38

Panel Interview of

Prof. Dr. Farrukh Zaman

MBBS, FCPS

Professor of Obstetrics and Gynaecology

Postgraduate Medical Institute, Services Hospital, Lahore.

(Following text has been prepared from the answers given to the questions by the panel members. Panel consisted of Dr Saadia Bakhtiar, coordinator for this issue, and Dr Mehboob Ashraf, Dr Liaqat Ali Chaudhry and Dr Saleem Akhtar Rana)

Reproductive Health.

Definition: Care of female gender starting right from female foetus upto the grave. Application of this concept is essential to alleviate all cruelities meted out to women in all fields such as female fetocide.

Background: It is a relatively recent term. Uplift of Society is not possible untill women are fully developed, given equal status in all matters, and are properly educated. They should be economically independent. All human rights must be implemented fully and forcefully as regards women in any society. Prejudices against them should be eliminated. These concerns were raised and policies adopted in very high profile conferences in Cairo in 1994 and later in Beijing.

Contrception use rate increases when literacy rate and income goes up. In Siri Lanka literacy rate is 98 % and number of children is 2.8/women. In India this is 3.4,in Pakistan it is 5.4.Infant and maternal mortality rates also improve with improvements in income, education and granting of more and more rights. Awareness about these things has to be created not only in ladies but in males also.

Expenditure on such essential sector is appauling low. One week’s expenditure on armaments worldwide is more than what is being spent on contraception in whole of the world.

Role of Family Physicians:

They should lead the crusade

• for uplifting the nutritional, educational and all social indicators.

• Awareness about the hazards of early age marriages.

• Advice right after marriage about birth spacing.

• To advocate and propagate about all human rights of women in the society.Especially to prepare the society to grant decision making power to the wives in the affairs of the family.To assist her to acquire the decisions about fertility matters

Sexually Transmitted Diseases, STDs:

• Incidence is probably coming down. May be due to use of antibiotics.

• Still vigilance about AIDS and Herpes Simplex is needed. There are cases of these infections. We need strong awareness in public and physicians about these.

• Chlamydial infections are most common cause of tubal blockage.These are asymptomatic. Difficult to diagnose.

• Use of codoms is much more desirable to avoid these STDs.An awareness compaign is much needed at this stage. Some users complain that they have allergy with condoms. A doctor must confirm allergy. If it is so low allegen condoms are also availabe or brand can be changed.

Prolapse of Uterus.

• In the etiology one important factor is inappropriate handling and effort to deliver and asking the mother to bear down baby in the phase of undilated cervix.

• Multiparity and chronic ill health are other factors.

• Main symptoms are feeling of pressure and something coming out.

• Pessaries can be used if family is not complete. Once Family is complete then surgical treatment is the only answer.

• Prior to surgery treatment of any local ulcers is mandatory.

Vaginal Discharge.

• This is most frequent complaint in our outdoors. Excessive but normal discharge needs only careful listening and giving due weight to the complaints of patients. Explanation of association with menstrual cycle and education may help the women to accept it as normal variant.

• Leucorrhoea, which is though inflammatory and pathological but it, is not due to any infection. Speculam examination is essential. Cervical erosions (ectopy) are usually there. These need cautery.

• Vaginal discharge associated with candida, trichomonas or anaerobes needs local treatment. First local treatment should be tried. If there is no response after 2 local courses then systemic therapy can be given.

• Neither there is routine nor there are facilities available for culture and sensitivity of vaginal discharge. For anaerobes culture has to be inoculated and transmitted to the laboratory. Logistics involved are not feasible.

Urinary Incontinence

Mainly of 3 types. Urge, Stress and Detrusor instability.

• Urge incontinence: Rule out U T I .It requires psychological management.

• Stress incontinence/Detruser Instability.Whenever there is sudden rise in abdominal pressure ,some urine leaks.Pelvic floor excercises are quite useful to strengthen.Here patient should be educated that she should contract her muscles as she would do when she is having urge to pass urine but can not pass due to any reason and she is trying to control the leaking of urine. After contracting the muscles she should keep these muscles contracted till she counts upto 10.Then she should release the pressure. It should be repeated 10-20 times at one time.Drugs like oxybutanil may be helpful.

Abortions

Diagnosis.Ultrasound examination is single most important investigation to diagnose the status.

At 6 weeks foetal pole should be visible. As long as it is visible at this time abortion should be labelled as threatened only. At 7-week gestation cardiac activity should be seen. If in doubt USG can be repeated after another one week. Again as long as cardiac activity is visible, abortion is not there.Urine pregnancy test can also be of help to diagnose pregnancy.

Repeated Abortions.

Recurrent U T I

A true midstream sample can really reduce many pus cell counts to normal.

If it is still 15-20 then urixin, Cefspan and Augmentin can be used after ordering for culture & sensitivity.These are safe in pregnancy also.

