, diabetes and stroke are laid in utero they are born with this imprint. These babies are usually small in weight and premature. They generally become fat by two years of age with the wrong type of nutrition.
This theory appears to me, that During World Wars 1 and 2 young women were neglected nutritionally and so now the baby boomers are suffering with these chronic diseases. Modern society has to pay more attention to nutrition and activity, to prevent the spread of these chronic diseases.
Now going back to diabetes there are several types of diabetes such Type1, Type2, Gestational Diabetes Mellitus and they happen for different reasons. A pregnant mother can have any of these.
Diabetes Mellitus usually means that our body is unable to maintain a healthy blood glucose level.
A hormone in the body called insulin helps to make a balance in our blood sugar. The blood sugar goes high if there is not enough insulin for the body's health or the body doesn't utilize this insulin properly.
The insulin is produced by cells called Beta Cells which are located in the pancreas. In Type 1 diabetes it usually happens in childhood the beta cells are destroyed so they do not have insulin. These individuals require artificial insulin to maintain there blood glucose throughout their life.
They need careful management and can live a normal life and women can have a safe pregnancy if looked after properly.
The other diabetes is called Type 2 which starts later on in life, but these days young adults are starting to get these problems due to obesity and lifestyle. The beta cells still secrete insulin but usually it may not be enough or the body becomes resistant to insulin, however young women suffering from Type 2 diabetes can be looked after during pregnancy by strict medical management before, after and during the pregnancy.
Some women who are quite normal before getting pregnant develop diabetes during pregnancy, this is addressed as Gestational Diabetes. During pregnancy hormonal changes can make you less responsive to insulin. The increasing levels of placental lactogens and oestregens interfere with insulin function.
This increases until 28 weeks of pregnancy and generally the need for insulin is at its highest.
Recent studies show that diagnosis or management of GDM is beneficial for the mother and the baby and the next generation.
There is still some controversy about this screening program, many countries including Australia do screening for all pregnant women during pregnancy, there is some conflict if this should only be done in high risk women and secondly at what stage that this should be done.
I feel that it is worthwhile doing a fasting glucose of all women at the initial visit with their other blood tests, and if it is more than 5.5 then they can have the full test for diabetes called oral glucose tolerance test.(OGTT)
Some people like to do a full OGTT in high risks groups and these are:
1- Age over 40 plus
2- Obesity BMI more than 35
3- Family history of diabetes mellitus or GDM
4- Women from some countries ie: India, China, South Asia and Pacific Islanders (In Nauru 1/3 of the population is diabetic)
5- Poor obstetric history eg: previous still birth, repeated miscarriages, previous GDM
6- Previous birth of a baby weighing 4.5 Kilograms or more
7- Other genetic factors
8- Polycystic Ovarian Syndrome
9- Any medications like Cortisone
10-Anyone who has given birth to more than 5 children
Although there is no international agreement as yet on screening for GDM universally, however in Australia this is done on every pregnant patient at 24-28 weeks. The patients at high risk are often investigated early.
Initially we did a glucose challenge test which involved one hour blood glucose level after seventy five grams of glucose solution and if one hour glucose was more than 10 a full OGTT was done.
This glucose challenge test is no longer carried out or required.
OGTT is done after the patient has been fasting for 10 hours, a fasting glucose is done and then the patient is given 75 grams of glucose and two further blood samples are taken at 1 hour and 2 hours.
There is some controversy about these blood levels as well;
1-The fasting should be more or same as 5.1mml/litre (Some labs take this figure up to 5.8)
2-One hour 10mml/litre (Some labs do not take this sample)
3-Two Hours 8.5mml/litre ( Some labs take it less than 7.9)
You have to take into consideration the area you live in, the ethnic groups and the laboratories practice.
The risk and management of GDM will be discussed in the next post.
Wednesday, March 19, 2014
SECONDARY AMENORRHEA-HYPERPROLACTINEMIA
One of the other common problems with periods is the rise in the hormones called prolactin. Prolactin is secreted by the pituitary gland which has a vital role in the reproductive function.
It is an essential factor for secretion of breast milk after child birth, it has a negative effect on the pituitary function, such as production of LH and FSH this we have discussed in the menstrual cycle.
