POSTMENOPAUSAL BLEEDING

Bleeding per vagina following established menopause is called postmenopausal bleeding. The significance of postmenopausal bleeding, whatever slight it may be, should not be underestimated. As many as one-third of the cases are due to malignancy. The same importance is also given to those cases where normal menstruation continues even beyond the age of 55 years.

Causes

The causes of postmenopausal bleeding are :

• ·         Senile endometritis
• ·         Atrophic endometrium.
• ·         Endometrial hyperplasia
• ·         Dysfunctional uterine bleeding.
• ·         Genital malignancy.

n  Carcinoma of the cervix, endometrium, vagina, vulva and Fallopian tube.

n  Sarcoma uterus.

n  Granulosa cell tumor of the ovary.

• ·         Uterine polyp.
• ·         Tubercular endometritis.
• ·         Cervical erosion and polyp.
• ·         Senile vaginitis.
• ·         Decubitus ulcer.
• ·         Retained and forgotten foreign body such as pessary or IUCD.
• ·         Withdrawal bleeding following estrogen intake.
• ·         Urethral caruncle, polyp, prolapse mucosa orcarcinoma.

Unknown is about 25 percent. The incidencehowever decreases with wider use of hysteroscopy.

Initial step is to establish the fact that it is vaginal bleeding and not bleeding per rectum or hematuria.

Detail history should be taken regarding,

• ·         Age of menopause.
• ·         Menstrual pattern prior to menopause.
• ·         Amount of bleeding, number of episodes.
• ·         Sensation of something coming out of the introitus.
• ·         Urinary problems like dysuria or frequency ofurination.
• ·         Intake of estrogen—Even if the history of intakeis present, full investigations should be carried outto exclude malignancy.
• ·         Family history of endometrial and/or ovariancarcinoma (first degree relative).

Obesity and hypertension are often related to endometrial carcinoma. Enlarged groin or supraclavicular lymph nodes may be palpated. Metastatic nodules in the anterior vaginal wall may be present. Breasts should be palpated because gynecological symptoms may be related to breast cancer

Ultrasonography transvaginal probe (TVS) is more accurate because of its proximity to the target tissue (endometrium). Endometrial thickness less than 5 mm indicates atrophy. On the other hand, thick polypoid endometrium (9–10 mm), irregular texture, fluid within the uterus require further evaluation (to exclude malignancy).

Saline infusion sonography (SIS) is more accurate compared to sonography alone and biopsy is taken.

Hysteroscopic evaluation and directed biopsy.

Endometrial biopsy may be done using the Sharman curette as an outpatient basis.

Fractional curettage, if the cervical cytology becomes negative.

Endometrial biopsy for diagnosis of endometrial carcinoma under guidance of sonohysterography or hysteroscopy has got the similar diagnostic accuracy.

Laparoscopy in suspected cases of ovarian or adnexal mass.

CT and MRI may be useful in selected cases of postmenopausal bleeding.

Detection of a benign lesion should not prevent further detailed investigations to rule out malignancy.

If the cause is found, the treatment is directed to it.  If no cause is detected and there is only minimal bleeding once or twice, careful observation is mandatory, if conservatism is desired.In cases of recurrences or continued bleeding whatever may be the amount, it is better to proceed for laparotomy and to perform hysterectomy with bilateral salpingo-oophorectomy. Unexpectedly, one may find a pathology either in the ovary or Fallopian tube or else, an uterine polyp — benign or malignant may be evident in the removed uterus

Secret to Premature Ejaculation Treatment

Premature ejaculation is when you ejaculate early before you want to and you cannot control it. It occurs just after penetration and is always short of the satisfying time required for you or your partner to enjoy the intercourse. It is a cause of distress and will always lead to trouble in the relationship and many a times low self-esteem on the man’s part. Most doctors range premature ejaculation from 0 to 2 minutes after penetration.

Early ejaculation can arise as a result of psychological issues or biological causes. Problems that affect your mental or emotional health for example stress and anxiety will lead to the uncontrolled ejaculation. The initial sex and the anxiety that comes with it will lead to premature conclusion. Also, when distressed or undergoing emotional stability, you are likely to aggravate your sexual problem. Initially as a teen one might condition oneself to ejaculate early to avoid apprehension. In cases where the men are brought up in an environment where sex is considered to be appropriate only in specific circumstances they may develop the condition.

Biologically, if the man has had a history of diabetes, high blood pressure or prostate problems, he is likely to experience the early ejaculation. There are reports of genetic causes where the problem is likely to be passed from an immediate relative.