Investigations to rule out urological malformations and persistent pathology should be ordered in all difficult to manage cases.

Infertility

Causes: Male factors = 40 %

Female factors = 40 %

Both factors = 20 %

Time for investigations:

If there is no apparent abnormality in history, and couple is living together and having norml intercourse, wait for one year before there is any need for specific investigations.

Investigations.

• History is of paramount importance. It should cover all aspects of menses, intercourse and any medical illness.

• Thorough Examination of both partners is next prerequisite. Pelvic examination of ladies by gynaecologist is essential. Hydrocele and varicocele in males usually do not affect fertility.

• Routine investigations of both partners. CBC + ESR, Urine, blood sugar should be done in both partners. USG of wife should be ordered.

• First Specific investigation is always Semen Analysis.Interpretation of findings should not be very strict. Lower limit of normal count is 20 millions. Forward motility of 20 % is good enough. Abstinence from intercourse should not be more than 3 days before sample collection. Pus cells and RBC in semen are not relevant to fertility.

• Laproscopy is the next investigation of my choice. It can check endometriosis, PID, tubal patency, ovaries and pouch of Douglas in addition to much other routine pathology.

Section by Dr Saadia Bakhtiar

Gynaecologist DHQ Hospital Gujranwala.

High-risk pregnancies. Vigilance needed by family physicians.

Firs term.1-13 weeks.

2^nd Term.14-26 weeks.

3^rd Term, 27 – 40 weeks.

___________________________________________________________

Pregnancy in the presence of medical problems.

Indications for termination of Pregnancy

Important Emergencies in Obstetrics and Gynaecology.
Shock may be the setting in which patient presents. It can be present in many of the following conditions.

Shock

Eclampsia

Torsion of Ovarian Cyst.

Peurperal Sepsis.

• Fever during this period needs stringent routine examination from head to toe.

If cause is located obviously management should be accordingly.

If no cause can be localized then PUO should be the diagnosis.

Vaginal Discharge.

Pelvic Inflammatory Disease.

Pelvic Tuberculosis.

Diagnostic features.

Low Backache

Since incidence of low backache is more in females, it is presumed that causes lie in genitalia. But the actual reason is weak musculature and insufficient ligamentous support in females along with stresses of pregnancy and coital positions.

Cuases in genital track.

Pain is diffuse and bilateral in distribution and below the level of L4.

1. P I D (Especially Ch Cervicits): Accompanies vaginal discharge, pain lower abdomen, Dyspareunia, Severe dysmenrrhoea. History of abortion or recent delivery or peurperal sepsis may be present.

2. Prolapse and retroversion: This is always relieved when patient lies down. Pain is dragging in nature.

3. Tumours: A large abdominal tumour, ovarian masses, Endometriosis involving uterosacral ligaments.

4. Pregnancy: Due to lordosis.

5. Premenstrual tension: or other causes of pelvic congesion

6. Gynaecological operations. Due to prolonged lithotomy positions, post op lying in sagging bed or prolonged lying on flat table.

Extra Genital causes.

1. Obesity: Obviously weight reduction and excercises are primary tools.

2. Grand multiparity and menopause: Ca supplementation with vit D & H R T and excercise.

3. Bad postures

4. Pendulous abdomen: Changes the centre of gravity and puts extra burden on back muscles.

5. Bone and Joint lesions: Needs investigations.

6. Diseases of Kidney and Ureters :

7. Psychological Causes:

Brief Review of Problems of Breast.

Rule of Thumb:

Lump in the breast is the commonest finding and greatest source of tension. Nowadays rule of thumb is that no matter how benign and innocent looking lump is, it must be subjected to fine needle aspiration (FNA)

Further management is as follows.

All masses FNA  (A) Cystic Mass (B) Solid Mass.

 

Findings 1) Clear Fluid 2) Residual Mass or thickening 3) Bloody Fluid 

   

Follow up at 3 months   

Excisional Biopsy Excisional biopsy 





Cytologic preparation.   



Malignancy Benign inconclusive

  

Treatment. Repeat FNA at 3 months Open surgical biopsy.

This scheme is simple one. If on aspiration there is fluid and this fluid clears on aspiration. All it needs to be done is to do aspiration again at 3 month. All other conditions require cytological examination whether tissue obtained on aspiration or on excisional biopsy.

Common Conditions.

Some Commercial Antifungal preparations.

Name How to use Total cost.

Vaginal Tablets.

• Nilstat Vag tab one daily for 10 days Rs 18

• Canesten I tab one stat only Rs 124.

• Canesten vag tab one each night for six nights. Rs 142

• Clotrima tab 100 mgs one each night for six nights Rs 51

• Clotrima tab 500 mgs One stat only Rs 50

• Gynosporin 500 mgs One stat Rs 60

• Gynotravogen tab One stat Rs 135

Vaginal Antifungal Creams.

