Case endometriosis

Electively admitted for laparotomy cystectomy for bilateral endometriosis

Patient is married since 7 years ago. After 7 years practice of regular unprotected sexual intercourse (about 2-3 times per week), patient was still unable to get pregnant. Patient undergone intrauterine insemination (IUI) once in 2010 in Hospital Kuala Terengganu but failed.

Patient started taking medication from homeopathy since October 2011 for 3 months duration. During the period of time she noted there was a swelling in her abdomen which progressively increased in size from the initial size of egg. The swelling was painless, round in shape and occur at suprapubic area with firm consistency and non pulsatile. Otherwise no constipation, diarrhea, abdominal distension, abdominal pain, hematuria, dysuria, passing sandy urine, loin pain, fever, unable to pass urine.

Patient also noted that the period became longer and she bled more than usual. Previously she only had 7-9 days period but currently it went up to 11 days. The peak was also longer than usual ;from 3 days peak to 5 days. During peak she usually bled 5 pads fully soaked without clots and currently she used up to 7 pads fully soaked without blood clot.

Besides that she also experienced cramping abdominal pain during menses lasted for 1 day. She claimed that prior to this she also had the similar episodes of abdominal pain during menstrual period since menarche but it increased in severity after she got married.

Otherwise there was no history of intermenstrual bleeding, pervaginal bleed, deep dyspareunia, postcoital bleed.

She went to private clinic nearby her house and the scan was done. She was told by the dr that she had cyst and was referred to HUSM.

hypertension in pregnancy

position during descent

heart disease in pregnancy

PID-pelvic inflammatory disease

http://www.mdguidelines.com/pelvic-inflammatory-disease

Risk: 

·       having multiple sexual partners,

·       having sexual intercourse at a young age,

·       using an IUD,

·       smoking cigarettes.

Complications

·       infertility,

·       scarring or obstruction of the fallopian tubes,

·       chronic pelvic pain,

·       tubal pregnancy, and

·       spontaneous abortion.

History: 

·       fever,

·       foul-smelling vaginal discharge, 

·       pain in the lower abdomen,

·       pain with sexual intercourse (dyspareunia),

·       abnormal uterine bleeding, and

·       tenderness or pain in the uterus, affected ovary, or fallopian tube.

·       Some cases occur without symptoms (asymptomatic).

Physical exam: 

·       The uterus, ovary, or fallopian tube can be enlarged or tender on bimanual pelvic examination.

·       An oral temperature of greater than 101° F (38.3° C) is indicative of infection, along with the other signs of lower abdominal tenderness and abnormal vaginal discharge.

Tests: 

·       Swabs from the vagina and cervix are cultured to identify the infecting microorganism.

·       A microscopic examination of the tissues (histologic exam) from endometrial biopsy may be performed to test for evidence of endometritis. 

·       Laparoscopic examination may also reveal abnormalities consistent with PID.

·       A complete blood count (FBC) may be done to detect an elevated white blood cell count in the presence of infection. 

PCOS

PCOS

Common symptoms of PCOS include:

§  Menstrual disorders: PCOS mostly produces oligomenorrhea (few menstrual periods) or amenorrhea (no menstrual periods), but other types of menstrual disorders may also occur.^[7][8]

§  Infertility:^[8] This generally results directly from chronic anovulation (lack of ovulation).^[7]

§  High levels of masculinizing hormones: The most common signs are acne and hirsutism (male pattern of hair growth), but it may produce hypermenorrhea (very frequent menstrual periods) or other symptoms.^[9][7] Approximately three-quarters of patients with PCOS (by the diagnostic criteria of NIH/NICHD 1990) have evidence of hyperandrogenemia.^[10]

§  Metabolic syndrome:^[8] This appears as a tendency towards central obesity and other symptoms associated with insulin resistance.^[7] Serum insulin, insulin resistance and homocysteine levels are higher in women with PCOS.

incomplete version:

• menstrual cycle disturbances, 
• obesity, 
• hirsutism,
•  acne and 
• subfertility.

