A Simple Guide to Amenorrhea

A Simple Guide to Amenorrhea
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What is Amenorrhea?
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Amenorrhea is a symptom defined as absence of menstruation.

What are the types of Amenorrhea?
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1.Primary Amenorrhea
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is defined as the absence of onset of menstruation (menarche) in a girl who has reached the age of 18 years.

2.Secondary Amenorrhea
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is defined as the absence of menstruation for a peroid of at least 6 months in a girl who has previously experienced normal menstruation and is not pregnant.

What are the causes of Amenorrhea?
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1.Physiological(hormonal):
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pregnancy hormones - pregnancy is the still the most common cause of secondary amenorrhea.
Growth hormone deficiency
Abnormal production of testosterone

2.Genetic Causes:
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abnormal formation of genital tract causing cryptomenorrhea -obstruction to the flow of menstrual blood such as imperforate hymen
Chromosonal abnormalities:
Turner syndrome
Ovarian agenesis

3.Uterine Pathology:
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adhesions from previous operation
endometriosis
tuberculosis infection
radiation

4.Ovarian:
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Agenesis(no ovaries)
Abnormal ovaries(again congenital)
Polycystic Ovaries
Granulosa-thca tumours of ovaries
radiation of ovaries

5.Pituitary:
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Pituitary tumours
Hypopituitarism
Hypothalamic abnormalities

6.Psychological:
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Depression
Anorexia nervosa,
starvation

7.Systemic Diseases:
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Hypothyoidism
Cushing syndrome

8.Medical causes:
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Chemotherapy
oral cotraceptive
corticosteroids
hypotensive drugs

How to establish a diagnosis of Amenorrhea
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History:
1.Primary Amenorrhea
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Genetic disorders:
failure to develop female sex characteristics
anatomic abnormalities due to chromosonal defects such as Turner syndrome
hirsutism-excessive male hormones

2.Secondary Amenorrhea
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Metabolic disorders:
symptoms of hypothyroidism
symptoms of polycystic ovarian syndrome
Obesity

Pyschologic disorders:
depression
anorexia nervosa

Pelvic examination:
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vulval and vaginal examination for cryptomenorrhea,
bimanual palpation for ovarian masses like polystic ovaries
abnormal uterus or ovaries

Investigations:
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Pregnancy test

blood for follicle stimulating hormones, luteinising hormones, prolactin

Progesterone withdrawal bleeding test
Luteinizing hormone releasing tests

Serum testesterone and androsterones

Transvaginal ultrasound to check on the uterus and ovaries
X-ray Skull, Brain CAT or MRI scans to exclude pituitary tumours

What is the Treatment of Amenorrhea?
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Medications:
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Specific treatment for amenorrhea depends on:

1.age,
2.overall health,
3.cause of the condition (primary or secondary)
4.the preference of the patient

Treatment for amenorrhea may include:
1.Pregnancy - no treatment if the patient wish to continue with pregnancy. Usually a referral to an obstetrician may be necessary

2.hormonal replacement(oestrogen and progesterone supplements ) in genetic cases and androgen producing tumours.

3.Cyproterone acetate is an anti-androgen which counters the effects of male hormones. It is usually given with a small dose of oestrogen.

4.Hyperprolactinaemia -treatment with bromocriptine which acts by stimulating the prolactin Inhibiting factor in the hypothalamus.

5.Polycystic ovary Disease -clomiphene and gonadatrophins may be given to improve menstruation and help fertility

6.Adrenal dysfunction due to deficiency of the enzyme 21-hydroxylase (androgegenital syndrome) results in excess ACTH and excessive production of androgens-treatment is with corticosteroids such as prednisolone

Other Treatments:
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1.Treatment of underlying systemic disease like thyroxine for hypothyroidism,

2.dietary changes to include increased caloric and fat intake especially in cases of low fat due to self induced dieting, anorexia nervosa

3.Pyschiatric treatment for women with depression, anorexia nervosa, or genetic dysfunction.

4.Healthy lifestyle for those who are obese

A Simple Guide to Dysmenorrhea

A Simple Guide to Dysmenorrhea
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What is Dysmenorrhea?
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Dysmenorrhea is a symptom, not an illness.
It means painful menstruation.

