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Hormone Levels There is 50% reduction in androgen production and 66% reduction in oestrogen at menopause menstruation under graviditet purchase estrace 2 mg fast delivery. Some oestrogen comes from the ovary women's health clinic overland park regional order estrace with a mastercard, but most of it is oestrone (E1) derived from peripheral conversion of androstenedione secreted by the ovary womens health valparaiso quality 1mg estrace, and its level varies between 30 and 70 pg/mL. The ovary also secretes a small amount of testosterone which causes mild hirsutism at menopause. E2/E1 ratio maintained over 1 in the premenopausal period is reduced to less than 1 in the menopausal age, causing an oestrogen deficiency state. Oestrogen level of over 40 pg/mL exerts bone and cardiotrophic effect, but the level below 20 pg/mL may predispose to osteoporosis and ischaemic heart disease (Table 5. Risk factors for menopause-related diseases are as follows: n n n n Demography Sixty million women in India are above the age of 55 years. With women living longer than before, a majority would spend one-third of their life in the postmenopausal stage. The health problems cropping up during this period and related to oestrogen deficiency of menopause are now obvious and better understood. It is important therefore to address all these menopause-related diseases and apply prophylactic measures so that these women can lead an enjoyable and healthy life. An average Indian woman now lives up to 65 years of age, whereas in developed countries a lifespan up to 80 years is possible. Menopause normally occurs between the ages of 45 and 50 years, the average age being 47 years. Late menopause is also common in women suffering from uterine fibroids and those at high risk of endometrial cancer. Menopausal age is not related to menarche, race, socioeconomic status, number of pregnancies and lactation, or taking of oral contraceptives. Initially, ovulation fails, no corpus luteum forms and no progesterone is secreted by the ovary. Therefore, the premenopausal Chapter 5 Perimenopause, Menopause, Premature Menopause and Postmenopausal Bleeding 67 Anatomical Changes the genital organs undergo atrophy and retrogression. The plain muscle in the fallopian tube undergoes atrophy, cilia disappear from the tubal epithelium and the tubal plicae are no longer prominent. The uterus becomes smaller through atrophy of its plain muscle, so that the connective tissues are more conspicuous. The endometrium is represented by only the basal layer with its compact deeply stained stroma, and a few simple tubular glands. It is common for the endometrial glands to dilate before menopause sets in, and cystic glandular hyperplasia reported in some premenopausal women causes metropathia haemorrhagica, with irregular heavy bleeding. The cervix becomes smaller and its vaginal portion is represented by a small prominence at the vaginal vault. The vaginal fornices gradually disappear as the cervix shrinks after the menopause. The vagina becomes narrow and its epithelium becomes pale, thin and dry and gets easily infected causing senile vaginitisure 5. The vulva atrophies and the vaginal orifice narrow and this can cause dyspareunia. The skin of the labia minora and vestibule becomes thin, pale and dry, and there is considerable reduction in the amount of fat contained in the labia majora. The red patches seen around the urethra and introitus are caused by senile vulvitis, and a urethral caruncle may be produced. The pelvic cellular tissue becomes lax and the ligaments that support the uterus and vagina lose their tone, and these conditions predispose to prolapse of the genital organs, stress incontinence of urine and faecal incontinence. Apart from the atrophy of the genital organs, general disturbances that develop are almost certainly caused by alterations in the endocrine balance maintained during the childbearing period. Although the mammary glandular tissue atrophies, deposition of fat often makes the breasts more pendulous. Whereas, glandular tissue constitutes 30% of the breast volume, it is reduced to only 5% after the menopause. Hypertension, cardiac irregularities and tachycardia are at times noticed after menopause. Arthritis and osteoporosis of the vertebral bones, upper end of the hip joint and wrist are related to oestrogen deficiency after menopause. Tooth decay, keratoconjunctivitis and cataract are related to menopausal oestrogen deficiency. Continuous bleeding, menorrhagia or irregular heavy bleeding in the perimenopausal period are considered abnormal and should be investigated for malignancy of the genital tract. Prolapse of genital tract and stress incontinence of urine and faeces are mostly menopausal related. Hot flushes are the waves of vasodilation affecting the face and the neck and these last for 2 min each. Several of these flushes occur in a day, but are more severe during the night, and can disturb sleep. Mental depression due to disturbed sleep or otherwise, irritability and lack of concentration are noticed. With passage of time, the frequency and severity of flushes diminish over a period of 1 years. Hot flushes are caused by noradrenaline, which disturbs the thermoregulatory system. Oestrogen deficiency reduces hypothalamic endorphins, which release more norepinephrine and serotonin. Other causes that can be associated with the symptom of hot flushes include: thyroid disease, epilepsy, pheochromocytoma, carcinoid syndromes, autoimmune disorders, mast cell disorders, insulinoma, pancreatic tumours and even leukemias. The vasomotor symptoms are more severe in surgical menopause than natural menopause. Neurological Depression, loss of memory, irritability, poor concentration and tiredness. Late Sequelae Menopausal women with chronic oestrogen deficiency are liable to develop the following: n n n n n n n n Other Symptoms Some women develop a condition of pseudocyesis, when they fear pregnancy and attribute amenorrhoea and increased abdominal girth to pregnancy. It is an incipient slowly progressing skeletal disorder characterized by microarchitectural deterioration of bone mass resulting in increased fragility and predilection to fracture in the absence of significant trauma. About 15% of elderly women suffer from osteoporosis and almost three times as many suffer from osteopenia (deficient bone mass). These constitute a significant cause of morbidity such as pain, deformity and impaired respiratory and other bodily functions. Neurological Vasomotor symptoms and paraesthesia take the form of sensations of pins and needles in the extremities. Libido Sexual feeling and libido may increase in some, if they feel happy to get rid of menstruation and fear of pregnancy. Many however notice decreased libido after menopause (15%; lack of orgasm and arousal.
