Melasma/ Chloasma

Chloasma is a condition of hyperpigmentation of skin of face caused mainly by hormones or Ultraviolet rays exposure.
Chloasma often first appears during pregnancy or while the patient is taking oral contraceptive pills and this indicates an influence of female hormones.
Sunlight- Pigmentation becomes darker after sun exposure. So UV rays are important.
Age- Peak incidence age is 35-50 years.
Clinical Features- Brown pigmentation with well defined borders mainly over cheeks, nose, forehead and chin.

The pigmentation becomes darker on sun exposure.
Treatment:
1. Protection from Sunlight- Sunscreens, Minimum with SPF 15.
2. Topical Hydroquinone 2-4%
3. Topical Retinoic acid 0.025%
4. Topical Corticosteroids like Mometasone
5. Glycolic Acid (6-12%) at night
6. Azelaic acid (20%).

Chemical peeling- The agents used are-
1. Glycolic acid (70%)
2. Trichloroacetic acid (15-30%)

CERVICAL INTRAEPITHELIAL NEOPLASIA

Cervical Intraepithelial Neoplasia

Cervical intraepithelial neoplasia refers to a pre-cancer stage of cervical cancer which can be easily detected and treated. Over 50,000 new cases of carcinoma cervix are diagnosed annually.

Stages

Cervical intraepithelial neoplasia (CIN) divides the epithelial thickness into thirds.

1. CIN I refers to problematic cells (cellular dysplasia) over lower one third of epithelium.

2. CIN II refers to lesions confined to the lower two thirds of the epithelium.

3. CIN III refers to problematic cells are more than two thirds

Epidemiology and pathogenesis

A. CIN is typically detected at an age 10 to 15 years before the invasive cervical carcinoma actually occurs.

B. Human papillomavirus (HPV) infection is the leading cause of malignant transformation. HPV is found in 70-78 percent of patients with CIN I and in 83-89 percent of CIN II/III. Risk factors for CIN include sexual activity at an early age, history of sexually transmitted diseases, multiple sexual partners, or sexual activity with promiscuous men. Other risk factors include cigarette smoking, multiparity, and immunodeficiency.

 Diagnosis A. Women are typically screened for CIN by cervical cytology PAP smear.

B. Abnormal cytology results should be further evaluated.

Evaluation of the cervix following abnormal cytology results includes visual inspection, repeat cytology, colposcopy, directed biopsy, and endocervical curettage.

Specific therapeutic techniques

1. Common techniques for treatment of CIN:

a. Cryotherapy (nitrous oxide or carbon dioxide)

b. Loop electrosurgical excision procedure (LEEP, LLETZ).

c. Carbon dioxide (CO2) laser ablation

d. Excisional (cold knife) conization

e. Carbon dioxide laser cone excision

2. Cryotherapy

a. Cryotherapy consists of the application of a super-cooled probe directly to the cervical lesion using two cooling and thawing cycles. The probe must be able to cover the entire lesion and the lesion cannot extend into the endocervical canal.

b. The multiple cycle freeze-thaw-freeze technique should be used, and the blanching should extend at least 7 to 8 mm beyond the edge of the cryo-probe to reach the full depth of the cervical crypts. Mild cramping accompanies the procedure.

c. The advantages of this approach include low cost and a low complication rate. Disadvantages are a copious vaginal discharge lasting for weeks and a lack of tissue for histology.

3. Loop electrosurgical excision procedure

a. The loop electrosurgical excision procedure (LEEP or LLETZ) has become the approach of choice for treating CIN II and III because of its ease of use, low cost, and high rate of success. It can be performed in the office using local anesthesia.

b. The procedure uses a wire loop through which an electrical current is passed. The transformation zone and lesion are excised to a variable depth, which should be at least 8 mm, and extending 4 to 5 mm beyond the lesion. An additional endocervical specimen is frequently removed to allow histologic evaluation.

 Follow-up

1. Patients with positive margins after LEEP or cold knife conization are at increased risk for residual disease.

2. Careful clinical follow-up with cytology and colposcopy/biopsy (when indicated) in women with positive margins, instead of immediate retreatment, is appropriate in patients who are compliant with frequent monitoring. Cytologic assessment should be continued at three month intervals until normal for one year after therapy and yearly thereafter.

