Medscape women's health最新文献

Uterine prolapse is often associated with a concomitant rectocele, cystocele, and/or an enterocele. Moderate degrees of prolapse are often associated with a feeling of pelvic heaviness or fullness or low back pain. The symptoms usually worsen with exertion and ease with bed rest. In severe prolapse, the cervix may descend outside the vaginal introitus, and patients may complain that a "mass" is protruding from the vagina. Bleeding from mucosal ulcerations or from the cervical os may occur due to rubbing of the prolapsed tissue against the patient's clothing. The commonly associated problems of cystoceles and rectoceles may lead the patient to complain of difficulty voiding, recurrent urinary infections, and/or "splinting" to defecate. Mild cases of uterine prolapse do not require therapy unless the patient is symptomatic; in most cases of second- or third-degree prolapse, however, patients may be quite uncomfortable and desire therapy. Nonsurgical options, such as a pessary, are usually tried first if the patient desires conservative therapy. Operative repair for uterine prolapse is usually approached vaginally if the uterus is small. An abdominal approach may be preferred if the uterus is large or if the woman has had multiple previous pelvic procedures or has extensive endometriosis or other processes that may obliterate the cul-de-sac. In either approach, the uterosacral and cardinal ligaments must be carefully ligated and tied together, and the cul-de-sac must be obliterated to reduce the risk of subsequent enterocele and to properly suspend the vaginal vault.

Recurrent miscarriage or fetal loss syndrome (also known as fetal wastage syndrome) is characterized by recurrent spontaneous abortion. There are many syndromes associated with recurrent fetal loss, including anatomic anomalies, endocrine/hormonal abnormalities, genetic/chromosomal abnormalities, and blood coagulation protein/platelet defects. Many of these syndromes are treatable, leading to normal term pregnancy, if the clinician is astute and vigorously pursues a thorough evaluation of why the patient has suffered unexplained, spontaneous miscarriages. There is no uniform agreement on how many spontaneous, unexplained miscarriages are needed to diagnose recurrent fetal loss; we generally pursue an evaluation for causation if a women has had 2 or more such events. In this article, we discuss the common reasons for recurrent fetal loss, plus diagnostic procedures to consider in pinpointing the problem, such as cytogenetic studies, blood coagulation protein/platelet tests, hysterosalpingography, sonography, and magnetic resonance imaging. We also describe management strategies that often lead to successful pregnancy outcome when the underlying problem is addressed. For example, in the case of thrombotic defects, a common cause of recurrent fetal loss, we report a 100% success rate in achieving a normal-term delivery among women who took low-dose (81 mg/day) aspirin preconception followed by postconception low-dose (5000 units q 12 h) heparin.

Dysfunctional uterine bleeding (DUB) is a common clinical condition that frequently leads to hysterectomy. Endometrial ablation --a "minimally invasive" surgical technique that removes or destroys the endometrial lining of the uterus -- is a conservative alternative to hysterectomy for DUB. While endometrial ablation has lower immediate costs and shorter recovery than hysterectomy, symptoms are not always resolved. Available data from studies with admittedly incomplete follow-up suggest that up to one quarter of patients treated with endometrial ablation require repeat ablation or subsequent hysterectomy to stop DUB. This suggests that the short-term advantages of endometrial ablation may be offset by possible longer-term disadvantages. The Surgical Treatments Outcomes Project for Dysfunctional Uterine Bleeding (STOP-DUB) is a randomized trial designed to compare endometrial ablation against hysterectomy. The primary outcomes address issues of importance to women, such as quality of life and resolution of symptoms that led to surgery. Other outcomes include subsequent surgery and cost-effectiveness of the procedures. The study's target enrollment is 800 women--400 in each treatment group -- from 20 clinical centers throughout the US. The women will be followed for 2 years after surgery. Part of the STOP-DUB is a parallel observational study that involves women who do not choose surgery or who are not eligible for the randomized trial but could become eligible with time. It is anticipated that the result of this research will provide important information to women and their health care professionals as they consider the relative merits of surgical treatments for DUB.

The data are conflicting, but the suspicion is that there may be a gender bias against referring women for angiography in coronary disease evaluation. These cardiologists, however, review the studies and conclude that, even with the available noninvasive tests, coronary angiography continues to be the gold standard for assessing and monitoring heart disease -- even in women. The burden of coronary artery disease (CAD) in women is significant. In spite of increasing uses of noninvasive testing, coronary angiography remains the gold standard in the diagnosis and assessment of CAD. Since gender differences exist in the clinical presentation of CAD and in the sensitivity and specificity of noninvasive testing, coronary angiography remains an invaluable tool in providing diagnostic and prognostic information in women. Angiography is also appropriate when vasospastic disease is suspected. Although gender differences in the indication for coronary angiography are recognized, evidence as to whether there is a bias against women in the referral for cardiac catheterization after noninvasive testing or myocardial infarction is conflicting. The possibility that physicians underestimate the risk of disease in women cannot be ruled out. Therefore, proper training of physicians in the clinical assessment and prediction of the pretest risk for coronary disease in women cannot be overemphasized. In addition, physicians should be aware that normal coronary angiograms in women cannot always rule out the existence of myocardial ischemia, especially in conditions such as variant angina and syndrome X. Coronary angiography has also been invaluable in elucidating the benefits of lipid-lowering therapy and estrogen use in women in the prevention of heart disease. Coronary angiography, therefore, remains an invaluable tool in the management of CAD in women.