An excess of prolactin is called Hyperprolactinemia , can be caused from some medications such as the drug used for underactive thyroid and the drug used for pituitary itself. Drugs used for mental disorders can also cause an increase in prolactin.
Increased levels of prolactin can be found in ten percent of the population. The women usually present with small periods , absent periods, infertility and galactorrhea (milk secretion from the breast).
Men can also get this problem with low gonadal function.
There is a complex physiological control of the pituitary prolactin secretion.
This includes many drugs and thyroid function.
One of the most important causes of increased prolactin is a pituitary tumour called Prolactinoma, they are usually benign. The thyroid underactivity also causes the increases in prolactin levels, there are several mechanisms which are involved however these are dealt with by an endocrinologist.
As gynaecologists we mainly deal with period problems and infertility.
To start with we should try and find out the cause of the increased prolactin level, asses their other medical history, drugs they are on and thyroid function.
The pituitary gland is located in the brain at the cross junction of the two optic nerves called optic chiasma.
When the pituitary gland is enlarged it puts pressure on the optic nerves and cause headaches, nausea, and disturbance in the visual field.
So this should be investigated by a CT or MRI if it is available. It is often a good idea to have the eyes checked by a good ophthalmologist.
If a prolactin level is not high and there is a macroadenoma (enlarged pituitary tumour) then it is often treated by an endocrinologist.
The drugs we commonly use for alleviated prolactin levels are Bromocriptin 50 to 100mgs used twice daily, this usually brings their periods back and helps them to get pregnant.
The other drug that is used, is called Dopamine Agonist and it is used once a week. It is often used when patients do not respond to Bromocriptin.
The surgery is only carried out if the prolactin level does not respond to drugs or pituitary macroadenoma is present or if their are any other tumours present in the surrounding area and this decision is taken by neurosurgeons.
This is a very simplified version of a condition called Hyperprolactinemia.
This mainly causes secondary amenorrhea and infertility in women, however it is easy to diagnose and treat, so do not despair, have yourself checked out if you have infrequent periods , no periods, infertility and milk secretion from the breast.
It is an essential factor for secretion of breast milk after child birth, it has a negative effect on the pituitary function, such as production of LH and FSH this we have discussed in the menstrual cycle.
An excess of prolactin is called Hyperprolactinemia , can be caused from some medications such as the drug used for underactive thyroid and the drug used for pituitary itself. Drugs used for mental disorders can also cause an increase in prolactin.
Increased levels of prolactin can be found in ten percent of the population. The women usually present with small periods , absent periods, infertility and galactorrhea (milk secretion from the breast).
Men can also get this problem with low gonadal function.
There is a complex physiological control of the pituitary prolactin secretion.
This includes many drugs and thyroid function.
One of the most important causes of increased prolactin is a pituitary tumour called Prolactinoma, they are usually benign. The thyroid underactivity also causes the increases in prolactin levels, there are several mechanisms which are involved however these are dealt with by an endocrinologist.
As gynaecologists we mainly deal with period problems and infertility.
To start with we should try and find out the cause of the increased prolactin level, asses their other medical history, drugs they are on and thyroid function.
The pituitary gland is located in the brain at the cross junction of the two optic nerves called optic chiasma.
When the pituitary gland is enlarged it puts pressure on the optic nerves and cause headaches, nausea, and disturbance in the visual field.
So this should be investigated by a CT or MRI if it is available. It is often a good idea to have the eyes checked by a good ophthalmologist.
If a prolactin level is not high and there is a macroadenoma (enlarged pituitary tumour) then it is often treated by an endocrinologist.
The drugs we commonly use for alleviated prolactin levels are Bromocriptin 50 to 100mgs used twice daily, this usually brings their periods back and helps them to get pregnant.
The other drug that is used, is called Dopamine Agonist and it is used once a week. It is often used when patients do not respond to Bromocriptin.
The surgery is only carried out if the prolactin level does not respond to drugs or pituitary macroadenoma is present or if their are any other tumours present in the surrounding area and this decision is taken by neurosurgeons.
This is a very simplified version of a condition called Hyperprolactinemia.
This mainly causes secondary amenorrhea and infertility in women, however it is easy to diagnose and treat, so do not despair, have yourself checked out if you have infrequent periods , no periods, infertility and milk secretion from the breast.
