Doctor D's Women's Health Corner

UP COMING - FROM MY CONTRIBUTOR:

2010-12-03T04:04:00.003-06:00

Child Soldiers in Somali Armies-

did you know they existed? Did you know that many of them are young girls? Don't want to give anything away, but please stay tuned for this interesting piece from Laine Strutton, my contributor.

Uterine Fibroids- Conclusion

2010-10-17T14:11:00.004-05:00

Management

Observation-
Regardless of their size, asymptomatic leiomyomas usually can be managed expectantly by annual pelvic exam.

Drug Therapy-
Pain medication for dysmenorrhea (painful periods) include NSAIDS such as Ibuprofen

Hormonal Therapy-
There are a myriad of medications that your doctor can use with the goal of shrinking the leiomyomas by targeting the growth effects of estrogen and progesterone. These include using substances that act similar to or against hormones that are naturally released from your hypothalamus.

Uterine Artery Embolization-
This is an angiographic interventional procedure that delivers polyvinyl alcohol (PVA) microspheres or other particulate emboli into both uterine arteries. Uterine blood flow is therefore obstructed, producing tissue death. Because vessels serving the fibroids have a larger caliber, these microspheres are preferentially directed to the tumors, sparing the surrounding uterine muscle.
Why else does the uterus survive? Because unlike the fibroids, the uterus also gets some blood supply from other smaller blood vessels.

Myomectomy-
Removal of a fibroid from the uterus is an option for women who are having symptoms but who desire to still bear a child in the future. or for those who do not want a hysterectomy. This can be performed in different ways.

*** Note: If the actual cavity of the uterus had to be invaded in order to get the fibroid out, then the woman has to have a cesarean section with her future pregnancy due to the risk of the uterus tearing during the contractions of labor, along that scar.
There is also the risk that the fibroids will return in the future.

Hysterectomy-
Removal of the entire uterus is the definitive and most common surgical treatment for leiomyomas. Hysterectomy can be performed vaginally, through the opened abdomen, or using small ports in the abdominal wall through which the uterus will pass.

Uterine fibroids is a common occurrence among women, with larger numbers in the African American women's population. There are many different types of fibroids, based on their location within and/or on the uterus. They can cause symptoms such as heavy bleeding, pelvic pain or discomfort, or even hamper fertility. But what is important to know, is that there are many options for the management of these benign tumors. If you or a loved one have been experiencing symptoms that lead you to suspect uterine fibroids, consult your Gynecologist for further investigation and treatment. Remember, due to risks involved with any surgical procedure, even if you incidentally discover that you have uterine fibroids, as long as the fibroid is not bugging you, don't bug the fibroid!

Uterine Fibroids Part One

2010-10-02T18:04:00.008-05:00

Leiomyomas are benign smooth muscle neoplasms that typically originate from the myometrium*
~They are often referred to as uterine myomas, and are incorrectly called fibroids because the considerable amount of collagen contained in many of them creates a fibrous consistency.
~Their incidence among women is generally cited as 20 to 25 percent, but has been shown to be as high as 70-80% in studies using histologic or sonographic examination.
~In many women, leiomyomas are clinically insignificant. Conversely, in some, their number, size or location within the uterus can provoke a myriad of symptoms.

Grossly, leiomyomas are round, pearly white, firm, rubbery tumors that on cut-surface display a whorled pattern

Uterine leiomyomas are estrogen- and progesterone-sensitive tumors. Consequently, they develop during the reproductive years and regress in size and incidence after menopause.

There are a number of conditions associated with increased estrogen production that encourage leiomyoma formation
---for example, the increased years of estrogen exposure found with early menarche*and with an increased body mass index (BMI) are each linked with a greater risk of leiomyomas.
---Obese women produce more estrogens due to increased production of estrogens in their fat tissue as well as a decreased ability of the liver to produce proteins that bind to sex hormones.

Because pregnancy is a progesterone- dominant state, it should provide an interlude from chronic estrogen exposure, and intuitively at least, should discourage leiomyoma development.
~In support of this, women giving birth at an early age, those with higher parity*, and those with a more recent pregnancy all display lower incidences of leiomyoma formation.

In premenopausal women, estrogen and progesterone hormone treatment probably has no inductive effect on leiomyoma formation. With few exceptions, oral contraceptive combination pills either lower or have no effect on this risk

Risk Factors

~During the reproductive years, the incidence of this tumor increases with age. After menopause, leiomyomas generally shrink in size and new tumor development is uncommon. Thus, it seems that most risk or protective factors depend on circumstances that chronically alter estrogen or progesterone levels or both.
~ Leiomyomas are common in African-American women compared with Caucasian, Asian, or Hispanic women.

Classification

Leiomyomas are classified based on their location and direction of growth

Symptoms
Most women with leiomyomas are asymptomatic. However, symptomatic patients typically complain of bleeding, pain, pressure sensation, or infertility. In general, the larger the leiomyoma, the greater the likelihood of symptoms.

Bleeding

This is the most common symptom and usually presents as menorrhagia*. The presence of the fibroids exert pressure on the venous system of the uterus, causing venous dilatation within the muscle and inner lining of the uterus, thus making it prone to heavier bleeding.