A 32-year-old woman does not resume menses even more than a year after the birth of her third child. How would you assess and treat this problem?

In distinguishing normal from abnormal hepatic changes, the author described the expected changes in liver tests that occur during complicated pregnancy. This article reviews the forms of pre-existing liver disease that may affect or be affected by pregnancy, as well as liver diseases that tend to arise during pregnancy. Among the pre-existing liver diseases are autoimmune chronic active hepatitis, which may be activated by pregnancy and tends to be associated with an increased risk of still and premature births. Worsening of chronic hepatitis B and C has occasionally been observed. While some women with cirrhosis can sustain a normal pregnancy without any worsening of hepatic function, others develop liver failure; plus, women with cirrhosis are less fertile and have higher rates of both stillbirths and premature infants. Other liver disorders that may or may not be affected by pregnancy include Dubin-Johnson syndrome, Gilbert syndrome, benign recurrent intrahepatic cholestasis, Wilson's disease, hepatic adenomas, and focal nodular hyperplasia. Among the hepatic disorders that occur during pregnancy in normally healthy women and then resolve after delivery is intrahepatic cholestasis of pregnancy (also known as pruritus gravidarum, recurrent intrahepatic cholestasis of pregnancy, and obstetric hepatosis). Others include acute fatty liver of pregnancy and HELLP syndrome (hemolysis, elevated liver enzymes, and low platelet count), which may be part of the spectrum of disorders associated with pre-eclampsia/eclampsia. Pregnancy may also trigger the dissemination of herpes infection to the liver.

A 25-year-old white woman arrives in your outpatient clinic with a red, nonpruritic genital rash. What is the differential diagnosis and treatment?

Abnormal liver tests occur in 1 of 10 pregnancies, though liver function is usually normal during pregnancy. The data suggest that liver metabolic capacity may be reduced in late pregnancy. Hepatic excretory function has been assessed in human pregnancy by both bromosulfophthalein (BSP) and bilirubin tolerance tests. The data suggest that the hepatic excretion of both compounds is impaired in the last half of normal human pregnancy. Thus, the clearance of compounds that are metabolized via the microsomal oxidizing pathway or secreted into bile may be impaired during pregnancy (especially late pregnancy). There is a 20% increase in total body water during pregnancy, and cardiac output increases 30% to 50%. The increment in cardiac output represents shunting of blood to the fetal-placental unit. Serum cholesterol and triglyceride levels begin to rise in the fourth month of pregnancy and peak at term. At term, pregnant women have a 25% to 50% rise in serum cholesterol levels to 265+/-8 mg/dL and a 150% increase in serum triglyceride levels to 180+/-13 mg/dL. Chemical analysis of tissue samples and histologic studies suggest that both cholesterol and triglycerides accumulate in the liver during normal pregnancy. The latter is thought to represent a storage pool of metabolic fuel to sustain the fetus during periods of starvation or inadequate nutrition. It is believed that both the enlarged gallbladder and supersaturation of bile with cholesterol contribute to gallstone formation in pregnant women.

Given the high risk of postpartum psychiatric problems, clinicians need to be prepared to appropriately manage the breast-feeding woman who needs psychotropics. These psychiatric researchers examine the issues and offer guidelines. Following childbirth, many women are at high risk for the onset or recurrence of psychiatric illness. Women who need psychopharmacologic treatment may wish to breast-feed their infants, but the data regarding the degree of drug passage to the infant and the subsequent effects of this exposure on infant growth and development are very limited, leaving clinicians with little guidance for responding in ways that protect the health and well-being of both mother and infant. In general, the less protein-bound, the more lipid-soluble, and the more weakly basic a drug is, the more likely it is to diffuse into breast milk. When a psychotropic medication is administered, the infant's clinical status and serum concentrations, including metabolite concentrations, should be closely monitored. Among the agents that have been the subject of at least limited studies in breast-feeding women are tricyclic antidepressants, selective serotonin reuptake inhibitors, benzodiazepines, and the mood stabilizers lithium, carbamazepine, and divalproex. This article examines the factors that influence infant exposure to psychotropic medication through breast-feeding and includes clinical guidelines for managing the breast-feeding woman on psychotropics as well as protecting and caring for her infant.