Treatment of premature ejaculation requires the self-initiative and will be an advantage if the couple can work together to manage it. For self-treatment, take deep breaths when you feel you are about to ejaculate, this will shut down ejaculatory process, use thick condoms when having intercourse which will help reduce the sensitivity. It might also help to let your mind wander periodically during sex to delay the reflexes. 

Masturbate a short duration before sex. The duration should be long enough so that you can be ready for sex with your partner afterwards. Different men have different interval times for erection after ejaculation.

If the relationship is long-term it will benefit you more if you put a combined effort to deal with the condition. Learn the different techniques to delay ejaculation together and the woman should help in implementing. The famous squeeze method is best applicable where the woman masturbates the man then stops and squeezes the man’s penis just before ejaculation. Deal with the psychological issues by seeking counselling to relieve anxiety, distress or frustration which may be the cause of the premature ejaculation.

There cannot be a straight forward solution to the problem but will take some effort and a continued practice on the techniques will give the desired results. They might appear simple but will take practice and effort to get used to. The cause will determine the best way of countering the condition. Therefore make sure you take care of the likely causes. Medicinal treatment is also available but will require a physician’s recommendation.

Amenorrhoea

Evaluation and management of a patient with amenorrhea is common in gynecology, and the prevalence of pathologic amenorrhea ranges from 3 to 4 percent in reproductive-aged populations (Bachmann, 1982; Pettersson, 1973). Amenorrhea is diagnosed in a female: (1) who has not menstruated by age 14 years and who lacks other evidence of pubertal development; (2) who has not menstruated by age 16, even in the presence of other pubertal signs; or (3) who has previously menstruated but has been without menses for a time equivalent to a total of three previous cycles or 6 months. Although amenorrhea has classically been defined as primary (no prior menses) or secondary (cessation of menses), this distinction may lead to diagnostic error and should be avoided.

In some circumstances, evaluation reasonably may be initiated despite the absence of these strict criteria. Examples include a patient with the stigmata of Turner syndrome, obvious virilization, or a history of uterine curettage. An evaluation for delayed puberty should also be considered before the ages just listed if the patient or her parents are concerned. Although the list of possible etiologies is extensive, most causes will fall into a limited number of categories. Of course, amenorrhea is a normal state prior to puberty, during pregnancy and lactation, and following the menopause.

Numerous classification systems for the diagnosis of amenorrhea have been developed, and all have their strengths and weaknesses. One useful scheme is outlined in. This is system divides the causes of amenorrhea into anatomic versus hormonal etiologies with further division into inherited versus acquired disorders.

As described earlier, normal menses require adequate ovarian production of steroid hormones. Decreased ovarian function (hypogonadism) may result either from a lack of stimulation by the gonadotropins (hypogonadotropic hypogonadism) or from primary failure of the ovary (hypergonadotropic hypogonadism). A number of disorders are associated with relatively normal LH and FSH levels (eugonadotropic), however, there is loss of appropriate cyclicity.

Anatomic abnormalities that may present as amenorrhea can broadly be viewed as either inherited or acquired disorders of the outflow tract (uterus, cervix, vagina, and introitus).

Amenorrhea will be observed in the presence of an imperforate hymen (1 in 2000 women), a transverse vaginal septum (1 in 70,000 women), or isolated atresia of the vagina (Banerjee, 1999; Parazzini, 1990; Reid, 2000). Patients with these anomalies have a 46,XX karyotype, female secondary sexual characteristics, and normal ovarian function. Therefore, the amount of uterine bleeding is normal, but its normal path for egress is obstructed or absent. Th ese patients may note moliminal symptoms, such as breast tenderness, food cravings, and mood changes, which are attributable to elevated progesterone levels. In addition, accumulation of menstrual blood behind an obstruction frequently results in cyclic abdominal pain. In women with outflow tract obstruction, an increase in retrograde menstruation may lead to development of endometriosis with associated complications such as chronic pain and infertility.

Postoperative scarring and stenosis of the cervix may follow dilatation and curettage (D&C), cervical conization, loop electro surgical excision procedures, infection, and neoplasia. Severe atrophic or radiation changes can also be causative. Stenosis most commonly involves the internal os, and symptoms in menstruating women include amenorrhea, abnormal bleeding, dysmenorrhea, and infertility. Postmenopausal women are usually asymptomatic until fluid, exudates, or blood accumulates. If obstruction is complete, a soft, enlarged uterus is palpable.