Pelvic Discomfort and Dysmenorrhea*

A sufficiently enlarged uterus can cause pressure sensation, urinary frequency, incontinence, and constipation. Rarely, leiomyomas extend laterally to compress the ureter (the structure that drains urine from each kidney and empties it into the bladder) and lead to obstruction and hydronephrosis *

Infertility and Pregnancy Wastage

Although the mechanisms are not clear, leiomyomas can be associated with infertility. It is estimated that 2-3% of infertility cases are due soley to leiomyomas. Their detrimental effects include occlusion of the openings that lead to each fallopian tube, and disruption of the normal uterine contractions that propel sperm or ova. Distortion of the uterine cavity may diminish implantation and sperm transport. Importantly, leiomyomas are associated with endometrial inflammation and vascular changes that may disrupt implantation.

On the next post....
So how are fibroids diagnosed, and what can be done about this common issue that many women face?

*******
Myometrium: middle layer of uterine wall consisting of smooth muscle cells and supporting stromal and vascular tissue
Menarche: the very first menstrual cycle that a human female experiences
Parity: The number of times a woman has given birth
Menorrhagia: abnormally heavy and prolonged menstrual period at regular intervals
Dysmenorrhea: severe uterine pain during menstruation
Hydronephrosis: distension and dilation of the kidney, usually due to obstruction of the outflow tract

Schorge JO, Schaffer JI, Halvorson LM, Hoffman BL, Bradshaw KD, Cunningham FG, "Chapter 9. Pelvic Mass" (Chapter). Schorge JO, Schaffer JI, Halvorson LM, Hoffman BL, Bradshaw KD, Cunningham FG: Williams Gynecology: http://www.accessmedicine.com/content.aspx?aID=3153525.

Side note on an old subject

2010-02-20T08:16:00.002-06:00

To compare male circumcisions with female clitorectomy demonstrates an ignorance of the human body and how it works. Embryologically, the clitoris is the analogous body part to the penis. It becomes engorged during sexual arousal and needs to be stimulated in order for a woman to have an orgasm, and to become lubricated enough to have safe and pleasurable intercourse. Penetration alone does not a climax make- something that most men fail to realize. In essence, removing the clitoris of a woman is the same as cutting off the entire penis, not just the skin around it. Please understand that. This is why sexual enjoyment and arousal are stunted for a woman who has had their clitoris removed. The tools simply are not there. Its like asking a man to have and enjoy the act of sexual intercourse without using his penis. Kind of a tall order.

In response to a Post Comment

2009-06-30T15:09:00.003-05:00

"The thing that I find interesting is how incensed people are about female genital cutting---yet male genital cutting is viewed by many as totally ok since it doesn't technically interfere with sexual relations, etc. Regardless, I think society holds a double-standard."

Male circumcisions do have cosmetic benefits but they also have health benefits too:

1. Some boys will suffer from a condition called Phimosis, in which the foreskin can not be pushed backward far enough to permit urination, proper cleaning of the penis, and can also become a problem called Paraphimosis in which, during sexual intercourse, the tight foreskin makes it back past the head of the penis (glans penis) and gets stuck there, unable to go back forward, thus cutting off circulation to the penis and to the skin itself- a very painful experience that requires immediate circumcision

2. Boys who are not properly educated by their parents as to how to properly clean around the head of the penis, under the foreskin, accumulate a cheesy foul smelling substance called Smegma. This strongly predisposes the man to penile cancer. Also, if they have phimosis, then there is definitely no way that they can clean the smegma even if they wanted to.

3. Sexually transmitted diseases are easier transmitted and carried in an uncircumcised man due to more vascular surface area and more "nooks and crannies" for things to be harbored.

I do not care whether a man in circumcised or uncircumcised, as long as they are not suffering from any issues and have good hygiene.

I personally think that it is my patients' choice as to whether or not they want to circ their sons. I do advise them however of the pros and cons. If there is an adequate opening i.e. enough foreskin, then it is mostly personal preference that governs the decision to remove the foreskin or not. There are cultural, religious and social factors that come into play. If they choose not to, then its fine with me, but I do encourage the parents to teach proper hygiene techniques to their son from a young age, to prevent some of the above mentioned issues.

If there is Phimosis, usually even if the moms decide not to circ their son, sooner rather than later they end up coming back to us because of issues with urinating etc. In that case, it would be much better to have the procedure done as a baby and not as a 5 yr old who would be more cognizant of and traumatized by the experience.

Female Genital Cutting, serves no health benefit. As a matter of fact, it puts the women in a constant uphill battle with their health for the rest of their lives. I do not believe that circumcisions on men and FGC are analogous.

My two cents on the subject

2009-06-29T10:18:00.003-05:00

Female Genital Cutting has always incensed me, as do any women's rights violations. These women do not feel pleasure during intercourse not only because they no longer have a clitoris, but because depending on the degree of the procedure, the vaginal opening can be barely large enough to fit the tip of a pinky through, and so intercourse is often very painful and results in tearing and bleeding and therefore very frequent infections. Other issues arise during childbirth. Some women will allow their vaginas to be cut open so that they can deliver the baby easily, and other women refuse such interventions, which as you can only imagine, results in very bloody and greusome childbirths.

In the recent years, when men of the societies involved have been asked about how they feel having a wife who has undergone FGC, it has become more and more common to hear them say that they are not fond of it either, for the same reasons as above. Many of the men want to know that they are pleasing their wives. This is a tradition that although has some patriarchal roots, is definitely reinforced and upheld by the women in the society.

I can put some pictures up if you would like to see them.