Wednesday, February 19, 2014
POLYCYSTIC OVARIAN SYNDROME
PCOS is one of the most complex disorders of modern society, about five to ten percent of the female population suffers from PCOS. In America there are five million women suffering from it.
In Madame Tussauds Wax museum in London in 1964 I saw a pair of wax figures of an elderly man and a women with long beards , somewhat obese and a child of about five years old standing in between them. This tells the major story of PCOS, obesity, hairiness(hirsutism) and infertility.
PCOS was first described in 1935 by two physicians Stein and Leventhal and therefore in days gone by it was often called Stein-Leventhal Syndrome.
In those days it was very rare and in my five years at medical school I saw about five cases. Now in my retirement fifty years later, I was seeing almost ten cases a week.
There is actually no international agreement as to what it should be called, but for the time being we have agreed to call it Polycystic Ovarian Syndrome all this is mainly due to failure of ovulation. This confusion is because there are many complex signs and symptoms of the disease and it is difficult to justify them by one explanation.
The main symptoms are irregular periods, obesity, hirsutism, hormone disturbances and polycystic ovaries. These women also suffer from infertility. If a women has no polycystic ovaries on ultrasound she could still be suffering from PCOS. The National Health Service in the United Kingdom estimates that one in five women has polycystic ovary on ultrasound but has no symptoms.
They are just labelled as Polycystic Ovaries.
PCOS is often referred to as a "Silent Killer" because the diagnosis is difficult and if left undiagnosed in women they develop massive obesity, insulin resistance, Type2 Diabetes, high cholesterol, heart disease, sleep apnoea, metabolic syndrome, gestational diabetes, increased risk of uterine and breast cancer.
PCOS the ovarian function is very disturbed because they do not produce hormones to trigger ovulation. The growth of the growing egg(The Follicle)stops in the middle and little cysts remain in the ovary filled with fluid and as a result they produce an excess of male hormones called androgens(Testosterone).There is an excess of oestrogens as well.
The ovary grows in size causing pain and failure to ovulate as a result the menstrual cycle stops.
Increase in testosterone causes hirsutism and also can result in a male type of baldness.
The diagnosis is usually made by symptoms of irregular periods, hairiness, acne, obesity and infertility. The investigations that are relevant are polycystic appearance of the ovary, and altered hormone studies.
Most experts around the world are not sure what causes PCOS however most feel that altered hormone levels probably play a key role along with Insulin Resistance and Obesity.
With insulin resistance they produce to much testosterone and this stops the development of the egg and with insulin resistance they become obese which makes PCOS worse.
In my personal experience I have found PCOS common in young girls who were obese and their parents had diabetes.
Diagnosing Polycystic Ovarian Syndrome includes:
1- Hormone Levels
2- Ultrasound Size of the Ovary and the number of follicles on the ovary
3-Test to exclude Diabetes
4-High Cholesterol levels
5-Thyroid Function
6-Prolactin is rarely raised causing irregular period
7-Rule out other causes such as pituitary and adrenal diseases
Management of PCOS
There is no definitive cure for PCOS, we only treat the symptoms.
This depends on the patients age and the main problems. It is best to have a multi specialist consultation including gynaecologist, endocrinologist, dietician, physiotherapist, psychologist, infertility expert and a dermatologist.
Treatment Options of PCOS
1-Multispeciality Consultation
2-Life style factors must be altered, this helps not only PCOS but also insulin resistance, metabolic syndrome and risk factors such as Type2 Diabetes, high cholesterol and so on.
3-Weight Loss, Weight Loss, Weight Loss cannot be over emphasised.
4-Exercise within your tolerance and capabilities. Ideally 150 minutes a week.
5-Contraceptive pills in younger women are useful, many of these newer pills contain anti-androgen hormones which helps with the acne and hairiness. Please discuss these with your doctor as some of these have a slightly increased risk of deep vein thrombosis.
6-There are anti-hormone medications that you can buy individually that act against testosterone. These take a few months to show the benefits.
7-Metformin(Glucophage) has a beneficial affect on your general health caused by insulin resistance. There are many other drugs in this group they are called Glitazone, but in Australia Metformin is commonly used. A combination of these drugs is also thought to be helpful.
8-Patient suffering from infertility in addition to lifestyle and weight loss need other drugs such as Clomiphene which is often used in conjunction with Metformin.