• Canesten vag cream Once only application Rs 112

• Gynosporin Cream Twice daily for 3 days Rs 96

• Gynotravogen cream Once daily for 7 days Rs 175

• Gynodaktarin two applicators od for 7days Rs 96

Antibacterial local applications.

• Dalacin V 3 nights Rs 410

• Sulphakream BD for 7 days Rs 60

• Vagibact cream Rs 250

Some commercial HRT preparations

Name Contents How to Use. Total monthly cost.

• Premarin Conjugated Estrogens 0.625 mgs one daily for 21 days Rs 45
  (may be combined with orgametral, OD, for last 10 days of cycle. Rs 35)

• Premarin Vaginal cream. 21 applications once daily ,only one course Rs 325

• Climen E & P Pack of 21 tab Rs 290

(O.D, from 5^th to 25^th day, Always gap of 7days.Then start new pack.)

• Femoston E& P Pack of 28 Orange and yellow tabs Rs 580

Start from orange, proceed towards yellow. No gap

• Livial Synthetic E O.D for minimum 3 months.No gap Rs 683

(More suitable for vasomotor symptoms)

• Trisequens Blue white and pink tabs. No gap. Rs 238

One daily no gap RS 250

(Should be started one year after menopause.)

Kliogest One daily for 10 days from 15^th to 25^th day. Rs 75

Section by Dr Liaqat Ali Chaudhry

A family physician.

Adolescent Gynaecology.

Puberty and Menarche.

During infancy and childhood, the hypothalamus is inhibited from producing gonadotrophin releasing factors by the small amount of steroids secreted by the infantile ovaries.

Puberty is initiated by the maturation of the hypothalamus. It depends upon a complex interaction of hypothalamus, pitutary ovarian axis and environmental & genetic factors.

Typical sequence of events of Puberty includes Thelarche, Adrenarche, and Growth sprut, Menarche.

Evaluation of Delayed Menarche.

Family physician has the capability to evaluate the vast majority of patients who depart from the normal timetable for sexual and somatic growth. Physiological delay, anatomic abnormalities and primary ovarian failure still comprise the largest number of patients with menarchal delay. Late adrenarche may be present in the family history but it does not eliminate the possibility of serious organic pathology.

• Most patients with physiologic menarchal delay have normal stature, normal phenotype, slight secondary sexual characters, palpable cervix, estrogenized vaginal smear and slightly retarded bone age.

For initial evaluation following basic studies are mandatory.

• History and physical examination, height, and evaluation of secondary sex characters.

• To rule out anatomic causes palpate cervix on rectal or vaginal examination. Presence of cervix guarantees a uterus and a patent lower genital tract. It also rules out complete vaginal agenesis. The cyclic or continous pelvic pain with bladder irritation almost invariably accompanies genital tract obstruction like imperforate hymen or transverse vaginal septum.

• A vaginal smear for hormonal cytology in girls, who do not have evidence of breast development, demonstrates superficial cells and Doderlein’s bacilli.

• A Pitutary tumour may interfere with the release of ovarian steroids after breast development has occurred and only vagina will clearly reveal an estrogen defecient state.

• Lateral X-Ray of Skull.
  A pitutary tumour, usually craniopharyngioma or chromophobe adenoma may interrupt the process of pubertal development.

• Reevaluation after 6 months. If there is still no menarche then buccal smear for chromatin mass study is necessary.

• X-ray for bone age. AP views of hand and pelvis are sufficient.

• Rare cause of delayed menarche, Tuberculosis, (may be shown by calcification). Patient with severe degree of growth retardation, (under 63 inches of height).

• Patients in whom vaginal smear reveals no evidence of estrogen effect Gonadotrophins, FSH & LH should be measured. High levels indicate primary ovarian failure.

• Trial of Progesterone If vaginal smear reveals over 20 % superficial cells then a synthetic progesterone such as medroxyprogesteron can be administered in doses of 10mgs daily for first five days every other month for six months. If menses occur, it confirms that uterus is responsive and genital tract is intact.

• In primary Amennorrhoea Diabetis Mellitus should be ruled out.

• Imperforate hymen should be corrected regardless of the age of patient.

Breast Problems in Adolescence.

• Asymmetry in size is the most frequent complaint in this age. Usaully it is not significant and does not need any treatment.

• Most of the adolescent tumours are fibroadenomas. Malignancy is rare. Observe for 2-3 cycles. If these do not disappear then excise.

• In 8-9 years old girs with precocious puberty, where all secondary sex characters are fully developed, Constitutional variety needs no treatment. Estrogen producing tumours can be ruled out by ruling out mass in abdomen or pelvis.

