Medscape women's health最新文献

A 46-year-old woman who had had occasional coarse, dark hairs on her chin and chest since she was 17 years old presented with rapidly progressive hirsutism and new onset of virilization--(eg, for the first time in her life, she had coarse, dark hair on her back and balding in the temporal and occipital areas of her scalp). A thorough evaluation, including laboratory tests, several imaging studies, and ovarian and adrenal vein catheterization, revealed a small ovarian hilus cell tumor that was successfully removed by a laparoscopic approach. During the 30 months after the testosterone-producing ovarian tumor had been diagnosed and the woman's ovary had been removed, her hirsutism progressed no further, hair began to grow back in the temporal and occipital areas of her scalp, and she began to lose some excess weight.

Genital herpes, usually the result of an infection with herpes simplex virus type 2 (HSV-2), is the most common cause of genital ulceration. The first clinical episode is called primary genital herpes; recurrent HSV infection occurs in up to 80% of patients. Because not every individual who acquires the virus develops symptoms, it is difficult to estimate the prevalence of HSV infection. Transmission of virus occurs not only in the presence of apparent lesions, but asymptomatic viral shedding can also spread infection in the absence of lesions. The primary episode of genital herpes is generally the most painful, characterized by multiple and bilateral lesions and associated with tender inguinal lymphadenopathy as well as systemic symptoms. Subsequent recurrences are generally milder and localized. Diagnosis is made clinically, but should be confirmed by culture or serology. Part 2, "Genital Herpes: Treatment Guidelines," addresses aspects of treatment, including special considerations in treating pregnant women.

The presence of tobacco-specific carcinogens in the cervical mucus of smokers and their effect on the local immune system strongly suggest that smoking has an etiologic role in the development of cervical neoplasia. However, it remains unclear whether smoking can affect the initiation of high-grade cervical neoplasia independently from human papillomavirus (HPV) infection. Studies that control for HPV infection may not entirely resolve the issue of the role of smoking in cervical neoplasia. Cigarette smoking may be causative through its effect on oncogenic HPV infection or by altering the immune response system. This article reviews the currently available data assessing the relationship between cigarette smoking and cervical neoplasia.

Posttraumatic stress disorder (PTSD) is a psychiatric disorder that may develop following exposure to threatened or actual injury or death. While commonly associated with war or natural disaster, symptoms of PTSD have been described in patients who are undergoing or who have completed infertility treatment or high-risk pregnancies. Three case studies of patients who developed PTSD following such pregnancies are discussed, demonstrating the variety of symptoms and presentations of these patients. The clinician must be vigilant in monitoring infertility patients with PTSD. These women, as the result of infertility, may be at increased risk of developing PTSD, one of the recognized postpartum psychiatric disorders. It is important to distinguish PTSD from postpartum depression, because treatment guidelines vary.

Heart disease, lung cancer, and HIV infection are among the diseases previously thought to be primarily men's health problems that have been documented in recent years to be serious health problems for women. Researchers have reported that women with heart disease have poorer outcomes and receive less intensive therapy than men. Clinicians and consumers are just beginning to realize that cardiac disease is the #1 cause of death in women -- outpacing breast cancer. In the breast cancer arena, the impact of such genetic links as BRCA1 and BRCA2 is still unclear, as is the issue of screening mammograms for women under the age of 50. Other top issues in women's health include efforts to ban "drive through" deliveries and early postmastectomy discharge, calculation of the high price of prematurity, changes in Pap screening techniques, and continuing efforts to understand the effects of estrogen. This editorial examines the key issues and trends in women's health reported and debated in 1996.

Formerly thought to be a neurodegenerative disease, Rett syndrome (RS) is a neurodevelopmental arrest of the brain that almost exclusively affects females and occurs in a variety of racial and ethnic groups worldwide. RS begins in late infancy and is characterized by autistic and dementia-like behavior, ataxia, and purposeless hand movements. Its cause and mode of transmission are unknown in over 90% of cases; however, there is strong and convincing evidence that genetic factors play a major role. The reported incidence varies, but in the US, as many as one quarter to one third of female children in mental wards/institutions may be affected. RS has been mistaken for numerous other conditions, including autism, cerebral palsy, and mental retardation, but the clinical picture is unique: No other condition has a period of rapid deterioration followed by apparent stabilization or even improvement in autistic features, eye contact, seizure activity, and hand stereotypies. The diagnosis is supported by deceleration of head growth, evidence of neurologic regression with associated neurologic signs, and purposeless hand stereotypies, with a clinical history of developmental regression. The differential diagnosis often involves ruling out syndromes with similar signs of neurodevelopmental arrest--for example, meningitis or encephalitis; chromosomal disorders such as Angelman's syndrome and Prader-Willi syndrome; metabolic disorders such as ornithine carbamoyltransferase deficiency; disorders of organic acids and amino acids; neurovisceral storage diseases; mitochondrial cytopathy; and Batten disease, or infantile neuronal ceroid lipofuscinosis. Management encompasses a comprehensive medical, therapeutic, educational, and psychosocial approach, best provided through a team in collaboration with the community agencies that serve families and children with special needs.