Bartholin gland abscess

Bartholin's glands are two glands located at the left and right of the opening of the vagina. They secrete mucus to lubricate the vagina. Two percent of women develop a Bartholin's duct cyst or gland abscess at some time in life.
   Obstruction of the Bartholin's duct may result in the retention of secretions, with resultant dilation of the duct and formation of a cyst. The cyst may become infected, and an abscess may develop in the gland.
  
   Organisms involved are Chlamydia trachomatis E coli, Streptococcus faecalis, pyococci, gonococcus.
  
   Clinical presentation: Soft, less than 2 cm in diameter, smooth surface, associated with and aggravated by pregnancy;and trauma.

   Treatment:  An asymptomatic cyst may require no treatment, but symptomatic Bartholin's duct cysts and gland abscesses require drainage.

   Incision and drainage, Excision,  Marsupialization are modalities of treatment.

   Cultures for N. gonorrhoeae and C. trachomatis may be obtained. However, Bartholin's gland abscesses tend to be polymicrobial, and empiric broad-spectrum antibiotic therapy should be used.

Normal Vaginal flora

Vaginal wall is lined by stratified squamous epithelium that is several layers thick. These layers contain glycogen, this glycogen is converted into lactic acid which keeps the pH level low and thus protect against the infections.
Lactobacilli accounts for  90% of the total organisms. They are actually useful as the check the growth of other organisms by maintaining the low pH by producing hydrogen peroxide, which inhibits bacteria. Other organisms are Staphylococcus epidermidis, hemolytic streptococci and coliforms.

Trichomonas Vaginalis

This is one of the commonest sexually transmitted disease in women. Nearly 20% of men partners with Urethritis are infected with Trichomonas Vaginalis (TV) and a co-infection with gonorrhea is very common. TV is an important cause of persistent or recurrent urethritis. Golden role:" a patient whose symptoms of urethritis persists after adequate treatment for gonorrhea and Chlamydia should be investigated for TV infection".
       Investigation are Wet mount studies, Culture and sensitivity, PCR is gold standard.
       Treatment options: First Regimen- Metronidazole as single dose of 2 g orally.
       Second Regimen- Metronidazole 500mg twice a day for 7 days.

Obesity

According to World Health Organization, when the body weights over and above 20% excess over the standard weight in relation to age and sex of that individual, its called as obesity.
Normally we call a person obese if BMI is more than 30.
BMI is measured as Wt of person in kgs divided by ht in meter square. Kg/m2. For example, an adult male weighing 60 kgs with a height of 1.70 meters has a BMI of 60/ 1.70*1.70 = 20.7.
Systemic hypertension, diabetes mellitus, ischaemic heart disease may be associated with Obesity.


Common causes of Obesity:
1. Physical inactivity
2. Hypothyroidism
3. Genetics
4. Drugs- Steroids, estrogen
5. Fatty foods

Hirsutism, Virilistion and Defeminisation

Hirsutism- It is the growth of hair in women in a pattern characteristic of men.
Causes of Hirsutism:
1. Cushing's Syndrome
2. Polycystic ovarian disease
3. Tumours affecting Adrenal glands, causing secretion of androgen.
4. Acromegaly
5. Hyperprolactinaemia
6. Drug Induced- Phenytoin, Oral Contraceptive pills, androgens, psoralens, minoxidil
7. Idiopathic or simple hirsutism: menopause

Virilisation- The characteristic features are:
1. Frontal Baldness
2. Coarsening of voice
3. Acne and seborrhoea
4. Hirsutism
5. Increase in size of Clitoris
6. Increase in size of shoulder girdle muscle

Defeminisation:
1. Decrease in Breast size
2. Loss of female body contours
3. Amenorrhoea

Vaginal Candidiasis

Women are more prone for getting candidiasis as the mucosa of the vagina and the secretions produced  by it provide an ideal environment for the growth of candida. Virtually all the sexually active women's may have candidial infection in there life time. In roughly about 13% of all women's candida albicans will be a part of healthy vagina
The most common causes of having this infection are:

• Sexual Intercourse- As women's vagina provide a wider surface area as compered to men.
• Pregnancy predispose candidial infecion.
• Hospitalization- It could occur as nosocomial infection that is acquired infection as a result of hospital stay.
• Use of intrauterine devices such as loops, copper T etc.
• Use of Oral Contraceptives.