6 Foods For Better Sexual Health

While there is a lot of talk about foods that are aphrodisiacs that supposedly boost libido and make sex better, recent studies on food and sex has revealed that there are a good number of foods that can improve sex drive and improve sexual experiences. By incorporating these foods into your daily diet or special romantic meals, you can have better sexual health.

Avocados

Due to their shape, the Aztecs associated these fruits with the testes. However, recent scientific research has revealed a deeper association between avocados and improved sexual health. Avocados contain high levels of unsaturated fats, which make them great for your heart and arteries. They have been associated with reducing heart disease, which can contribute to erectile dysfunction in men. When the blood is flowing throughout the whole body better, the sex is better.

Almonds

This is another food that has long been associated with sexual health as a way to increase passion, stimulate libido, and boost fertility. Almonds are not only packed full of nutrients that help promote overall health, but they also have some trace minerals that have been proven to have an impact on sexual health and fertility, including zinc, vitamin E, and selenium. Although science hasn’t figured out how, there has been a clear connection between zinc and sexual desire.

Strawberries

One of the biggest parts of strawberries that increases sexual desire is their bright red color. In fact, a recent study found that men rated women higher in terms of sexiness while they were wearing the color red. They also contain high levels of folic acid which help prevent birth defects in women, and have recently been connected to higher sperm counts in men. When covered in chocolate, their effectiveness multiplies as chocolate is filled with methylxanthines, a chemical that boosts libido in men and women.

Seafood

Possibly one of the most well-known aphrodisiacs is oysters. There is truth behind this tradition as oysters contain high levels of zinc which does give the libido a big boost. Outside of oysters, however, there are a number of other seafoods to choose from that can help boost sexual health. Wild salmon, mackerel, herring, and sardines all contain high levels of essential omega-3 fatty acids that promote heart health and improve blood flow throughout the body.

Arugula

This dark leafy vegetable has been known for its ability to increase sexual arousal since the first century. With modern technology, science has been able to discover what makes this plant so great for sexual health. Not only does arugula have trace minerals that improve sexual health, but it is also packed full of powerful antioxidants that help the body remove harmful toxins in the body. Many of the toxins that the antioxidants in arugula are those that have a negative impact on libido which means that including this vegetable in your next romantic dinner can boost libido by driving out toxins.

Citrus Fruits

There are a number of different citrus fruits to choose from, all of which are rich in vitamin C, folic acid, and antioxidants. Antioxidants remove toxins from the body, folic acid improves reproductive health, and vitamin C helps boost the immune system which helps the whole body stay healthier. An easy way to incorporate citrus fruits in romantic meals is to add mandarin oranges or pink grapefruit into salads, or to use lime or lemon in dressings.

Disorders of gender identity: transsexualism

In this rare disorder, called transsexualism, the person has the conviction of being of the opposite sex to that indicated by the external genitalia. This is getting more and more common in Sydney. The person wishes to alter the external genitalia to resemble those of the opposite sex, and to live as a member of that sex. Most transsexuals are men; most women who cross-dress and imitate men are homosexual, not transsexual. In transsexuals, the conviction of being a woman usually dates from before puberty, but medical help is not requested until early adult life, when most transsexuals have begun to dress as women. Unlike transvestites (also called transvestitism is the practice of dressing and acting in a style or manner traditionally associated with the other sex.) they report no sexual arousal from cross dressing, and unlike the homosexuals who dress as women, they do not seek to attract people into a homosexual relationship.

Transsexual men may take a series of steps to become more like women. They practise female styles of speaking, gesturing, and walking, they remove body hair by electrolysis, they attempt to increase breast tissue by taking estrogen or by obtaining a surgical implant, and they may seek an operation to remove the male external genitalia and form an artificial ‘vagina’. Requests for such operations are often made in a determined and persistent way reflecting the person’s great distress, and may be accompanied by threats of suicide or self-mutilation if surgery is not provided. Since such threats are carried out occasionally with serious consequences, a specialist opinion should be obtained.

It might be thought that a logical treatment of transsexualism would be a psychological procedure to alter the person’s beliefs about his gender identity. No form of psychotherapy, however, has been shown to succeed in this aim. In any case, most transsexual patients reject this approach, hoping instead to alter their body to conform more closely to the gender they feel is theirs. In a few specialist centres operations with this purpose are carried out on selected patients (gender reassignment), and good results have been reported. However, there is no high quality evidence of the long-term effectiveness of the procedure.

Decisions about such treatment are therefore taken on an individual patient basis with thorough assessment, and are made jointly by an experienced psychiatrist and surgeon, in consultation with the general practitioner.