What are the types of Dysmenorrhea?
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Dysmenorrhea may be classified into:

1.Primary or Spasmodic Dysmenorrhea

2.Secondary Dysmenorrhea due to causes like

Endometriosis or

Pelvic Inflammatory Disease

What are the Causes of Dysmenorrhea?
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The cause of primary Dysmenorrhea is still not known.

There are a few theories:
1.during menstruation, contraction of the uterine muscles occurs in spasms trying to push the menstrual flow through a narrow cervical opening

2.Prostagladins output occurs at time of menstruation producing muscles spasms

3.Menstrual clots occludes the uterine opening and requires more contractions of the uterine muscles to push it through

4.Stress may constrict the opening of the uterus and hence greater contraction of the uterine muscles is required to force out the menstrual flow.

What are the Symptoms of Dysmenorrhea?
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Primary Dysmenorrhea:
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1.typically occurs on the first day of menses and becomes less after the 2nd day.

2.lower abdominal cramp radiating down to thighs and back

Secondary Dysmenorrhea:
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1. Starts about 1 week before menses and reach maximum on first day before reducing intensity for rest of menses peroid

2.dull aching pain in lower abdomen with radiation to the back

Symptoms may be associated with
1.vomiting,

2.urinary frequency,

3.headache,

4.painful breasts,

5.abdominal distension,

6.depression and

7.irritabilty.

What is the Treatment for Dysmenorrhea?
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Primary Dysmenorrhea:
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1.simple analgesics like paracetamol

2.Non-steroidal anti-infammatory drugs like Ponstan, Synflex

3.Antispasmodics

4.Tranquilliser or antidepressant

5.Muscle relaxant

6.female hormones

Secondary Dysmenorrhea:
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1.Identify and treat the underlying cause(eg. antibiotics for PID)

2.Endometriosis may require a course of female hormones or surgery for control

3.Dilatation of the endocervical canal may help

What is the prognosis of Dysmenorrhea?
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Primary Dysmenorrhea may end with first pregnancy due to widening of uterine opening.

Secondary Dysmenorrhea prognosis depends on the treatment of causes.

A Simple Guide to Syphilis

A Simple Guide to Syphilis
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What is Syphilis?
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Syphilis is a infectious sexually transmitted disease caused by the bacterium Treponema pallidum.
It can be acute, subacute or chronic depending on the stage.

How is Syphilis spread?
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Syphilis is passed from a infected person through sexual contact with a infected sore which occur mainly on the external genitals, anus, or rectum.
The lips and the mouth may also have sores.

The bacteria can penetrate through normal mucous membrane and minor abrasions of the epithelium.
Transmission of the organism usually occurs during sexual contact.
Pregnant women with the disease can pass it to the babies they are carrying.

What are the symptoms of Syphilis?
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The signs and symptoms of syphilis may occur in four stages:

Primary
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These signs may occur from 10 to 90 days after exposure:

1.A small, firm, painless sore (chancre) appears on the body where the syphilis enter the body, usually the genitals, rectum, or lips.
A single chancre is typical, but there may be multiple sores.

2.Enlarged lymph nodes in your groin.

The chancre lasts 3 to 6 weeks, and it heals without treatment.
However, if untreated, the infection progresses to the secondary stage.

Secondary
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The signs and symptoms of secondary syphilis may begin two to 10 weeks after the chancre appears, and may include:

1.Rash marked by red or reddish-brown sores over any area of the body especially the palms and soles. The rash usually does not cause itching.

2.Fever

3.Fatigue and a vague feeling of discomfort

4.swollen lymph glands,

5.sore throat,

6.weight loss,

7.Soreness and aching

The signs and symptoms of secondary syphilis will resolve with or without treatment.
Without treatment, the infection will progress to the latent and late stages of disease.

Latent
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A period called latent syphilis in which no symptoms are present may follow the secondary stage.
Signs and symptoms may not appear until the disease may progress to the tertiary stage.

Tertiary
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Without treatment, syphilis bacteria may spread, leading to serious internal organ damage including the brain, nerves, eyes, heart, blood vessels, liver, bones,joints and finally death years after the original infection.