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In highrisk circumstances the women's health big book of exercises free download buy 1 mg estrace amex, such as neonatal sepsis or bacteremia in immunocompromised persons women's health clinic in el paso tx buy 2 mg estrace with mastercard, empirical therapy includes broad-spectrum antimicrobials (see Chapters 96 and 120) womens health and fitness cheap estrace. Because rabies is one of the deadliest infections, recognition of potential exposure and prophylaxis are crucial. Any healthy-appearing domestic animal responsible for an apparently unprovoked bite should be observed for 10 days for signs of rabies, without immediate treatment of the victim. Prophylaxis should be administered if the animal is rabid or suspected to be rabid, or if the animal develops signs of rabies while under observation. A captured wild animal should be euthanized (by animal control officials) without a period of observation and its brain examined for evidence of rabies. If the biting animal is not captured, particularly if it is a wild animal of a species known to harbor the virus in the region, rabies should be presumed and prophylaxis administered to the victim. Skunks, raccoons, foxes, woodchucks, most other carnivores, and bats are regarded as rabid unless proved negative by testing. Prophylaxis also should be provided following exposure to a bat for persons who might be unaware or unable to relate that a bite or direct contact has occurred, such as a mentally disabled person, a sleeping child, or an unattended infant. All rabies postexposure management begins with immediate thorough cleansing of the bite using soap and water and, if available, irrigation with a virucidal agent such as povidone-iodine. Definitive therapy can additionally minimize drug toxicity, development of resistant microorganisms, and cost. Infections associated with foreign bodies, such as an intravascular catheter, are difficult to eradicate with antimicrobials alone because of organism-produced biofilms that impair phagocytosis. Similarly it is difficult for phagocytic cells to eradicate bacteria amid vegetations of fibrin and platelets on infected heart valves. Prolonged, bactericidal therapy is required with these infections, and outcomes are not always satisfactory. Foreign body devices may have to be removed if sterilization does not occur promptly. Infections in closed spaces with limited perfusion (such as abscesses or chronic osteomyelitis with poorly perfused bone) are difficult to cure without surgical drainage, debridement of the infected tissue, and reestablishment of a good vascular supply. Optimal antimicrobial therapy requires an understanding of both the pharmacokinetics. The bioavailability of orally administered antibiotics varies, depending on the acid stability of the drug; degree of gastric acidity; and whether it is taken with food, antacids, H2 blockers, or other medications. An ileus or profuse diarrhea may alter intestinal transit time and result in unpredictable absorption. Aminoglycosides, active against aerobic organisms only, have significantly reduced activity in abscesses with low pH and oxygen tension. Infections of the central nervous system or the eye necessitate treatment with antimicrobials that penetrate and achieve therapeutic levels in these sites. Limited renal function (as in premature infants or those with renal failure) requires increasing dosing intervals to allow time for excretion of certain drugs. The larger volume of distribution of certain hydrophilic antimicrobials and increased renal clearance. Weight-based dosage regimens may result in overdoses in obese children due to significantly smaller volumes of distribution for hydrophilic drugs. Drug-drug interactions must be considered when multiple antimicrobial agents are used to treat infection. Use of two or more antimicrobial agents may be justified before organism identification or for the benefit of two drugs with different mechanisms of action. The use of a bacteriostatic drug, such as a tetracycline, along with a -lactam agent, effective against growing organisms only, may result in antibiotic antagonism, or less bacterial killing in the presence of both drugs than if either is used alone. There is a normal diurnal variation, with maximum temperature in the late afternoon. Normal body temperature is maintained by a complex regulatory system in the anterior hypothalamus. Development of fever begins with release of endogenous pyrogens into the circulation as the result of infection, inflammatory processes, or malignancy. Microbes and microbial toxins act as exogenous pyrogens by stimulating release of endogenous pyrogens, including cytokines such as interleukin-1, interleukin-6, tumor necrosis factor, and interferons. These cytokines reach the anterior hypothalamus, liberating arachidonic acid, which is metabolized to prostaglandin E2. Elevation of the hypothalamic thermostat occurs via a complex interaction of complement and prostaglandin-E2 production. Antipyretics (acetaminophen, ibuprofen, aspirin) inhibit hypothalamic cyclooxygenase, decreasing production of prostaglandin E2. Aspirin is associated with Reye syndrome in children and is not recommended as an antipyretic. The response to antipyretics does not distinguish bacterial from viral infections. The pattern of fever in children may vary, depending on age and the nature of the illness. Fever to this degree is unusual in older children and adolescents and suggests a serious process. The fever pattern does not reliably distinguish fever caused by infectious microorganisms from that resulting from malignancy, autoimmune diseases, or drugs. Children with fever without a focus present a diagnostic challenge that includes