Female Genital Cutting throughout Sub-Saharan Africa

2009-06-29T09:57:00.005-05:00

Female Genital Cutting (FGC) is a traditional form of body mutilation practiced throughout western, north central, and northeastern Africa. Also known as female circumcision, it can be defined as a wide range of practices involving the partial or total alteration or removal of the external genitalia for non medical reasons.

There are four recognized types of FGC. Type I is a “clitoridectomy” that is an excision of the prepuce* and Type II is an “excision” that includes removal of the prepuce, clitoris, and potentially the labia minora. More severe, Type III is called “infibulation” and it is the removal of all outer genitalia and stitching of the vaginal opening. The most drastic form is Type IV is considered “unclassified” as it includes all of the above, plus burning, piercing, pricking, or stretching of the genitalia.

The health problems that arrive from the procedure are too numerous to count, but they include uncontrolled bleeding, infection of the cuts, fistulae, and life-threatening complications during childbirth.

Although there has been a plethora of technical information on the practice since it was brought to the fore of international human rights discourse, it is actually little understood for its cultural entrenchment. We do know that the operation is performed generally

before or around puberty. There is intense social stigma for those adult girls who have not undergone genital cutting, which interferes with their abilities to have their own families. Therefore, many parents insist on FGC because they believe it will make the girls less

promiscuous and therefore better wives to potential husbands. On a continent where a daughter is often viewed as an economic burden, FGC is mainly practiced in impoverished rural areas to ensure that the daughter does not remain at home unmarried.

Although the practice spans all religions in Africa, it is commonly associated with Islam

and the most severe form of FGC is practiced in countries with a Muslim majority, such as Somalia and Sudan.

Public awareness campaigns were first prevalent internationally, and those campaigns only later became localized. The most well-known film about FGC is Alice Walker and Pratibha Parmar’s 1993 British film Warrior Marks. It internationally convinced large numbers of people that a highly damaging, oppressive ‘ritual’ was being inflicted without reflection, based on patriarchy and lack of education. The goal of the filmmaker was to galvanize a global movement against the practice. A year earlier, the Inter-American Committee had produced a film on Nigeria called Female Circumcision: Beliefs and Misbeliefs. It depicts how FGC can be done even on a three-year old through decorative scarification and tattooing by a male barber. This film weakened the cultural argument that the ritual is solely helping young women make the transition into womanhood. Contrary to Warrior marks, Beliefs and Misbeliefs was actually intended for African audiences as an education tool. It includes spoken language and subtitles in various indigenous languages and includes culturally-pertinent images related to FGC. Interestingly, when this film was screened by a health worker to groups of women, the health worker had the chance to clarify certain misconceptions of audience members about health. For example, she debunked the myth that if the clitoris touches the baby’s head during labor, the baby will die. The screening led to a great discussion about other violations of women, such as early marriage.

Perhaps the spread of technical health education coupled with culturally-relevant media is the key to mitigating the harm caused by female genital mutilation.

written by Laine Strutton

*prepuce is a retractable piece of skin which covers part of the genitals of primates and other mammals.

On a male, this covers the head of the penis (glans penis).

On a female, it surrounds and protects the head of the clitoris (glans clitoridis).

Sources:

Gruenbaum, E. (2001). The female circumcision controversy: An

anthropological perspective. Philadelphia: Philadelphia: University of

Pennsylvania Press.

Shell-Duncan, B., & Hernlund, Y. (2000). In Shell-Duncan B., Hernlund

Y. (Eds.), Female "circumcision" in Africa : Culture, controversy, and

change. Boulder: Lynne Rienner Publishers.

Rahman, A., & Toubia, N. (2000). In Center for Reproductive Law &

Policy, RAINBO (Organization) (Eds.), Female genital mutilation: A

guide to laws and policies worldwide. London ; New York: Zed Books in

association with Center for Reproductive Law and Policy and Research,

Action and Information Network for the Bodily Integrity of Women.

The World Health Organization's website,

<http://www.who.int/gender/other_health/en/index.html>.

2009-06-23T21:33:00.002-05:00

Sorry for the long hiatus from this blog. If you've read my regular blog, you would know that this last month has been one of hectic transition for me. I hope to put the Female Genital Cutting post up this weekend and then hopefully add to the blog at least every 2-3 weeks. This first year of residency training will either prove to power my Women's Health Corner or overshadow it. I hope and pray that I am able to do both and give each of my posts the time and effort that they deserve. Thanks for your patience.

Human Papilloma Virus

2009-05-14T15:09:00.010-05:00

When many think of Human Papilloma Virus (HPV),the first thing that comes to mind now a days is the alarming link between HPV infection and the development of cervical cancer.
What is even more scary, is that both men and women can be carriers of this virus and not ever know it. But, what is less commonly known is that there are symptomatic manifestations of HPV infection as well.

There are different types of HPV. HPV types are often referred to as “low-risk” (wart-causing) or “high-risk” (cancer-causing), based on whether they put a person at risk for cancer. In 90% of cases, the body’s immune system clears the HPV infection naturally within two years. This is true of both high-risk and low-risk types. For example, HPV type 1 causes plantar warts. HPV type 6 causes anogenital warts and HPV type 16 infection can produce abnormal cervical cell changes, a process called Dysplasia. These dysplastic cells can then progress to becoming cervical cancer.

The clinical manifestations of HPV infection depend on the location of the lesion and the type of the virus.

Common warts usually occur on the hands as flesh colored to brown lesions that are raised above the skin (exophytic) and are thicker than skin in texture (hyperkeratotic).