1.Neurological problems. These may include stroke; infection and inflammation of the membranes and fluid surrounding the brain and spinal cord (meningitis); poor muscle coordination; numbness; paralysis; deafness or visual problems; personality changes; and dementia.

2.Cardiovascular problems. These may include bulging (aneurysm) and inflammation of the aorta and of other blood vessels.
Syphilis may also cause valvular heart disease, such as aortic valve insufficiency.

Many people infected with syphilis do not have any symptoms for years, yet remain at risk for late complications if they are not treated.

What is the danger of Syphilis during pregnancy?
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The syphilis bacterium can infect the baby of a woman during her pregnancy. Depending on how long a pregnant woman has been infected, she may have a high risk of having a stillbirth or of giving birth to a baby who dies shortly after birth.
An infected baby may be born without signs or symptoms of disease.
Untreated babies may become developmentally delayed, have seizures, or die.

How do you diagnose Syphilis?
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1. dark-field microscope: examining material from a chancre using this microscope.
If syphilis bacteria are present in the sore, they will show up when observed through the microscope.

2.A blood test for syphilis antibodies is accurate, safe, and inexpensive. There will be some antibodies in the blood for months even when the disease has been successfully treated.

Because untreated syphilis in a pregnant woman can infect and possibly kill her developing baby, every pregnant woman should have a blood test for syphilis.

What is the treatment of Syphilis?
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Syphilis is easy to cure in its early stages.

Treatment with intramuscular injection of penicillin can kill the organism that causes syphilis.
If you're allergic to penicillin, other antibiotics such as erythromycin will kill the syphilis bacterium.
Treatment however will not repair damage already done.
Left untreated, the disease can lead to serious complications or death.

Persons who receive syphilis treatment must abstain from sexual contact with new partners until the syphilis sores are completely healed.
Persons with syphilis must notify their sex partners so that they also can be tested and receive treatment if necessary.

Even if you were treated for syphilis during your pregnancy, your newborn child should receive antibiotic treatment.

To make sure you're responding to the usual dosage of penicillin, the doctor likely will want you to have periodic blood tests.
Blood test may remain positive up to 18 months even after successful treatment of syphilis.

Having syphilis once does not protect a person from getting it again. Following successful treatment, people can still be susceptible to re-infection.

How do you prevent Syphilis?
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The surest way to avoid transmission of sexually transmitted diseases, including syphilis, is to 1.abstain from sexual contact

2.in a long-term mutually monogamous relationship with a partner who has been tested and is known to be uninfected.

3.Avoiding alcohol and drug use may also help prevent transmission of syphilis because these activities may lead to risky sexual behavior.

4.Correct and consistent use of latex condoms can reduce the risk of syphilis only when the infected area or site of potential exposure is protected.

5.Complications from syphilis such as neurosyphilis are rare because of better diagnosis and treatment

A Simple Guide to Headache

A Simple Guide to Headache

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What is Headache?

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Headache is a very common complaint, not an illness.

It literally means pain in the head.

What are the Common Types of Headaches?

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Tension headache:

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as defined by the International Headache Society is characterised by:

1.bilateral location

2.pressing/tightening (non-pulsating) quality

3. mild to moderate in intensity

4. not aggravated by routine physical activity like walking or climbing stairs.

It is the most common headache and may be associated with contractions of head and neck muscles due to physical or mental stress. The headache is made worse by changes in the environment, drugs, or factors unique to the individual.

It can also be classified into 2 side types:

episodic (<>

chronic (> 14 days a month on average and <>

Treatment can be divided into:

pharmaceutical

non pharmaceutical

Pharmaceutial:

can be divided into acute and prophylactic.

In acute treament simple painkillers is usually effective.

In prophylactive treatment,antidepressants like amitriptyline usually help in the prevention of tension headache.

Medicines should always be given at low doses and titrated up to therapeutic doses to minimise side effects.

Non-pharmaceutical:
1. rest

2. removal of aggravating factors.

3. relaxation exercises

Migraine:

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is defined as a heavy throbbing pain usually over one side of the scalp, forehead and about the eye, caused by abnormally dilated blood vessels.

Migraine may be accompanied by nausea, vomiting or sensitivity to loud noises or bright lights.