• Hypoplastic breasts with regular menstrual cycles may need augmentary surgery. Girls on crash diet and with Anorexia Nervosa also have atrophy of breasts.

• Primary amenorrhea associated with absent breast development may be due to a lesion at pitutay-hypothalamus level or at gonadal level.

• Heterosexual development if evident then androgen producing tumour in pitutary, adrenals or ovries has to be ruled out. Chromosomal sex should be determined.

• Virginal hypertrophy of breast may be present. It is of unknown etiology.

• Pathologic Galactorrhoea is usually associated with, secondary amenorrhoea of hypothalamic –pitutary origin. Oral contraceptives tranquilizer steroids stress.

Serum prolactin levels and lateral X-ray of Skull are mandatory.

Vulvovaginitis.

Dysmenorrhoea.Symptoms include cramps in lower abdomen and back. Headache, nausea, vomiting, tension, irritability and depression. Prostaglandins cause contractions of smooth muscles.

• First of all proper examination and history should rule out or label any specific cause.

• Reassure the patient and yourself in primary dysmenorrhea.

• In primary dysmenorrhoea typically pain occurs many months after the onset of menarche with a secretory endometrium. Symptoms occur before the menstrual flow.

• If dysmenorrhoea is associated with very first period and symptoms arise after the flow, psychogenic factors play part.

Section written by Dr Saadia Bakhtiar and Dr Mehboob Ashraf.

Contraception

Different Categories of patients. First choice for them.

At the end of this chapter 7 possible categories have been defined with specific needs. Method of choice for each has been defined.

Three Cardinal principals.

When to start contraception.

First pregnancy should be ruled out. The best time in this regard is just starting all measures immediately after menses or during menses. This will ensure that there is no pregnancy.

Intrauterine Contraceptive Device I U C D.

• No systemic effects. Highly effective. Can not be prescribed without pelvic examination.

• Mode of Action.

I U D causes local sterile inflammatory reaction. This releases endothelial leukocytes. These are toxic to all cells including sperms and blastocyst. Addition of copper increases the capacity for inflammatory reaction. Medicated I U D contain progesteron which makes implantation difficult. It also changes the character of mucus in cervix.

• Checklist before advising IU C D. (Contraindications.)

It can not be advised if following situations are present.

Hormonal preparations

Checklist for Hormonal methods.

If answer is NO to all-following questions then hormonal methods can be started rightaway. Otherwise further assessment is required.

• First day of menses 7 days ago.

• ? Breast-feeding and less than 6 weeks postpartum.

• ? Any irregular or post coital bleeding.

• ? History of jaundices 3-6 weeks ago.

• ? Severe pain in calves, thighs, or swollen legs.

• ? B P more than 180/105 or above.

• ? CA breast or suspicious lump.

• ? Taking any drug.

Contraceptive Pills.

• Types.

Combination pills (COC)
Contain estrogens and low doses of progestogens. These may be high dose or low doses.
High dose: Ovral.Eugynon, Low dose: Microgynon.Nordette.
These are taken for 21 days with placebo tab for another 7 days to make the pack of 28 tabs.

Progestin only pills (POP): Microlut, Micronox, and Ovrette.

Sequential pills.

• Mode of Action.All kinds of tablets inhibits ovolution by suppressing gonadotrophins. Cervical mucus changes into thick viscous material, which is hostile to transport of Sperms.Endometrium becomes flat and inactive under the influence of progesteron and it is not prepared for implantation of the embryo.

• Need additional barrier contraceptives when Women should select a back up method such as condomes or spermicidal cream under following conditions.

*For 1^st two weeks of first time use.
*For rest of the cycle when she misses tablest on two consective days. If she misses on one day only, she should take two tabletes next day and complete the pack as usual.
*For rest of the cycle if She had diarrhoea or vomitting.
*When she stops taking the pills for any side effect.
*If she needs any protection against STDs.

• Drugs rendering pills less effective Seizures drugs like Phenytoin, Carbamazepine etc. ATT drugs as Rifampicin. Antibiotics like ampicillin and tetracycline. All other drugs that change liver function or G I T absorption.

• Absolute Contraindications.of oral pills. *Genital bleeding of unknown cause. *Past or active breast or liver cancer. *Thromboembolic disorders. Estrogens cause increase in factors 8 and 3,increasing the incidence of superficial and deep thrombosis withen 10 days of starting. *Smokers over 35 years of age. *Cardiovascular death rate is higher; four fold, in women using these pills. This is not related to the period of use. *Breast feeding till 6 months after delivery.

• Relative Contraindications. *Smokers under 35 years of age. *Diabetes. *Chronic hypertension. *Hyperlipidaemia. *Chronic migranous headackes. *Seizures.Actually it needs monitoring if pills are used.

• Benefits of Oral Contraceptives other than contraception. Regulation of menses. Reduction of Menorrhagia and Dysmenorrhoea Decreases risk of uterine and ovarian cancers, functional ovarian cysts and anaemia.