Plantar warts may be quite painful. They look a bit like calluses, but have thrombosed capillaries underneath

Flat warts (verruca plana) are most common among children and occur on the face, neck, chest and flexor surfaces of the forearms and legs.

Anogenital warts usually appear as small bumps or groups of bumps, usually in the genital area. They can be raised or flat, single or multiple, small or large, and sometimes cauliflower shaped. They can appear on the vulva, in or around the vagina or anus, on the cervix, and on the penis, scrotum, groin, or thigh. Warts may appear within weeks or months after sexual contact with an infected person. Or, they may not appear at all. If left untreated, genital warts may go away, remain unchanged, or increase in size or number.They will not turn into cancer.

-Genital HPV is contracted through genital contact, most often during genital and anal sex. A person can have HPV even if its been years since he or she has had sex. Most infected people do not realize that they are infected or that they are passing the virus to a sex partner.
- Very rarely, a pregnant woman with genital HPV can pass HPV to her baby during vaginal delivery. In these cases, the child may develop warts in the throat or voice box- a condition called Recurrent Respiratory Papillomatosis (RRP)

-There are no symptoms for cervical cancer until it's reached its later stages, so it is very important that all women from age 21 or no later than one year after their first sexual intercourse, should have yearly PAP smears so that any abnormal cells can be identified and further examined for any existence of HPV.

-Other less common HPV-related cancers, such as cancers of the vulva, vagina, anus and penis, also may not have signs or symptoms until they are advanced.

-An HPV DNA test, which can find high-risk HPV on a woman’s cervix, may also be used with a Pap test in certain cases. The HPV test can help healthcare professionals decide if more tests or treatment are needed.

There is a vaccine available called Gardasil, which protects against HPV types 6,11,16 and 18. It is administered in three doses and is a recommended vaccination for females 11-12 years of age; catch-up vaccination is recommended for females 13-26 years of age. It is best to have received the vaccine before becoming sexually active so that there is optimal chance of preventing acquiring genital warts and cervical and vaginal cancers.

(I am not personally endorsing Gardasil, just presenting all that is available. It is a personal choice that parents have to make for their young girls)

-Even women who got the vaccine when they were younger need regular cervical cancer screening because the vaccine does not protect against all cervical cancers.There is currently no vaccine licensed to prevent HPV-related diseases in males.

While it can be difficult to prevent coming into contact with all of the types of HPV, genital HPV and all of its consequences can be easily averted by abstinence from sex, always using barrier methods such as condoms, and being honest about you and your partner's sexual history. Keep in mind though, that apart from abstinence, there is no method with 100% guarantee that you won't become symptomatically infected, or a carrier of the virus. This is because a condom only covers the penis, leaving other parts of the genitalia that can carry the virus, and unless men have had a genital wart episode, they may never know that they are infected.

Post Partum Psychological disorders

2009-04-20T07:00:00.001-05:00

Although pregnancy and childbirth are usually joyous times, for some women the experience is followed by significant emotional distress. Approximately 25% of women with previous postpartum mental disease have a recurrence after their next pregnancy. One-third of women with psychiatric illness during the postpartum period have a history of psychiatric disease.

The exact cause of most of the postpartum emotional changes is unknown, although suggested causes include changing hormone levels (as is seen with premenstrual changes), difficulty adjusting to a new lifestyle, and the stresses of parenthood.

Depression after childbirth has largely been divided into three categories:

Postpartum Blues
Postpartum Depression (ppd)
Postpartum Psychosis

Postpartum Blues

This transient state of heightened emotional reactivity can develop in 50-80% of women.

Onset is 2-14 days after childbirth, with peak being at about the 4th day and duration of less than 2 weeks.

Symptoms include:

Mild insomnia
Tearfulness
Fatigue
Poor concentration
Depressed affect(emotion)

Treatment:

Blues generally require no intervention. Rest and social support contribute significantly to remission. However, postpartum blues do constitute a significant risk factor for subsequent depression during the postpartum period- in 20%

Postpartum Depression

Any depression developing within 12 months following childbirth is considered to have postpartum onset. About 10-15% of postpartum women suffer from this.

Average duration is 3-14 months

To be diagnosed with ppd, one must exhibit 5 or more of the following symptoms, including one of the first 2, for most of the past 2 weeks:

Depressed mood- tearfulness, hopelessness, feeling empty inside with or without severe anxiety
Loss of pleasure in either all or almost all of daily activities
Appetite and weight changes- usually a decrease in appetite and weight, but sometimes the opposite
Sleep problems-trouble sleeping even when the baby is sleeping
Noticeable change in how you walk and talk- restlessness but sometimes sluggishness
Extreme fatigue or loss of energy
Feelings of worthlessness or guilt with no reasonable cause
Difficulty concentrating and making decisions
Thoughts about death or suicide. Some women with ppd have fleeting, frightening thoughts of harming their babies. These thoughts tend to be fearful thoughts, rather than urges to harm

Treatment consists of :

Antidepressant pharmacotherapy -The first line agent right now is Selective-serotonin reuptake inhibitors (SSRIs), although caution is necessary in breast feeding mothers.
Psychotherapy- Cognitive-behavioral therapy and group therapy have had the most significant effects.
Support groups nationwide

Postpartum Psychosis

This severe condition is most likely to affect women with bipolar disorder or a history of postpartum psychosis. Affects less than 2% of postpartum women

Symptoms, which usually develop during the first 3 postpartum weeks (as soon as 1 to 2 days after childbirth), include:

Feeling removed from your baby, other people, and your surroundings (depersonalization).
Disturbed sleep, even when your baby is sleeping.
Extremely confused and disorganized thinking, increasing your risk of harming yourself, your baby, or another person.
Drastically changing moods and bizarre behavior.
Extreme agitation or restlessness.
Unusual hallucinations*, often involving sight, smell, hearing, or touch.
Delusional* thinking that isn't based in reality.