It is also triggered by certain factors unique to the individual such as:

1.menstruation,

2.alcohol,

3.anxiety,

4.loud noises,

5.bright lights

A validated 3 items questionaire covering

1. disability

2. nausea

3. sensitivity to lights

should given to every patient to screen the severity of the migraine.

Treatment again is divided into:

phamaceutical

non-pharmaceutical.

Pharmacetical:

can be divided into acute and prophylactic.

In acute treament simple painkillers like paracetamol is usually effective in mild cases.

Non-steroidal anti-inflamatory drugs should be tried if paracetamol fails.

If NSAIDs are ineffective then migraine-specific drugs like triptans or ergotamine which act to constrict blood vessel should be tried.

In some cases anti-emetic drugs like stemetil to prevent vomiting is given together with the migraine medication.

In prophylactic treatment, the goals are to:

1. reduce frequency,severity and duration

2.improve function and reduce disability

3.improve responsiveness to treatment of acute attacks

Medicines used include:

betablockers

Calcium channel blockers

Serotonin receptor antagonists

Antidressants

Anticonvulsants

Angiotensin blockers

NSAIDs

Non-pharmaceuticals:

1.resting in a cool, dark and quiet room.

2.relaxation exercises

3.Solving the triggering factors also help.

4.Oestogen containing oral cotraceptives should avoided in menstrual migraine.

During pregnancy or lactation treatment should be non-pharmaceutical when possible. If necessary paracetamol is the safest drug for women during pregnancy or lactation.

Cluster headaches

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is defined as pain which occurs in runs with tearing pain over the forehead or behind the eye(s) with flushing of the face.

There are aura of stars,flashing lights etc associated with this headache.

The cause is beleived to be due to histamine release from ingestion of certain foods like cheese, seafood,alcohol etc.

It is more common in males.

Treatment is by

1.strong painkillers

2.avoidance of food triggers

3.rest.

What are Secondary headaches?

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Secondary headaches refer to headaches associated with a known medical illness.

It is diagnosed by its close relation to a disorder that is known to cause headache.

The headache improves or disappear after successful treatment or spontaneous resolution of the causative illness.
1.Sinus headaches:

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are due to acute sinus inflammation attacks.

Pain is over the frontal forehead and the upper cheeks.

It may be associated with fever and heavy mucus production.

Treatment is by

1.antibiotics for the sinus infection,

2.antihistamines to reduce mucus production

3.painkillers

4.rest.

2.Referred headaches:

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these are caused by by referred pain from disorders of structures around the head. Common ones are

1. earaches,

2. toothache causing pain over an entire part of the face and

3. temporomandibular joint dysfunction from mechanical pain from the jaw joint.

4. temporal arteritis, a rare inflammatory blood vessel condition causing persistent headache at the temporal artery. There is possible complication of blindness secondary to anterior ischemic optic neuropathy. The headache usually resolves or improves with 3 days of high dose steroid treatment.

3.Meningitis / Encephalitis headaches:

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caused by infection of the brain tissue (encephalitis) or the membranes surrounding the brain (meningitis).

Headache is the most common symptom. The pain is diffuse and progressive with fever, a painful stiff neck and other symptoms such as drowsiness, seizures and neurological problems including weakness and numbness.

This type of headache needs immediate hospital treatment.

4.Cerebrovascular Accidents (haemorrhagic stroke):

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a stroke happens when a blood vessel in the brain is blocked or bursts.

Bleeding in the brain causes a sudden severe headache.

There is also associated loss of consciousness and other neurological signs such as weakness, numbness and seizures.

This type of headache needs immediate hospital treatment.

5.Brain Tumour:

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is rare and causes a gradual headache lasting for weeks.

It is localised and associated with nausea, vomiting, loss of appetite and loss of weight.

It is worse in the morning and aggravated by coughing or leaning forward.

By the time neurological symptoms appear such as seizures, numbness, weakness or blindness, the brain tumour has already grown to an advanced stage.

Treatment includes surgery, chemotherapy or radiotherapy.