• Main drawbacks Must be taken regularly Common side effects may become unacceptable to women. Affects natural hormonal cycle. May cause menstrual irregularity. Can delay fertility upto 6 months.

Common Side effects.

• Break through bleeding Amenorrhoea/Spotting. Breakthrough bleeding is common in first 3 months. Only Reassurance is needed. Gynaenocological problems like tumours, pregnancy, abortion should be excluded. Make sure patient is not missing any tablet. She is using at the same time each day. Bedtime is better. If bleeding still persists then set her on higher dose of estrogoen untill bleeding is settled then bring her down to lower dose.
  Amenorrhoea: If pills are missed then risk for pregnancy is increased. During the continous use of pill amenrrhoea may develop. Just reassure her if she has not missed any tablet. If there is pregnancy and patient wants to continue it, discontinue pill and then again just reassure her that these pills had no adverse effects on foetus. If paient has stopped pills and there is no pregnancy yet, along with amenorrhoea, just reassure the patient that it may take little time before the regualr menses will start.

• Breast tenderness. Usually improves within first 3 months. Pregnancy should be ruled out. If there is a lump then until this is disposed off, pills should be stopped and barrier methods should be used. If patient is breast-feeding, examine for infection and treat. Support can be advised.

• Headaches rule out any past history. Check for sinuses and organic causes. If headache is severe, frequent and associated with nausea then discontinue the pills and adopt other non-hormonal measures.

• Mild Depression After ruling all other possible causes If pills are held responsible for causing it or worsening already present depression then pills should be discontinued.

• Acne/Oily skin. Weight gain.

• Nausea/Dizziness/Nervousness. These complaints improve within 3 months. Pregnancy should be ruled out. Pills should be taken before bedtime. If problem still persists then an informed choice should be given to patient between other pills and other methods.

• Hypertension. Hypertension is a contraindication for pills. If it develops during the use then record readings on 3 visits, one week, apart, with proper protocol. If Systolic remains above 160 or Diastotic above 90 or diastolic alone above 110 on any single visit, pills should be discontinued.

• Warning signs of dangerous complications. In the presence of following conditions pills should be discontinued immediately and patient refered to appropriate specialist.
  Severe abdominal pain: May be there is gall bladder, pancreas or liver disease. Clot may be there.
  Severe leg pains? Thrombophlebitis.
  Severe chest pain with shortness of breath. Heart attack? Pulmonary embolism.
  Loss of vision or blurred vision, headache, Dizziness, Weakness, Numbness, Slurred speech. Stroke or Hypertension.

Contraceptive Injections.

These contain progesterone, which inhibits hypothalamus-pitutary-Ovarian axis. It also affects the endometrium and cervical mucus. Two kinds of injections.

Depoprovera: Medroxyprogesterone 150 mgs.
Given every 3 months. Deep intramuscular. Failure rates 1%.

Noristerat (Not-En): Norethistrone 200 mgs. Given every 2 months. Deep intramuscular.

• Main Side effect: Amenorrhea or Heavy irregular frequents menses.

• Use alternate methods during first week after first injection.

• When first injection should be given? Between day 1 and 5 of cycle. First 7 days after abortion. First 4 weeks post perpeurium if mother is not breast-feeding. After 6 weeks post perpurium if mother is breast-feeding.

• If patient presents late for next injecion! Delay uptill 2 weeks does not matter. Injection can be given anytime. If delay is for more than 2 weeks, then first rule out pregnancy. Then patient should be advised to use alternative methods for one month. After this period pregnancy should be ruled out and injection can be given again.

• If patient presents early for next injection! Next injection can be repeated 2 weeks earlier. But then period of 3 months should be counted from this date.

• Warning signs. In the presence of following complaints, patient should report to doctor immediately.

• Heavy bleeding (Twice as long or as much as normal bleeding) continuing for more than 7 days between periods.

• Delay in menstrual periods after regular periods for long time.

• Migrainous headaces or blurred vision.

Side effects of contraceptive injections and their management.

• Light bleeding or spotting. Patient should be assessed for anaemia. Rule out any gynaecological problem. Reassure that these problems will settle down in 9-10 months and do not need any treatment.

• Moderate Bleeding. Anaemia should be checked. Ectopic missed abortion, infection of Genital tract or fibroid, polyp or neoplasia should be ruled out.
  14-21 low dose combined oral contraceptive pills can be given. Next injection should be given 4 weeks earlier.

• Heavy or Prolonged Bleeding &Amenorrhoea Anaemia should be corrected. Pregnancy test should be done to rule out pregnancy or abortion. A one-month course of oral pills in addition to one-week use of NSAIDs can be tried. If patient wants to discontinue then help her to find alternative methods.
  Amenorrhoea is common in injection users. Uptill 50 % patients can have it. If there is amenorrhoea after having regular periods for sometimes after starting injections then pregnancy should be ruled out.