Diagnosis- The diagnosis is mainly done by history of itching and physical examination by either a gynaecologist or a dermatologist.
Alternatively one slide is prepared by taking a specimen from vagina and either a KOH mount is done or a Grams staining is done and candida is demonstrated.
Treatment:

• A single dose of 150mg of Fluconazole is effective, or
• Cotrimazole could be used 
• Along with this Cotrimazole vaginal gel could be used.
• Topical corticosteroids like betamethasone could be used for control of itching and burning
• Pheneramine could be used in pregnancy for control of itching safely 
• Topical Tacrolimas can be used for treatment of pruritis.

Heart burn/ Esophageal reflux in pregnancy

Heart burn is a common complaint, characterized by discomfort in chest, burning pain, and also at times difficulty in swallowing.
Why it occurs-- This result from the reflux of gastric juices, biles, which is acidic into esophagus or into the mouth. This reflux is caused by::
1. Pressure of the enlarging uterus on the stomach.
2. Incompetence of the sphincters (Gates) of the stomach.
3. Hiatus hernia- which causes herniation of the upper part of stomach into the chest. 

Management-
1. Antacids- Aluminum hydroxide/ Magnesium hydroxide should be taken at night or morning.
2. Light and frequent meals, addition of milk and avoidance of alcohol.
3. Head end of the bed should be raised.
4. At times even endoscopy (flexible) is required to exclude any disease of stomach.

Nausea and vomiting in pregnancy.

Nausea usually occurs around 5th week of pregnancy and remains around 12 weeks. The exact cause for nausea is still not known but it is most likely associated with rising serum hCG levels. If nausea is very severe, it suggest the possibility of multiple pregnancy or hydatidiform mole.

Management

1. Dietary change:           A-   4 to 6 meals are easily tolerated.

                                      B-   High protein food help to prevent low blood sugar levels.

                                      C-   Fatty, greasy or highly spiced food are best avoided.

2. Antiemetic drugs- Nausea usually requires no any specific medication.

                               Vomiting- Metoclopramide, Promethazine, Pyridoxine, and Prochlorperazine appears quite safe.

3. Psychological support- It is most important step in management, if the self limiting nature of the symptom is properly explanied, and reassurance is given and explained that the hCG is actually very important for the development of the baby, copes with the problem.

4. Admission to hospital- It is required when the women is unable to tolerate food and looses weight significantly or if ketone bodies are detected in urine.

Advice at first vist to a Gynecologist.

After doing all the history taking and examination stuff its time for getting some really good advice.
Firstly as a doctor our goal is to produce at the end of 40 weeks a healthy baby and a healthy mother for this a few things should be followed like::
1. Diet- It should be a good diet essentially rich in proteins, minerals and vitamins but at the same time should be light and digestible. It should at least contain 1 litre of milk, and plenty of green vegetables and fruits. The calorie requirements is to be increased at least 300 over the non pregnant state by second trimester. The addition of iron tablets containing 60 mg of elemental iron after 16 weeks onwards is required.
2. Occupation- The lady should continue her usual activities and life throughout pregnancy but hard work should be avoided.
3. Clothing- Loose clothes should be worn during pregnancy, flat shoes should be worn.
4. If any signs of Constipation take plenty of fluids, green vegetables, or mild laxatives like lactulose, isafgul, 2tsf at bed time with warm water.
5.Coitus- Coitus should be avoided during the first trimester and last six weeks, other times it could be done.
6. Smoking- It should be avoided as there are more chances of abortion, and also heavy smokers tends to have small babies and low birth weight babies.
7. Alcohol- It should also be better avoided as there is chance of growth restriction.
8. Drugs- Almost all drugs are capable of crossing the placenta, so better be taken on consultation with doctor and pregnancy state should be kept in mind.
9. Immunisation- 0.5 ml of Tetanus toxoid should be given to mothers at 4th month and 6th month protects mothers and neonates against deadly tetanus. All other live vaccines like measles, mumps, rubella, vericella, yellow fever are contraindicated during pregnant state.

Red Flag Signs during pregnancy, Rush to hospital.

1. Active vaginal bleeding.
2. Sudden gush of water fluid per vaginum.
3. Painful contractions at an interval about 15 minutes for one hour suggest onset of labour.

Antenatal Care, Procedure at first visit to a gynecology and obstetrics department.