6. Other causes of secondary headaches are:

a.post traumatic headache following a head injury

b.whiplash injury

c.cerebral venous thrombosis

d. idiopathic intracranial hypertension

e. hydrocephalus

f. sleep apnea

g.cardiac cephalgia

h.acute glaucoma

Simple Treatment of Headache

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Consume a painkiller.

Lie down in a dark, quiet room.

Use muscle relaxation techniques or a gentle massage.

For tension headaches, try a warm bath.

For migraines, put an ice bag or cold towel on your temple.

If the headache do not improve, go for a complete investigation of the headache.

What are the investigations done in Headache?

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You should be investigated for your headache if the headache has:

1. associated fever and and change in mental state.

2. numbness of part of the body or with paralysis.

3. associated fits.

4. sudden onset of severe headache

5. lasted for more than a day even after taking painkillers.

6. increased headache frequency.

7. appeared different from your usual type

8. been precipitated by coughing,sneezing,bending

9. associated with stiff neck and vomiting

10.appeared for the first time in middle age

Common tests:

Blood tests - for infections,raised ESR, bleeding disease

MRI of brain- to exclude brain tumours, bleeding in the brain

Lumbar puncture - used only if there is suspected infection of brain or meninges

A Simple Guide to Hypertension

A Simple Guide to Hypertension

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What is Hypertension?

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Hypertension, or high blood pressure, refers to a condition in which the blood is pumped around the body above normal pressure.

It is a silent disorder and the only way to detect it is to have your blood pressure checked.

When is it High Blood Pressure?

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Blood pressure is not fixed. It varies with time of day or night, physical activity and emotional factors. Therefore, blood pressure has to be taken under resting condition and on more than one occasion.

A blood pressure reading of 120/80 is read as 120 over 80 millimetres of mercury.

The top number is your systolic pressure. This is the pressure in your arteries when your heart pumps.

The bottom number is your diastolic blood pressure. This is the pressure measured in your arteries when your heart relaxes between pumps.

Blood pressure may vary from 90/60 in a young healthy person to 130/80.

Normal blood pressure is below 130/80.

Blood pressure between 130/80 and 139/89 is called "pre-hypertension".

Blood pressure of 140/90 or above is considered high.
Hypertension is present when your blood pressure is persistently at or above 140/90( at least 3 consecutive readings).

What are the Causes of Hypertension?

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In 95% of cases, there is no definite known cause and it is known as essential hypertension. Older people and men are more likely to develop high blood pressure.

It also tends to run in families. Although, you may inherit the tendency to get high blood pressure, other lifestyle choices (eating an unhealthy diet, smoking, not exercising) will often determine if you eventually get the disease.

The other 5% of high blood pressure cases are due to kidney disease, glandular (hormone/endocrine) problems or a side effect of some medications and are called secondary hypertension.

Listed below are some causes of secondary hypertension:

Adrenal gland tumours

Cushing's syndrome

Kidney disorders

Kidney failure

Use of medications, drugs, or other chemicals

Pregnancy or the use of oral contraceptives

Diabetes mellitus

Obesity

What are the Symptoms of Hypertension?

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Hypertension often causes no noticeable symptom but can cause damage of various organs in the body if the blood pressure remains persistently high. It is thus often called the silent killer. Over years it can lead to damage to the heart and blood vessels, making it more likely that the individual will develop a stroke or heart attack.

Occasionally, especially when the blood pressure is extremely high, the individual may experience:

Headaches,

Dizziness,

Alterations in vision.

Confusion

Nausea

Vomiting

Anxiety

Excessive perspiration

Redness of the face or other areas

Muscle tremors

Angina-like pain: crushing central chest pain

How is Hypertension Assessed?

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Assessment of hypertension is important in determining the known causes of Hypertension (5%) and in the treatment of the condition:

1. Medical history

2. Physical examination

3. Evidence of complications

4. Blood and urine tests

5. Chest x-ray

6. ECG (electrocardiogram)

What are the Complications of Hypertension?

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Hypertension is an important risk factor for coronary heart disease and cerebrovascular disease e.g. strokes.

Poorly controlled hypertension ultimately can cause damage to blood vessels in the eye, thickening of the heart muscle and heart attacks, hardening of the arteries (arteriosclerosis), kidney failure, and strokes.