Postpartum psychosis is considered an emergency requiring immediate medical treatment (Antipsychotic pharmacotherapy and antidepressants). If you have any psychotic symptoms, seek emergency help immediately. Until you tell your doctor and get treatment, you are at high risk of suddenly harming yourself or your baby.

*A hallucination is a perception of something that is not really there.

A hallucination can involve any of the senses: hearing, sight, smell, taste, or touch.
The most common hallucinations are seeing (visual) and hearing (auditory) things. For example, the person may hear voices or see an object that other people do not see.
Other types of hallucinations include tasting (gustatory), smelling (olfactory), or feeling (tactile) something that is not there.
Treatment for hallucinations depends on the cause.

*Delusions are firmly held but false beliefs. The most common delusion people have is that someone is trying to steal from them.

Technical difficulties

2009-04-18T18:58:00.001-05:00

I appologize if my last post on the Reproductive cycle looked kinda weird. On my computer screen it looked fine. It was not until using my sister-in-law's computer that I realized that the words were getting bigger and bigger and wacky different fonts etc. I had to re-do the post and it looks better as of right now. Please let me know if it still looks strange.
Thanks
Dionne

The Female Reproductive Cycle- A Dynamic Monthly Undertaking

2009-04-15T15:46:00.023-05:00

E2= estradiol LH=Luteinizing hormone P=progesterone FSH=Follicle Stimulating Hormone

Basically, the reproductive cycle is divided into three phases:

Menstruation and the follicular phase
Ovulation
Luteal phase

These three phases refer to the status of the ovary during the reproductive cycle.

Key Players:

GnRH-Gonadotropin releasing hormone- is released from the hypothalamus in a pulsatile fashion, stimulating the anterior pituitary gland to secrete LH and FSH accordingly.
FSH- follicle stimuating hormone- secreted pulsatiley from the anterior pituitary. Stimulates cells in the ovaries called granulosa cells.In charge of developing and maturing follicles in the ovary, one of which will become dominant and detach from the egg during ovulation. The granulosa cells is where estradiol (estrogen) is made.
LH- Luteinizing hormone- secreted pulsatiley from the anterior pituitary. Stimulates cells in the ovaries called theca cells. The surge of LH at the middle of the cycle is what triggers ovulation. The theca cells surround the granulosa cells. They secrete androgens which serve as precursors for the estradiol production by the granulosa cells.
Estradiol - Secreted by the ovaries. In the female, estradiol acts as a growth hormone for tissue of the reproductive organs, supporting the lining of the vagina, the cervical glands, the endometrium and the lining of the fallopian tubes. It enhances growth of the myometrium ( the muscle of the uterus). Estradiol appears necessary to maintain oocytes in the ovary. During the menstrual cycle estradiol that is produced by the growing follicle triggers, the hypothalamic-pituitary events that lead to the LH surge, inducing ovulation. In the luteal phase estradiol, in conjunction with progesterone prepares the endometrium for implantation. During pregnancy, estradiol increases due to placental production.
Progesterone- Secreted by the ovaries. Progesterone is sometimes called the "hormone of pregnancy", and it has many roles relating to the development of the fetus: Progesterone converts the endometrium to its secretory stage to prepare the uterus for implantation. At the same time, progesterone affects the vaginal epithelium (epithelium is a tissue composed of cells that line the cavities and surfaces of structures throughout the body) and cervical mucus, making the mucus thick and impermeable to sperm. If pregnancy does not occur, progesterone levels will decrease, leading, in the human, to menstruation. Normal menstrual bleeding is progesterone withdrawal bleeding. During implantation and gestation, progesterone appears to decrease the maternal immune response to allow for the acceptance of the pregnancy. Progesterone decreases contractility of the uterine smooth muscle In addition progesterone inhibits lactation during pregnancy. The fall in progesterone levels following delivery is one of the triggers for milk production. A drop in progesterone levels is possibly one step that facilitates the onset of labor.

Phase I: Menstruation and the Follicular phase:

The first day of menstrual bleeding is considered day 1 of the menstrual cycle.

Menstruation marks the beginning of the follicular phase of the cycle.
The endometrium (innermost lining of the uterus) is sloughed off in response to withdrawal of progesterone
Development of a new follicle with renewal of the endometrial lining

At the beginning of menstruation, concentrations of estradiol, progesterone and LH reach their lowest point.
This causes the levels of FSH to increase because usually, higher levels of the above hormones, cause the pituitary gland to secrete less FSH.

So: FSH is increased at the beginning of menstruation. This increase begins about 2 days before onset of menstruatiuon and is involved in the maturation of another group of ovarian follicles with selection of a dominant follicle for ovulation in the next cycle. It also stimulates the granulosa cells which surround the individual egg (oocyte) to increase in number and secrete estradiol.

Estradiol begins to rise by day 4.