Rotterdam

In 2003 a consensus workshop sponsored by ESHRE/ASRM in Rotterdam indicated PCOS to be present if any 2 out of 3 criteria are met^[14]

1.     oligoovulation and/or anovulation

2.     excess androgen activity

3.     polycystic ovaries (by gynecologic ultrasound)

 

Standard diagnostic assessments

§  History-taking, specifically for menstrual pattern, obesity, hirsutism, and the absence of breast development. A clinical prediction rule found that these four questions can diagnose PCOS with asensitivity of 77.1% (95% confidence interval [CI] 62.7%–88.0%) and a specificity of 93.8% (95% CI 82.8%–98.7%).^[18]

§  Gynecologic ultrasonography, specifically looking for small ovarian follicles. These are believed to be the result of disturbed ovarian function with failed ovulation, reflected by the infrequent or absent menstruation that is typical of the condition. In a normal menstrual cycle, one egg is released from a dominant follicle – essentially a cyst that bursts to release the egg. After ovulation the follicle remnant is transformed into a progesterone-producing corpus luteum, which shrinks and disappears after approximately 12–14 days. In PCOS, there is a so called "follicular arrest", i.e., several follicles develop to a size of 5–7 mm, but not further. No single follicle reaches the preovulatory size (16 mm or more). According to the Rotterdam criteria, 12 or more small follicles should be seen in an ovary on ultrasound examination.^[13] The follicles may be oriented in the periphery, giving the appearance of a 'string of pearls'. The numerous follicles contribute to the increased size of the ovaries, that is, 1.5 to 3 times larger than normal.^{[citation needed]}

§  Laparoscopic examination may reveal a thickened, smooth, pearl-white outer surface of the ovary. (This would usually be an incidental finding if laparoscopy were performed for some other reason, as it would not be routine to examine the ovaries in this way to confirm a diagnosis of PCOS.)^{[citation needed]}

§  Serum (blood) levels of androgens (male hormones), including androstenedione and testosterone may be elevated.^[7] Dehydroepiandrosterone sulfate levels above 700-800mcg/dL are highly suggestive of adrenal dysfunction because DHEA-S is made exclusively by the adrenal glands.^[19][20] The free testosterone level is thought to be the best measure,^[20][21] with ~60% of PCOS patients demonstrating supranormal levels.^[10] The Free androgen index of the ratio of testosterone to sex hormone-binding globulin (SHBG) is high^[7][20] and is meant to be a predictor of free testosterone, but is a poor parameter for this and is no better than testosterone alone as a marker for PCOS,^[22] possibly because FAI is correlated with the degree of obesity.^[23]

§  Some other blood tests are suggestive but not diagnostic. The ratio of LH (Luteinizing hormone) to FSH (Follicle stimulating hormone) is greater than 1:1 (sometimes more than 3:1),^[20] as tested on Day 3 of the menstrual cycle. The pattern is not very specific and was present in less than 50% in one study.^[24] There are often low levels of sex hormone binding globulin,^[20] particularly among obese or overweight women.^{[citation needed]}

http://en.wikipedia.org/wiki/Androgen

http://en.wikipedia.org/wiki/Polycystic_ovary_syndrome

 diagnosis - tenteachers
The diagnosis is based on the biochemical
abnormalities 

• (low sex hormone-binding globulin concentrations and 
• high androgen concentrations)
• and the ultrasound appearance of the ovaries (an enlarged ovary with multiple subcapsular follicles and a dense stroma; 

IUCD

IUCD

What?

The intrauterine device (IUD) is a form of birth control; it is an object placed in the uterus to prevent pregnancy.^[1] 

Types?

Among modern IUDs, the two types available are copper-containing devices, and a hormone-containing device that releases a progestogen.

Currently, there are over 10 different kinds of copper IUD available in different parts of the world, and there is one hormonal device, called Mirena.

Copper IUCD

·       Copper IUDs work by impairing the mobility of sperm and preventing them from joining with an egg.

·       Additionally, the foreign body irritates the lining and wall of the uterus making it hard for an embryo to implant.^[5]

Hormonal IUCD

·       The hormonal I.U.D. (brand name Mirena) does not increase bleeding as copper-containing IUDs do.

·       Rather, they reduce menstrual bleeding or prevent menstruation altogether, and can be used as a treatment for menorrhagia (heavy periods).

·       Although use of the Mirena results in much lower systemic progestogen levels than other very-low-dose progestogen-only hormonal contraceptives, they might possibly have some of the same side effects.

mirena