Treatment of procidentia and vaginal inversion in older women either with pessaries or surgery commonly brings poor results. Women are unable to retain the pessary; they develop vaginitis and vaginal ulcerations; and surgical "correction" fails due to age-induced genital atrophy or previous obstetrical trauma. We performed a retrospective chart review to assess results of our own technique of vaginectomy/hysterectomy and pelvic floor closure for vaginal vault prolapse and procidentia in 26 aged sexually inactive women seen in our practice. The women ranged from 63 to 83 years of age and had borne 0 to 9 children. Where possible, an estrogen-containing medication was introduced into the vagina preoperatively to stimulate thickening of the vaginal mucosa. A standard Heaney or Doderlein vaginal hysterectomy was performed. Operative time averaged 100 minutes, blood loss averaged 278mL, and 5 patients required a blood transfusion. All patients were discharged in good condition after an average stay of 4.67 days, although 9 of the 24 patients had complications. Since body-cavity invasion was minimal, postoperative care was simple, consisting of hydration with intravenous fluids, urine drainage utilizing an indwelling catheter, (while preventing bladder distension), early ambulation, and prophylaxis against infection and thromboembolism.

Bacterial vaginosis (BV), candidiasis, and trichomoniasis account for more than 90% of vaginal infections. BV typically is associated with a decrease in commensal, protective lactobacilli and a proliferation of other flora. Mobiluncus is pathognomonic but found in only 20% of cases. Presence of 3 of 4 criteria indicates BV: a homogenous noninflammatory discharge (not many WBCs); pH >4.5; clue cells (bacteria attached to borders of epithelial cells, > 20 % of epithelial cells); and a positive whiff test. New intravaginal BV preparations cause less-adverse systemic effects than oral regimens. Trichomonas vaginalis, a protozoan, appears to be sexually transmitted and causes up to 25% of vaginitis cases. Diagnosis is made by observation of a foul, frothy discharge; pH >4.5 (present in 70% of cases); punctate cervical microhemorrhages (25% of cases); and motile trichomonads on wet mount (50%-75% of cases). Recommended treatment is a single 2g dose of oral metronidazole. Treatment failure is usually due to nontreatment of the male partner. Candidiasis typically presents as a thick, "curdled" white discharge or vulvar pruritus, with a hyperemic vagina and an erythematous and/or excoriated vulva. Vaginal pH is usually in the normal range of 3.8-4.2 in uncomplicated candidiasis. Microscopic examination of the discharge reveals hyphae or budding yeast in 50%-70% of cases. While the most common offender is Candida albicans, Candida tropicalis and Candida glabrata have become increasingly prevalent. Approximately 15% of C albicans organisms are resistant to clotrimazole and miconazole. Recurrent infections may be treated with fluconazole 150mg weekly for up to 12 consecutive weeks.

Gender discrepancies have developed in the evaluation of coronary heart disease (CHD), arising from such early myths as "CHD is a man's disease." The challenge is to make sure that the noninvasive testing for CHD in women is sensitive and specific enough to lead to the correct treatment. Coronary angiography, the gold standard for CHD diagnosis, must be interpreted along with functional information. The standard noninvasive test--stress electrocardiograph (ECG)--is associated with up to 40% false-positive S-T segment depressions in women, versus fewer than 10% in men. The predictive value of exercise stress testing in women is particularly poor. In one study, stress ECG had a specificity of 61%, a sensitivity of 68%, a positive predictive value of 0.61, and a negative predictive value of 0.68. Stress echocardiography can have high sensitivity (86%) and specificity (86%), but often examiners stop the test before detecting less severe areas of damage. Also, acquiring adequate images is difficult in women with breast implants or large breasts. Nuclear perfusion imaging with thallium-201 has shown a sensitivity of 84% to 90% and a specificity of 75% to 87% in women, but the diagnostic accuracy can be reduced in patients who are obese or have large breasts. A higher-energy radiotracer, technetium-99m (Tc-99m) sestamibi, has been introduced. In one study, the sensitivity of the 2 agents was similar (85% to 90%), while the specificity of Tc-99m was higher (84% to 94%) than that of thallium-201 (71%).

Female carriers of germline BRCA1 mutations have a lifetime risk of breast cancer exceeding 80% and of ovarian cancer approaching 60%. The cumulative lifetime risk of developing either breast or ovarian cancer, therefore, approaches 100%. Carriers of BRCA2 mutants have a similar risk of breast cancer and a more moderately increased risk of ovarian cancer. BRCA1 and BRCA2, located on the long arms of chromosomes 17 and 13, respectively, are thought to be tumor suppressor genes, inhibiting tumor development when functioning normally. Both are large genes, distributed over approximately 100,000 base pairs of genomic DNA, encoding large negatively charged proteins. Inactivating mutations identified to date are distributed throughout both genes, with an increased frequency of two distinct BRCA1 mutations and one BRCA2 mutation in individuals of Ashkenazi Jewish descent. Given the high lifetime penetrance of germline BRCA1 and BRCA2 mutations and the early age of onset in many carriers, it may seem prudent to carry out regular mammography on carriers from a young age. The benefits or risks of such screening, however, have yet to be demonstrated. Preventative measures, including prophylactic mastectomy, oophorectomy, and chemoprevention, still require assessment within research protocols.