Stimulates LH receptors on theca cells to increase their secretion of androgen precursors even more, so that the granulosa cells can continue to make more estradiol. This increase in estradiol causes the pituitary gland to secrete less FSH and also tells the pituitary gland to secrete more LH

*** NOTE: as the follicles enlarge, they secrete both androgens and estrogens. However, if the estradiol:androgen ratio is less than 1, the follicle shrinks and never becomes dominant. The dominant follicle is the one that has follicular fluid estradiol:androgen ratio of more than 1

This is why the levels of FSH, estradiol, testosterone and LH, are checked around the 3rd day of the cycle when testing a woman's fertility status.

Phase II: Ovulation:

As the dominant follicle secretes more and more estradiol, there is more stimulation of the pituitary gland to secrete more and more LH.

by Day 11 to 13- LH surge occurs which triggers ovulation within 30-36hrs after that. The oocyte is expelled from the follicle and the follicle is converted into the corpus luteum to facilitate progesterone production during the remainder of the cycle.

*** it is this LH surge that is detected in home ovulation tests
A woman is most fertile within 24-48 hours after this LH surge.

Phase III: Luteal phase:

Characterized by a change in secretion of sex steriod hormones from estradiol predominance to progesterone predominance. Now that there is a lot of LH, that LH stimulates the granulosa cells and theca cells to produce progesterone now, instead of estradiol. Production of progesterone begins about 24hrs before ovulation and rises rapidly thereafter, with max production 3 to4 days after ovulation and is maintained for about 11 days post ovulation. If fertilization and implantation do not occur, progesterone diminshes rapidly, initiating the events leading to the beginning of a new cycle.

**** adequate progesterone is necessary to facilitate implantation of the fertilized oocyte into the endometrium and to sustain pregnancy into the early first trimester

If initial rise in FSH is inadequate and if the LH surge does not achieve max amplitude, an "inadequate luteal phase" can occur, resulting in progesterone production that is inadequate to facilitate implantation of a fertilized oocyte or to sustain pregnancy.

Corpus Luteum

measures about 2.5cm wide and has a characteristic deep yellow color. As it fails, it decreases in volume and loses its yellow color. After a few months, it becomes a white fibrous streak within the ovary and is called the corpus albicans Has a fixed life span of 13-14 days unless pregnancy occurs. If oocyte is fertilized and implants within the endometrium, the early pregnancy begins secreting hCG- human chorionic gonadotropin, which sustains the corpus luteum for another 6-7wks.
*** hCG is the hormone that home pregnancy tests look for

Progesterone causes the pituitary gland to decrease the secretion of both FSH and LH, so, during the luteal phase, both FSH and LH are suppressed to low levels.

As corpus luteum fails and progesterone secretion diminishes, FSH begins to rise to prepare a woman for the next reproductive cycle.

Note, that as all of these changes are occuring in the ovaries, drastic corresponding changes are occuring in the vagina, endometrium and cervix as well. These changes serve to facilitate either menstruation or fertilization and implantation depending on which stage of the cycle it is.

So:

Menstruation is governed by FSH and estradiol
Ovulation is governed by LH
Luteal phase/pregnancy is governed by progesterone

Obstetrics and Gynecology 5th edition, Charles R.B. Beckmann and co-authors.

Topics for conversation

2009-04-03T07:01:00.001-05:00

THOUGHTS OPEN FOR DISCUSSION

While we see the practice of breast ironing and wonder how people could be so ignorant or misplace their good intentions the way that they do, I look at our "modern" society and wonder if we are also somewhat misguided in the way that we raise our young women.

So many times I have found the need to encourage women to be candid and open about educating their daughters about their bodies, because it is most often the lack of knowledge about how their bodies work that leads them to end up pregnant or with unwanted STDs etc.

Some things that I have observed are:

-Putting a taboo on female (and male) body parts

using nicknames because either the parent does not feel comfortable with saying the proper names or they don't want to hear their kids call it by its proper name.

-Making girls feel all the pressure about their role in getting pregnant while putting no restraints or restrictions on the activities of our boys

So many young men are completely uneducated about women and their bodies and end up having to rely on what their girlfriends say (about periods, mythical methods of not getting pregnant etc). Also, they are not taught to take ownership of the possibility of impregnation when choosing to have sexual intercourse, instead of leaving that up to the girl to control

-Parents who are not educated enough about how the body works to be able to therefore educate their kids.

This is one of my peeves. I believe that if a parent knows that the subject is over their head then it is their responsibility to read and figure it out before it is time to convey the information to their children. Not knowing is not good enough!

The people of Cameroon were frustrated about the increasing numbers of young women getting pregnant and as a result, failing to pursue an education. They chose to make their girls less attractive to men in hopes that they would be left alone. But:

What about educating the men, encouraging them to take some responsibility in the matter?

What about educating the women about abstinence, methods of birth control (there are free ways to prevent pregnancy)

What about encouraging the women to choose education over short term gratification?

What about looking for resources that will help mothers to still pursue their education?

This is another example of where education/knowledge can bring power. Power to the women over their own bodies and their own lives. Power to the community so that disfigurement does not have to be resorted to, and the female body can be celebrated instead of seen as a detractor or a curse.

How can we better educate our young women?
How can we better prepare them for puberty?
How can we teach them our ideals and morals while not over sheltering them from the realities?