9-If Clomiphene fails to produce ovulation then we use special drugs called Gonadotrophins. These drugs increase risk of multiple pregnancies. Recent researchers have shown that a new drug called Letrozole works better, it has less side effects and the risk of multiple pregnancies is less.
10-Surgical treatment this consists of diathermy of the ovary and this helps with ovulation. If the Clomiphene has failed it works after the drilling of the ovary.
11-You require a curettage if you are having unexplained bleeding from the uterus this will tell us the cause of bleeding and what to do next.
12-Bariatric surgery of various types(Surgery to lose weight) is very useful, this should not be taken lightly as it has many complications and is very expensive. The simplest of this is gastric banding.
In conclusion PCOS is a manageable problem do not neglect it, if you look after yourself you will be happy and healthy. A long time ago when laparoscopy, ultrasounds and drilling of the ovaries was not available the surgeons performed what was called a wedge resection of the ovaries, this helped in a few cases of infertility. It suggests to me that the removal of the thick stromal tissue decreased excessive secretion of the hormone called luteinizing hormone and this helps ovulation.
As there is no definitive treatment for PCOS some of the researchers are trying to see if we can prevent it. Towards this a group of young girls aged between 8 and 12 suggesting signs of PCOS were given Metformin, they were restudied at 18 years of age, in the treated group there were only 5 percent who developed PCOS, whereas, in the untreated group 50 percent developed PCOS.
Hopefully after further study this may provide prevention of PCOS in some girls.
Follow the lifestyle factors, of losing weight, exercise, correct diet and see if you can live without the PCOS and the whole mess of endocrine problems that you have. It is just not the ovaries. We have not yet succeeded in untangling the whole complex web of these problems.
In Madame Tussauds Wax museum in London in 1964 I saw a pair of wax figures of an elderly man and a women with long beards , somewhat obese and a child of about five years old standing in between them. This tells the major story of PCOS, obesity, hairiness(hirsutism) and infertility.
PCOS was first described in 1935 by two physicians Stein and Leventhal and therefore in days gone by it was often called Stein-Leventhal Syndrome.
In those days it was very rare and in my five years at medical school I saw about five cases. Now in my retirement fifty years later, I was seeing almost ten cases a week.
There is actually no international agreement as to what it should be called, but for the time being we have agreed to call it Polycystic Ovarian Syndrome all this is mainly due to failure of ovulation. This confusion is because there are many complex signs and symptoms of the disease and it is difficult to justify them by one explanation.
The main symptoms are irregular periods, obesity, hirsutism, hormone disturbances and polycystic ovaries. These women also suffer from infertility. If a women has no polycystic ovaries on ultrasound she could still be suffering from PCOS. The National Health Service in the United Kingdom estimates that one in five women has polycystic ovary on ultrasound but has no symptoms.
They are just labelled as Polycystic Ovaries.
PCOS is often referred to as a "Silent Killer" because the diagnosis is difficult and if left undiagnosed in women they develop massive obesity, insulin resistance, Type2 Diabetes, high cholesterol, heart disease, sleep apnoea, metabolic syndrome, gestational diabetes, increased risk of uterine and breast cancer.
PCOS the ovarian function is very disturbed because they do not produce hormones to trigger ovulation. The growth of the growing egg(The Follicle)stops in the middle and little cysts remain in the ovary filled with fluid and as a result they produce an excess of male hormones called androgens(Testosterone).There is an excess of oestrogens as well.
The ovary grows in size causing pain and failure to ovulate as a result the menstrual cycle stops.
Increase in testosterone causes hirsutism and also can result in a male type of baldness.
The diagnosis is usually made by symptoms of irregular periods, hairiness, acne, obesity and infertility. The investigations that are relevant are polycystic appearance of the ovary, and altered hormone studies.
Most experts around the world are not sure what causes PCOS however most feel that altered hormone levels probably play a key role along with Insulin Resistance and Obesity.
With insulin resistance they produce to much testosterone and this stops the development of the egg and with insulin resistance they become obese which makes PCOS worse.
In my personal experience I have found PCOS common in young girls who were obese and their parents had diabetes.