An elevation of the systolic and/or diastolic blood pressure increases the risk of developing

1. Heart (cardiac) disease,

2. Kidney (renal) disease,

3. Hardening of the arteries (atherosclerosis),

4. Eye damage, and

5. stroke (brain damage).

These complications of hypertension are often referred to as end-organ damage because damage to these organs is the end result of chronic (long duration) high blood pressure.

For that reason, the diagnosis of high blood pressure is important so efforts can be made to normalize blood pressure and prevent complications.

It was previously thought that rises in diastolic blood pressure were a more important risk factor than systolic elevations, but it is now known that in people 50 years or older systolic hypertension represents a greater risk.

Prevention, early detection and adequate treatment of hypertension are necessary to prevent complications of hypertension.

What is the Treatment of Hypertension?

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The aim of treatment is to reduce the risk of complications.

This is done in 2 ways:

Control of high blood pressure

Management of the risk factors eg obesity, diabetes, raised blood cholesterol

Every hypertensive patient or person at risk of developing high blood pressure should adopt a healthy lifestyle.

This means eating wisely:

A diet with reduced salt,

Low fat and high fibre.

Keep your weight in the healthy range,

Exercise regularly,

Not smoke or drink and

Manage your stress better.

Occasionally, marginally raised blood pressure goes back to within the normal range when the patient loses weight, exercises more and cuts down salt intake.

If these measures are not successful, then drug treatment is necessary.

Once medication is started, it important to continue treatment as well as continue with healthy lifestyle practices.
The goal of treatment is to reduce blood pressure to a level where there is decreased risk of complications. Your doctor will try to prescribe a single drug with minimal side effects to control your hypertension. But if a single drug does not work, he will prescribe two or more drugs.

Some of the common drugs used are:
1. Diuretics, which increase urination, to reduce salt and water retention and lower blood volume. They may be used alone or in combination with other drugs.

2. Beta-blockers, which slow the heart rate and cause the heart to beat less forcefully. 3.Calcium channel blockers which relax the blood vessels by slowing the entry of calcium into cells.

4. Angiotensin-converting enzyme (ACE) inhibitors which block the production of angiotensin II (which causes arteries to constrict and stimulate the release of a hormone which causes salt retention).

5. Angiotensin II receptor blockers (ARB) which relax blood vessels by blocking the action of angiotensin II.

Which drug is suitable for you depends on the effectiveness of the drug on your blood pressure and also on the side effects. If the the side effects are severe, it is advisable to change the medications until you have a suitable drug.

Treatment for most people is life-long.

Do not stop or reduce the dosage of your medications without consulting your doctor.

For effective blood pressure control, you should visit your doctor regularly to monitor your blood pressure. You can also monitor your own blood pressure at home with an electronic blood pressure monitor.

How do you prevent the risk of Hypertension?

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You can adopt these lifestyle measures to reduce your risk of high blood pressure.

Lifestyle changes are also important for those who already have high blood pressure.

1.Lose weight, if overweight. Excess weight adds to strain on the heart. In some cases, weight loss may be the only treatment needed.

2.Adopt a healthy diet. Dietary adjustments may be beneficial, especially a decrease of sodium in your diet. Sodium intake may have little effect in persons without hypertension but may have a profound effect in those with hypertension. Salt, MSG, and baking soda all contain sodium. Make sure you eat a diet rich in vegetables and fruit and low in fat.

3.Stay active. Do at least 30 minutes of moderate intensity exercises five or more days a week. You can break up the 30 minutes of exercise a day into 10 minute bouts. As your fitness level improves, do vigorous intensity exercise for 20 minutes a day at least 3 times a week for example, jogging or swimming continuous laps. Remember to consult your doctor before you embark on any exercise plan.

4.Stop smoking. If you are a smoker, stop smoking. Smoking greatly adds to the risk of suffering a heart attack or stroke.

5.Limit alcohol intake. Keep your alcohol intake to less than 1 or 2 standard drinks a day.

6.Learn to relax and avoid stress. Meditation, yoga, tai-chi are some ways in which you can learn to relax and lead a less stressful life.

REMEMBER that long term effective control of high blood pressure is crucial in reducing the risks of serious complications of HYPERTENSION !