Breast Ironing in Cameroon

2009-04-03T07:00:00.004-05:00

In southern Cameroon, the practice of “breast ironing” affects an estimated quarter of the female population, or 4 million women and girls . It is a form of female body mutilation in which household objects such as rocks, spatulas, coconut shells, wooden pestles and unripe bananas are heated over a fire and then used to “iron” flat the breast tissue of pubescent girls.

Scholars and activists who have documented it agree that it is clearly a painful procedure to undergo. The long-term medical complications that can arise from breast ironing are troubling: breast cancer, infections, lesions, and permanent
damage to milk ducts.

The ironing is generally performed by girls’ mothers at the first sign of puberty, but occasionally girls do it to themselves. In sharp contrast to many forms of female body modification, this procedure is carried out specifically to make young women less attractive to men and boys.

Woman using a heated rock

to flatten the young girl's breast

In a country with high pregnancy rates due to lack of sexual
education, many mothers claim that making their daughters’ breasts less attractive to males helps to ensure that their daughters will avoid pregnancy and finish school. Some girls do it to themselves in this effort to secure an education free from male harassment.

Tools used in Breast Ironing

In 2005, representatives from Cameroon's local Aunties' associations formed the National Network of Aunties' Associations (RENATA), whose members themselves have undergone breast ironing. In 2006, the Aunties began a culturally-sensitive campaign to draw public attention to the hidden psychological trauma and other health risks of the practice.
RENATA has produced radio and television spots, and several radio and television journalists have joined in spreading information about breast ironing in local languages. Utilizing images common to Cameroonians, leaflets and calendars outlining the types of objects
used in breast ironing have also been produced. The United Nations Population Fund (UNFPA) concludes that the Aunties' approach utilizing media is transferable to other countries with traditions and contemporary situations not unlike those found in Cameroon. “This approach is a good example of capacity development in that it enables young women at risk of marginalization to connect and support each other, locally and nationwide, and to shape their own futures.”

The question that begs an answer in my mind is an anthropological one. All of central Africa suffers from the same maladies as Cameroon--teen pregnancy, poor education about health, lack of children's rights--but the practice hasn't been adopted elsewhere. Other harmful ceremonial
acts against women have spread throughout sub-Saharan Africa, such as female genital cutting, stoning, and trokosi, but not breast ironing. I don't ask why breast ironing is practiced in Cameroon. On the contrary, why isn't it practiced in neighboring countries? Interesting.

A piece written by Laine Strutton

Pictures imbedded by Dionne Mills

Adams, S. (2007). 'Aunties' for sexual and reproductive health: How
unwed young mothers become advocates, teachers and counsellors in
cameroon. German HIV Practice Collection (Deutsche Gesellschaft Fur
Technische Zusammenarbeit), (July), 35. Retrieved from
http://www.popline.org/docs/1763/319736.html

DeMello, M. (2007). Encyclopedia of body adornment. Westport, CT:
Greenwood Publishing Group.

Sa'ha, Randy Joe. (2006). "Cameroon Girls Battle Breast Ironing." BBC
World New, 23 June, 2006. See:
http://news.bbc.co.uk/2/hi/africa/5107360.stm

United Nation Population Fund (UNFPA). (2006). Breast ironing. New
York: United Nations. Retrieved from
http://www.unfpa.org/16days/documents /pl_breakironing_factsheet.doc

Polycystic Ovarian Syndrome

2009-04-01T11:00:00.004-05:00

PCOS, also known as Stein Leventhal syndrome, is an endocrine(hormonal disorder) that affects 5-10% of females, with variation among races and ethnicities.
This syndrome can be diagnosed if at least 2 of the following conditions are present:

- Oligomenorrhea *or amenorrhea *

-hyperandrogenism* and

-polycystic ovaries on ultrasound.

Laboratory testing often reveals mildly elevated serum androgen (such as testosterone etc) levels, an increased ratio of luteinizing hormone to follicle stimulating hormone (LH:FSH), lipid abnormalities and insulin resistance.

PCOS is a constellation of problems. The body's endocrine system is all about checks, balances, and feedback. When one hormone is secreted abnormally, like a domino effect, other systems in the body are negatively affected.

Gonadotropin Releasing hormone (GnRH) is released by the hypothalamus ( ) in a pulsatile manner which causes the release of LH and FSH from the pituitary gland. In PCOS, there is an abnormal release of GnRH, causing LH to be released more than FSH in an erratic fashion. LH stimulates the ovaries to produce androgens (testosterone). Couple this with the lower levels of FSH, whose job is normally to stimulate the ovaries to take those androgens and convert it to the potent form of estrogen called estradiol, you now have a state in which there are too much androgens in the body (hyperandrogenism).

These increased androgens cause the follicles in the ovaries to shrink and also contribute to abnormalities in the lipid metabolism and distribution in the body as well as the development of acne and hursuitism- defined as the presence of coarse, dark, terminal hairs distributed in a male pattern, seen most commonly on the upper lip, chin, sideburns, chest and the midline of the lower abdomen.

Now, even though there is decreased estradiol, fat cells in the periphery of the body can take those androgens and convert them to another form of estrogen called estrone. This constantly feeds back to the hypothalamus and pituitary gland (as opposed to cyclically) and causes problems there. That estrone also continuously stimulates the lining of your uterus, leading to endometrial hyperplasia, which can predisopse you to endometrial cancer and other health problems in the future.

Another problem with PCOS is the issue of insulin resistance. Insulin is the hormone that allows glucose to get into the body's cells. Insulin resistance is defined as a reduced glucose response to a given amount of insulin. The mechanism of this decreased sensitivity to insulin appears to be due to an abnormality in one of the insulin receptors. Both lean and obese women with PCOS are found to be more insulin resistant than non-PCOS counterparts of the same weight.