Examination and advice during pregnancy is called antenatal care.
It comprises of:: 1. History taking
                         2. General physical examination
                         3. Advice
Why it is done?
It helps to screen the high risk cases, to detect and treat any complications as early as possible, education of mother, to remove the fears and anxiety, about place, time and mode of delivery, family planning, appropriate advice on medical termination of pregnancy.

What will doctor ask you in history::
She will ask you firstly your particulars, followed by your age, then about any past pregnancies and there history. With this they will derive a formula known as obstetrics formula.
Then they will ask about your occupation and life style. This is followed by the chief complaints, sleep, appetite, bowel habits and urination.
If this is your second pregnancy whole history of the past pregnancy about year and date, pregnancy events, labour events, method of delivery and condition of the baby is taken.
The next important question they will ask you is your last menstrual period (LMP). From LMP, the doctor will calculate the expected date of delivery, its 9 months and 7 days if the periods are regular.

Examination performed on you during first visit.
General physical examination to see your build, nutrition, height, weight, any signs of anaemia, jaundice, neck veins, edema, pulse, blood pressure, breast examination, etc
Obstetrics examination- Muscle, signs of any tenderness, herniation and skin over abdomen. palpation of the fundus of uterus which just becomes palpable at 12 weeks.
Vaginal Examination- It is done to diagnose the pregnacy, to rule out any pathology. At times bivalve speculum is used in a good light source when any sample is required for vaginal swab, or exfoliative cytology.
Ultrasonography examination. It helps to detect number of fetuses, dating accurately, any gross fetal abnormality, etc.
Blood investigation especially hemoglobin, ABO, and Rh testing along with VDRL, HIV, HBs screening
Urine examination for protein, sugar and pus cells.
Maternal serum Alpha Feto Proteins- In mothers carrying the risk for neural tube defects (above 35 years of age), Down syndrome, or other chromosomal abnormalities.
A Tetanus Toxoid could be given but is usually given around 4th month.
These are basically the things done at the first visit to the gynecology and obstetrics department. 

How to know that you are pregnant

Women can get pregnant anytime in her reproductive period, i.e about 15- 45 years practically, Now when to know that you are pregnant.
Symptoms- 1. Amenorrhoea- Absence of normal periods. This is the first symptom that will strike you that you are pregnant. Cyclic bleeding at times may occur up to 12 weeks of pregnancy, but its usually scanty.
2. Morning sickness- It occurs in 50% of cases, It is the second thing to appear, soon after the missed period. It varies, at times only nausea on rising from the bed to loss of appetite to vomiting, but its usually not too severe and rarely lasts beyond first 3 months.
3. Frequency of micturation- This is quite troublesome during first two months of pregnancy. This occurs as there is heavy uterus on the fundus of the urinary bladder, but this also disappear by 3rd month as uterus straightens up.  
4. Breast discomfort- There is a feeling of fullness, breast becomes enlarged and even veins become visible in them, This becomes evident in 6-8 weeks. Nipples become more pigmented, Thick yellowish secretion comes out around 3 rd month.
These are the common symptoms you will experience and will take you to your family physician or Gynaecologist. Now the doctor will examine you after that, she'll take your pulse, blood pressure, weight, and do an abdominal examination to feel for the fetal parts. Then she'll send you for Urine Pregnancy Test, there is a kit for this test available at every medical store, there are colour bands in there, put two drops of urine in sample cavity, and see the result even at home. If there is a single line of control then you are not pregnant, if there are two bands of line then you are pregnant. This test is positive on the first day of missed period itself, and is accurate 99%. If the test is positive then you'll sent for ultrasonography for identification of structures, size, shape of the gestational sac. Doppler effect of ultrasound can pick up the fetal heart rate by second month and is the surest sign of pregnancy.
This is basically what is happening to you in your first three months and what your family physician will do to you. Happy Blogging.   

women health how important it is..

Women has different roles to play in her life. She is a daughter, lover, wife, mother, grand mother. She is one of the strongest person from emotionally one will ever meet in their life. But her body, the amount of strains it takes is awesome. To keep a baby in womb for 9 months and 6 days and then delivering her, and that also not once, in her life time, does shows the amount of strength possessed by her. But her body, as it takes the amount of mental, physical, emotional  traumas all these years tends to fade up. In this blog we'll take up the issues related to women's health and try to solve them in more scientific and holistic way. Thank you all for your time in reading this and happy blogging..