Diagnosing Polycystic Ovarian Syndrome includes:
1- Hormone Levels
2- Ultrasound Size of the Ovary and the number of follicles on the ovary
3-Test to exclude Diabetes
4-High Cholesterol levels
5-Thyroid Function
6-Prolactin is rarely raised causing irregular period
7-Rule out other causes such as pituitary and adrenal diseases
Management of PCOS
There is no definitive cure for PCOS, we only treat the symptoms.
This depends on the patients age and the main problems. It is best to have a multi specialist consultation including gynaecologist, endocrinologist, dietician, physiotherapist, psychologist, infertility expert and a dermatologist.
Treatment Options of PCOS
1-Multispeciality Consultation
2-Life style factors must be altered, this helps not only PCOS but also insulin resistance, metabolic syndrome and risk factors such as Type2 Diabetes, high cholesterol and so on.
3-Weight Loss, Weight Loss, Weight Loss cannot be over emphasised.
4-Exercise within your tolerance and capabilities. Ideally 150 minutes a week.
5-Contraceptive pills in younger women are useful, many of these newer pills contain anti-androgen hormones which helps with the acne and hairiness. Please discuss these with your doctor as some of these have a slightly increased risk of deep vein thrombosis.
6-There are anti-hormone medications that you can buy individually that act against testosterone. These take a few months to show the benefits.
7-Metformin(Glucophage) has a beneficial affect on your general health caused by insulin resistance. There are many other drugs in this group they are called Glitazone, but in Australia Metformin is commonly used. A combination of these drugs is also thought to be helpful.
8-Patient suffering from infertility in addition to lifestyle and weight loss need other drugs such as Clomiphene which is often used in conjunction with Metformin.
9-If Clomiphene fails to produce ovulation then we use special drugs called Gonadotrophins. These drugs increase risk of multiple pregnancies. Recent researchers have shown that a new drug called Letrozole works better, it has less side effects and the risk of multiple pregnancies is less.
10-Surgical treatment this consists of diathermy of the ovary and this helps with ovulation. If the Clomiphene has failed it works after the drilling of the ovary.
11-You require a curettage if you are having unexplained bleeding from the uterus this will tell us the cause of bleeding and what to do next.
12-Bariatric surgery of various types(Surgery to lose weight) is very useful, this should not be taken lightly as it has many complications and is very expensive. The simplest of this is gastric banding.
In conclusion PCOS is a manageable problem do not neglect it, if you look after yourself you will be happy and healthy. A long time ago when laparoscopy, ultrasounds and drilling of the ovaries was not available the surgeons performed what was called a wedge resection of the ovaries, this helped in a few cases of infertility. It suggests to me that the removal of the thick stromal tissue decreased excessive secretion of the hormone called luteinizing hormone and this helps ovulation.
As there is no definitive treatment for PCOS some of the researchers are trying to see if we can prevent it. Towards this a group of young girls aged between 8 and 12 suggesting signs of PCOS were given Metformin, they were restudied at 18 years of age, in the treated group there were only 5 percent who developed PCOS, whereas, in the untreated group 50 percent developed PCOS.
Hopefully after further study this may provide prevention of PCOS in some girls.
Follow the lifestyle factors, of losing weight, exercise, correct diet and see if you can live without the PCOS and the whole mess of endocrine problems that you have. It is just not the ovaries. We have not yet succeeded in untangling the whole complex web of these problems.
Wednesday, February 5, 2014
SECONDARY AMENORRHOEA (SECONAMEN)
As we have seen in our previous posts, the female sex organ ovary responds to hormone messages from hypothalamus and pituitary glands, this cyclic function is called hypothalamic pituitary ovarian axis. This produces regular menstrual cycles, we have seen that sometimes these menstrual cycles never commence and this situation is called Primary Amenorrhoea, however when a woman has commenced her regular menstrual cycle and then she stops the cycle it is called Secondary Amenorrhea(seconamen).
There is also another word mixed with seconamen called oligomenorrhoea, this means that the periods are somewhat irregular and infrequent.
The two physiological causes of seconamen are pregnancy and menopause.
Doesn't matter how old or young a women is between the ages of twelve and fifty always make sure she is not pregnant. Many people consider seconamen only if they have missed two or three months, but I do not agree with that , I feel one should do a pregnancy test or see a clinician after six weeks especially if this is an unplanned pregnancy.