Insulin resistance has been associated with an increase in several disorders including type 2 diabetes mellitus, hypertension, dyslipidemia*, and cardiovascular disease. Therefore, PCOS is not simply a disorder of short-term consequences such as irregular periods and hirsutism, but also one of long-term heath consequences

Short-term consequences
1. Irregular menses
2. Hirsutism/acne/androgenic alopecia
3. Infertility
4. Obesity
5. Metabolic disturbances
6. Abnormal lipid levels/glucose intolerance

Long-term consequences
1. Diabetes mellitus
2. Cardiovascular disease
3. Endometrial cancer

During a normal menstrual cycle, the various hormones listed go through cycles - rising and falling at certain times. In PCOS however, they tend to remain at a constant level throughout the cycle.

A follicle swells but does not release an egg, so it becomes a cyst. The cells surrounding the cyst release weak levels of testosterone, which the body converts into estrogen ( in the form of estrone). The brain senses the high levels of estrogen present and therefore assumes that the ovaries are functioning normally and a ripe egg is ready to be released. The secretion of FSH is cut back and the LH is sent out. LH usually triggers the ripened egg to break away ready for impregnation, but as there is in fact no egg, the follicle forms a cyst and the process is repeated cycle after cycle and the problem gets worse.

In short - polycystic ovaries are where follicles have matured in the ovaries but are never released due to abnormal hormone balance.
What are the symptoms?

Each woman with PCOS will have varying symptoms and though there is a particular set of dignostic symptoms, each case should be looked at separately.

Some of the symptoms are:
-Acne
-Irregular or absent periods
-Numerous cysts on the ovaries
-Hirsutism
-Obesity
-Infertility or reduced fertility
-Hair loss (androgenic alopecia - similar to male pattern baldness)
-High Blood Pressure
-Elevated Insulin levels, diabetes or insulin resistance.

There are some techniques that your doctor can employ to keep this chronic disease under control. PCOS has been shown to be amenable to ovulation inducing drugs (such as Clomiphene), for patients that want to become pregnant, as well as diabetic medications (such as Metformin).

Since women with PCOS can present with a number of combinations of symptoms, it is important to be patient with your physician since most of these symptoms could be independant or part of many other conditions. However, if you feel as though your symptoms could be explained by PCOS, encourage your doctor to investigate it further and at least attempt to rule it out.

Be an advocate for your health. Knowing is the first step.

* Oligomenorrhea is the medical term for infrequent uterine bleeding episodes with intervals of more than 35 days

*Amenorrhea is the absence of a menstrual period in a woman of reproductive age

*Hyperandrogenism is a medical condition characterized by excessive production and/or secretion of androgens

Schorge JO, Schaffer JI, Halvorson LM, Hoffman BL, Bradshaw KD, Cunningham FG, "Chapter 17. Polycystic Ovarian Syndrome and Hyperandrogenism" (Chapter). Schorge JO, Schaffer JI, Halvorson LM, Hoffman BL, Bradshaw KD, Cunningham FG: Williams Gynecology: http://www.accessmedicine.com/content.aspx?aID=3157034.

Pasted from <http://www.accessmedicine.com/citepopup.aspx?aid=3157034&citeType=1>

Tzadik Mor, Purcell Karen, Wheeler James E, "Chapter 40. Benign Disorders of the Ovaries & Oviducts" (Chapter). DeCherney AH, Nathan L: CURRENT Diagnosis & Treatment Obstetrics & Gynecology, 10th Edition: http://www.accessmedicine.com/content.aspx?aID=2389603.

Pasted from <http://www.accessmedicine.com/citepopup.aspx?aid=2389603&citeType=1>

2009-03-31T16:55:00.003-05:00

As shown below in the "Up-Coming Post Topics" section, tomorrow will be this blog's first post! The topic will be about Polycystic Ovarian Syndrome, a condition that is near the top of the list for causes of infertility in young adult women.

On Friday the 3rd, Laine's post on Breast Ironing in Cameroon is scheduled to post, followed by some discussion topics that I've put together. I look forward to hearing from you all and seeing the different ways that you will react to this interesting and provocative topic.

The "Up-Coming Post Topics" section at the bottom will show the topics that I am working on highlighting and will have post dates as soon as I have scheduled them.

WELCOME!!!!

2009-03-28T19:33:00.000-05:00

Hello everyone and welcome to Dr. D's Women's Health Corner!!!! I hope that this site will be interesting, informative, and a way for women to communicate and collaborate about issues affecting women's health and women's rights. I encourage you to get involved in upcoming discussion topics. Also please feel free to suggest issues or health conditions that you feel are relevant and would like clarification on. I do not know everything but I have at my disposal a lot of resources.

New information will not be put on this blog every day since I will be in my residency training and will be quite busy. My goal is to at least update it once every 2 weeks with enough to keep you thinking and talking until the next post.

I will try to be as concise as possible but please understand that some of these posts may not be the shortest, since certain health conditions are quite complicated. I will try to condense the information into a form that is easy to follow, gets you thinking, and at least arms you with the information that you need so that you can go out and be the number one advocate of your own health.

Thanks again to Laine Strutton who is my contributor extraordinaire. Her knowledge about the struggles of women all over the world will prove very insightful.