• Lower abdominal pain. Differential diagnosis includes ectopic pregnancy, Ac Appendicitis, Ovarian cysts, and PID.Patient should be advised consultation with gynaecologist.

Emergency /Post Coital Contraception.

Morning after pills can be used within 72 hours, although withen 24 hours is preferable. High dose steroids disrupt endometrium and render it difficult for implantation. Following tablets can be used.

Take 4 COCs of low dose, e.g, nova, nordette, and feminol. Repeat 4 tabs 12 hours later. Or 2 tabs of high dose (ovral) can be used, to be repeated 12 hours later.

Tab Postinor: one tablet withen one hour of intercourse. If there is another intercourse withen 3 hours then one more tablets should be taken. No more than 4 tabs can be taken in one month.

Laevonorgesterol implants. (Nor plants.)

This is long acting, reversible and affective birth control device. Six flexible silicon rubber implants, containing laevonorgesterol can be implanted under the skin on forearm. Small amounts of progesteron are released after regular intervals for 5 years. Main side effects are menstrual irregularities, which tend to settle in few months. Mode of action, side effects profile and their management is similar to injections.

Check list for Permanent Sterlization (Vasectomy, Tubal Occlusion)

• Family should be complete obviously.

• Diabetes Mellitus must be tightly controled.

• Hb must be more than 10 gms/dl. Otherwise it should be raised.

• Patient should be rejected if there is any active lung or kidney disease.

• Emotional status should be assessed. Thorough understanding should be there. Later on it should not be a cause of psychiatric problems.

• B P should not be >180/105.

• Previous abdominal & pelvic surgery, history of induced abortion need to be done under GA, unless thorough assessment by gynaecologist. If pelvis is fixed on examination then this also needs full assessment. Complicated patients, after their medical problems are controlled, can be assessed for this procedure.

• Vasectomy should be preceded by search for scrotal and inguinal infections or anomalies.

Contraception in-patients with gynaecological problems.

All patients with any kind of gynaecological problem, who wish to be on contraception, need a thorough pelvic examination. Management should be obviously according to the findings. Following guidelines are for those patients whose examination is normal.

• Patients with slight intermenstrual spotting without any organic cause should be advised injections and cervical smear.

• If patient has severe dysmenorrhoea COCs are drugs of choice.

• Patients with symptomatic fibroids and complete family TAH are advisabe. If family is not complete then they should complete it quickly. Otherwise they can use low dose COCs, Condoms, or IUD.

• Patients with active pelvic infection should be treated vigorously with antibiotics and meanwhile condoms can be used. Once the infection is irradicated then normal protocol should be appllied.

• Patients with previous history of PID or ectopic should be advised condoms, COCs and injections.

Contraception In patients with medical problem.

Patients with chronic medical problems should calculate the risks of pregnancy, contrception and sterlization. Doctor should help to focus the issues and provide complete information.

• Diabetics: in controlled and uncomplicated patients no extra calculation is needed. In uncontrolled or with complications present, condoms, IUD and injections can be used.

• Patients on anticoagulants: COCs are contraindicated. Use other methods.

• Patients on anticonvulsants: No COCs and implants.

• Headaches and migraine: No COCs.

• Hepatitis, Cirrhosis: Try to avoid COCs, implants, and injections.

• Hypertensives: If BP is >180/105,no COCs.If these have to be used then watch BP and modify antihypertensives.

• Cardiac Patients: No COCs, or injections. Convince patient for sterlization if patient can not bear pregnancy. Otherwise condoms or IUD can be used.

• Tuberculosis: No hormones.

Different categories of patients.

Category: Future planning first other methods
of family choice

1. Newly weds 6-12 months period Oral COCs Condoms

2. Couples with planning some I U D COCs, Injecs-
   1-2 children interval condoms.

3. Couples with no more planning Permanent I U D, COCs
   complete families. of children Methods

4. Lactating mothers undefined I U D and inj condoms.
   (If more than 6 weeks post partum)

5. Emergency Contraception.6) Patients with Gynaecological problems 7) Patients with medical problems. Management of these described above.

Internet Section. Debate on Male menopause is included to complete this topic of decline in sex hormones levels with age.
Section on HRT to relieve specific symptoms of Menopause, use of HRT is noncontroversial. Controversy is only about its prophylactic use for osteoporosis, risk for heart diseases and other problems of aging. This Internet section is ment to update our readers on this controversy.

For The male menopause

Duncan C Gould, consultant, Richard Petty, medical director.