In my practising lifetime I have seen three females aged twelve, thirteen and fifty-one with unexpected pregnancy. The two young girls in fact had never had a period.
The twelve year old was a school girl who went for a picnic and perhaps became pregnant with her very first period, she had a very complicated pregnancy and she and her mother looked after the baby well.
The other person I saw was a thirteen year old girl who had no idea about menstruation or realities of life. She was left alone with her sixteen year old cousin and they had sex and when we saw her she was full term pregnant and in labour.
We delivered the baby and with the consent of the mother and other parties the baby was adopted.
The third person I saw was a fifty-one year old women who was in menopause transition.
It is important to continue contraception if you do not want to get pregnant in later years of your life for twelve to eighteen months when you have stopped having periods.
The other common causes of seconamen are
1- Obesity
2- Too Much Exercise
3-Losing too much weight as in sports women*
4-Anorexia
5-Anxiety and Stress (such as exams, new job, domestic problems and so on)
6-Drugs used to treat psychological disorders
7-Under Active and Over Active thyroid
8-Failing Hypothalmic Pituatary and Ovarian Axis
9-Pituitary Tumour - Prolactinoma
10-Polycystic Ovarian Syndrome
Generally the symptoms of seconamen are not very conspicuous despite the fact that you have not had a period. You may have some change in your moods, diet habits, nausea and vomiting if you are pregnant.
If that's the case you can do a home pregnancy test or go and see your GP.
Look into your weight, stress, anxiety, abnormal thyroid function, polycystic ovary syndrome as they can all affect your weight gain or loss.
*Losing too much weight by exercising has been documented to being a risk factor for seconamen , infertility and osteoporosis.
The three most important reasons for Secondary Amenorrhea to be discussed further are failing ovarian function, pituitary and hypothalamic function and polycystic ovarian syndrome.
I am sure you all know about PCOS which is the most discussed women's problem in modern society.
I will discuss these in my next post.
There is also another word mixed with seconamen called oligomenorrhoea, this means that the periods are somewhat irregular and infrequent.
The two physiological causes of seconamen are pregnancy and menopause.
Doesn't matter how old or young a women is between the ages of twelve and fifty always make sure she is not pregnant. Many people consider seconamen only if they have missed two or three months, but I do not agree with that , I feel one should do a pregnancy test or see a clinician after six weeks especially if this is an unplanned pregnancy.
In my practising lifetime I have seen three females aged twelve, thirteen and fifty-one with unexpected pregnancy. The two young girls in fact had never had a period.
The twelve year old was a school girl who went for a picnic and perhaps became pregnant with her very first period, she had a very complicated pregnancy and she and her mother looked after the baby well.
The other person I saw was a thirteen year old girl who had no idea about menstruation or realities of life. She was left alone with her sixteen year old cousin and they had sex and when we saw her she was full term pregnant and in labour.
We delivered the baby and with the consent of the mother and other parties the baby was adopted.
The third person I saw was a fifty-one year old women who was in menopause transition.
It is important to continue contraception if you do not want to get pregnant in later years of your life for twelve to eighteen months when you have stopped having periods.
The other common causes of seconamen are
1- Obesity
2- Too Much Exercise
3-Losing too much weight as in sports women*
4-Anorexia
5-Anxiety and Stress (such as exams, new job, domestic problems and so on)
6-Drugs used to treat psychological disorders
7-Under Active and Over Active thyroid
8-Failing Hypothalmic Pituatary and Ovarian Axis
9-Pituitary Tumour - Prolactinoma
10-Polycystic Ovarian Syndrome
Generally the symptoms of seconamen are not very conspicuous despite the fact that you have not had a period. You may have some change in your moods, diet habits, nausea and vomiting if you are pregnant.
If that's the case you can do a home pregnancy test or go and see your GP.
Look into your weight, stress, anxiety, abnormal thyroid function, polycystic ovary syndrome as they can all affect your weight gain or loss.
*Losing too much weight by exercising has been documented to being a risk factor for seconamen , infertility and osteoporosis.
The three most important reasons for Secondary Amenorrhea to be discussed further are failing ovarian function, pituitary and hypothalamic function and polycystic ovarian syndrome.
I am sure you all know about PCOS which is the most discussed women's problem in modern society.
I will discuss these in my next post.
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