The WellMan Clinic, 32 Weymouth Street, London W1N 3FA

It is not inevitability but may occur mainly in middle aged and elderly men when testosterone production and plasma concentrations fall. There seems to be a threshold plasma concentration below which symptoms may become apparent. Testosterone concentrations found to be critical for sexual functioning in men lie around 10.4 nmol/l (300 ng/dl), though there is variation between individuals. While some have found that differences in plasma testosterone concentrations within the normal range in young healthy men do not correlate with differences in sexual activity and interest, others have shown that differences in the concentrations of the potent metabolite, dihydrotestosterone, do.

An abnormally low concentration of testosterone (hypotestosteronaemia) may occur because of testicular dysfunction (primary hypogonadism) or hypothalamic-pituitary dysfunction (secondary hypogonadism) and may be congenital or acquired.

Endocrinology

In the ageing man reduction in testosterone concentration is due mainly to a decline in Leydig cell mass in the testicles or a dysfunction in hypothalamic-pituitary homeostatic control, or both, leading to abnormally low secretion of luteinising hormone with resultant low testosterone production.Mirroring this decline in plasma testosterone concentration is an age-associated increase in plasma concentration of sex hormone binding globulin, resulting in a more pronounced decline in the active or bioavailable testosterone moiety. Concentrations of bioavailable testosterone decrease by as much as 50% between the ages of 25 and 75 years, and it has been proposed that with respect to bioavailable concentrations as many as 50% of men over the age of 50 re hypotestosteronaemic when compared with peak early morning concentrations in young men. With age there is a loss of hypothalamopituitary circadian rhythm, which may result in exaggerated falls in plasma testosterone concentrations by evening.

Symptoms encountered in the male climacteric syndrome

Effects of hypotestosteronaemia

A quantitative definition of hypotestosteronaemia has generally been accepted as 11 nmol/l (320 ng/dl) as only 1% of healthy men aged 20-40 will have a concentration below this limit. Development of hypotestosteronaemia may be related to heredity as 60% of the variability of testosterone concentrations and 30% of sex hormone binding globulin may be due to genetic factors. A history of orchitis, testicular trauma, or other pathology may be contributory.The presence of obesity is associated with lower concentrations of bioavailable testosterone, and insulin concentrations have been found to be indirectly correlated with sex hormone binding globulin and testosterone concentrations. With respect to lifestyle, excess intake of alcohol and physical and psychological stress are all associated with lowered testosterone concentrations.

Affective symptoms have long been associated with hypotestosteronaemia: depressed mood is significantly correlated with low concentrations of bioavailable testosterone in older men. Some longitudinal uncontrolled studies of hypotestosteronaemic men have shown that symptoms of depression, anger, irritability, sadness, nervousness, friendliness, sense of wellbeing, and energy levels significantly improved with androgen treatment. There is evidence for mood disturbance being linked to hypotestosteronaemia and for testosterone replacement therapy being beneficial, but placebo-controlled trials are needed to confirm these issues. Fatigue may occur with hypotestosteronaemia. Profound hypotestosteronaemia in younger men results in accelerated bone loss and osteoporosis. In older men bioavailable testosterone concentrations are positively correlated with bone mineral density at the radius, spine, and hip,and men with hypotestosteronaemia have been reported to be at increased risk of hip fracture.

Investigations and treatment

Investigations should include assessments of concentrations of plasma gonadotrophin, prolactin, and sex hormone binding globulin and early morning concentrations of testosterone. Men with hypotestosteronaemia with unequivocal signs and symptoms of androgen deficiency, and when reversible causes of testosterone deficiency and contraindications have been excluded, should be offered treatment with testosterone replacement therapy in line with the current WHO

Against The concept of Male Menopause.

Howard S Jacobs, emeritus professor of reproductive endocrinology. 

Royal Free and University College School of Medicine,Middlesex Hospital, London W1N 8AA

The normal menopause the final cessation of menstruation is caused by primary ovarian failure. The oestrogen deficiency that often causes vasomotor instability (flushing and sweating attacks), genital atrophy (vaginal dryness and discomfort), and bladder irritability, together with difficulties in cognition and loss of a general feeling of wellbeing. This climacteric syndrome, readily reversible by oestrogen treatment, is obviously sex specific.

In thinking about this we do well to consider how many of the changes in men as they pass from middle to old age should be attributed to the passage of years and how many to a decline in hormone concentrations. It is easy to see the attraction of an endocrine explanation because it raises the possibility of hormone treatment for symptoms that occur at this time of life.Careful review of the literature is at best suggestive. Firstly, what are the hormonal changes that occur in ageing men? Certainly gonadal function wanes: by the age of 80 years.Serum total testosterone concentrations have fallen to about 75% and free testosterone concentrations to about 50% of what they were at the age of 20. The fall of free testosterone (that is, of the fraction that is biologically available to the tissues) is amplified by a difficult to explain but regularly observed increase in concentrations of the sex hormone binding globulin. The fall in testosterone production is partly caused by testicular failure and partly by changes in pituitary gonadotrophin secretion. The key difference from the menopause, however, is the gradual nature of the change in men compared with the precipitate fall of oestrogen concentration in women.

Secondly, what are the biological changes that can be related to these endocrine alterations? So far as sexual activity is concerned the role of testosterone in elderly men is still not well defined. Circulating concentrations of testosterone in older men are usually well above those needed for a normal sexual response, although the proportion of men complaining of erectile dysfunction rises dramatically with age, such that 50% of men between the ages of 50 and 70 years complain of impotence. As many as 80% of cases of erectile dysfunction are now thought to have a medical cause, such as diabetes mellitus, cardiovascular disease (especially angina and after myocardial infarction), neurological disorders (multiple sclerosis and spinal injury), pelvic surgery (prostatectomy), and trauma. Indeed some have suggested that the development of erectile dysfunction should be regarded as sentinel of disease and constitute an indication for careful medical assessment.

Recent work, reviewed elsewhere, has shown that what ultimately determines potency is the ability of muscles in the walls of the artery supplying the penis to relax and so permit engorgement to occur. Nitric oxide released from parasympathetic nerve endings in response to sexual stimulation causes guanylate cyclase to produce cyclic guanosine monophosphate (cyclic GMP), which relaxes arterial smooth muscle. Cyclic GMP is metabolised by a specific phosphodiesterase. Sildenafil citrate (Viagra) inhibits this enzyme, prolongs arterial relaxation, and so enhances erection. As far as impotence in the older man is concerned, unless hypogonadism can be clearly shown, treatment with sildenafil citrate (with appropriate warnings about cardiovascular risks and drug interactions with nitrites) is likely to be safer and more efficacious than injections of testosterone esters.

To conclude, I really do not find the analogy of the female menopause helpful in understanding or trying to manage the problems of senescence in men. Moreover, the endocrinology of ageing is much broader than that the term suggests. As Lamberts, van den Beld, and van der Lely have pointed out, while the fragility of elderly people might be related to a gonadopause, an adrenopause (the age related fall of dehydroepiandrosterone sulphate concentrations), or a somatopause (the decline in secretion of growth hormone and insulin like growth factor), actually in old people the commonest endocrine disorders are diabetes mellitus and hypothyroidism. These conditions are definitely treatable.

Hormone replacement therapy

Kay-Tee Khaw, Professor of clinical gerontology.

Clinical Gerontology Unit, University of Cambridge, Addenbrooke's Hospital,

Cambridge CB2 2QQ

(Appeared as editorial in BMJ 1998; 316:1842-44, 20 June)

Risk-benefit relation differs between populations and individuals

Hormone replacement therapy is increasingly advocated not just for short-term treatment of menopausal symptoms but as long term prophylactic therapy against heart disease, osteoporosis, and even Alzheimer's disease, as the solution to many of the problems of ageing women. Should universal hormone replacement therapy be recommended in asymptomatic healthy postmenopausal women?

Many clinicians now take it as established that postmenopausal hormone therapy protects against coronary heart disease in women. However, this is not based on data from randomised trials with coronary end points.

Nevertheless, oestrogen has biological actions that could plausibly explain cardioprotective effects. The PEPI trial has clearly shown that exogenous oestrogen administration in women raises high-density lipoprotein cholesterol, lowers low-density lipoprotein cholesterol, and decreases fibrinogen concentrations. Other studies indicate that oestrogens can have antioxidant effects, lower homocysteine concentrations, act as calcium channel blockers, alter vascular reactivity, and, more variably, improve glucose tolerance. The demonstrable effect on lipids, which are the strongest coronary risk factors, and the consistent strong findings for coronary heart disease in observational studies indicate a real protective effect of oestrogens, though perhaps not as great as the halving of risk observed.

In contrast, the evidence for stroke is much more equivocal. Postmenopausal hormone therapy had no effect on blood pressure in the PEPI trial, and observational studies indicate both increased as well as decreased stroke risks in hormone users.Nevertheless, hormone replacement therapy is also widely accepted to be protective for osteoporosis.and possibly for Alzheimer's disease, as well as for a variety of other menopause related conditions such as urinary symptoms and depression so why are there still reservations about universal prescription?

The concerns are over possible adverse effects and the overall risk-benefit balance of long term therapy in healthy women.The observed cardioprotective effect of oestrogen appears to be related to current use and diminishes after stopping. Thus, continued use is required for cardioprotection. While oestrogens undoubtedly increase bone density in women in trials, observational studies on fracture risk suggest that the protective effect be related to duration of use; as with cardiovascular disease, benefits appear to diminish rapidly after cessation. Weiss reported that women have to use oestrogens for at least five years before a protective effect on hip fractures is observed. Unfortunately, oestrogen use increases the risk of both