identifying bacteremia and sepsis. Bacteremia, the presence of bacteria in the bloodstream, may be primary or secondary to a focal infection. Sepsis is the systemic response to infection that is manifested by hyperthermia or hypothermia, tachycardia, tachypnea, and shock (see Chapter 40). Children with septicemia and signs of central nervous system dysfunction (irritability, lethargy), cardiovascular impairment (cyanosis, poor perfusion), and disseminated intravascular coagulation (petechiae, ecchymosis) are Chapter 96 readily recognized as toxic appearing or septic. These younger infants usually exhibit only fever and poor feeding, without localizing signs of infection. Differentiation between viral and bacterial infections in young infants is difficult. Febrile infants <3 months of age who appear ill, especially if follow-up is uncertain, and all febrile infants <4 weeks of age should be admitted to the hospital for empirical antibiotics pending culture results. After blood, urine, and cerebrospinal fluid cultures are obtained, broad-spectrum parenteral antibiotics (typically ampicillin with cefotaxime or gentamicin) are administered. The choice of antibiotics depends on the pathogens suggested by localizing findings. Well-appearing febrile infants 4 weeks of age without an identifiable focus and with certainty of follow-up are at a low risk of developing a serious bacterial infection (0. Fecal leukocyte testing and chest radiograph can be considered in infants with diarrhea or respiratory signs.
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Dark or poorly perfused lung fields suggests decreased pulmonary blood flow pregnancy labor pains cheap estrace express, whereas diffusely opaque lung fields may represent increased pulmonary blood flow or significant left atrial hypertension breast cancer 90 purchase 2mg estrace fast delivery. Longitudinal study of the standard electrocardiogram in the healthy premature infant during the first year of life pregnancy updates buy cheap estrace 1mg on line. Comparative study of the electrocardiograms of healthy fullterm and premature newborns. In all neonates with suspected critical congenital heart disease (not just those who are cyanotic), a hyperoxia test should be considered. This single test is perhaps the most sensitive and specific tool in the initial evaluation of the neonate with suspected recent disease. In sites with timely access to echocardiography, a complete hyperoxia test may not be performed; however, it is important to realize what a valuable test this can be when echocardiography is not easily and quickly available. To investigate the possibility of a fixed, intracardiac right-to-left shunt, the arterial oxygen tension should be measured in room air (if tolerated) followed by repeat measurements with the patient receiving 100% inspired oxygen (the "hyperoxia test"). A markedly higher oxygen content in the upper versus the lower part of the body can be an important diagnostic clue to such lesions, including all forms of critical aortic arch obstruction or left ventricular outflow obstruction. There are also rare cases of "reverse differential cyanosis" with elevated lower body saturation and lower upper body saturation. This occurs only in children with transposition of the great arteries with an abnormal pulmonary artery to aortic shunt due to coarctation, interruption of the aortic arch, or suprasystemic pulmonary vascular resistance ("persistent fetal circulation"). On the basis of the initial evaluation, if an infant has been identified as likely to have congenital heart disease, further medical management must be planned, as well as arrangements made for a definitive anatomic diagnosis. This may involve transport of the neonate to another medical center where a pediatric cardiologist is available. For the neonate who presents with evidence of decreased cardiac output or shock, initial attention is devoted to the basics of advanced life support. A stable airway must be established and maintained as well as adequate ventilation. In the neonate, this can most reliably be accomplished through the umbilical vessels. Volume resuscitation, inotropic support, and correction of metabolic acidosis are required with the goal of improving cardiac output and tissue perfusion (see Chap. The neonate who "fails" a hyperoxia test (or has an equivocal result in addition to other signs or symptoms of congenital heart disease) as well as the neonate who presents in shock within the first 3 weeks of life is highly likely to have congenital heart disease. In infants who will not require transport, intubation may not be required but continuous cardiorespiratory monitoring is essential. In the neonate with ductal-dependant pulmonary blood flow, oxygen saturation will typically improve and the pulmonary blood flow remains secure until an anatomic diagnosis and plans for surgery are made. In neonates with transposition of the great arteries, maintenance of a patent ductus improves intercirculatory mixing. Most important, neonates who present in shock in the first few weeks of life have duct-dependent systemic blood flow until proved otherwise; resuscitation will not be successful unless the ductus is opened. This is usually due to lesions with left atrial hypertension: hypoplastic left heart syndrome with restrictive patent foramen ovale, subdiaphragmatic total anomalous pulmonary venous return, mitral atresia with restrictive patent foramen ovale, transposition of the great arteries with intact ventricular septum with restrictive patent foramen ovale, and some cases of Ebstein anomaly (see V. Continuous infusions of inotropic agents, usually the sympathomimetic amines, can improve myocardial performance as well as perfusion of vital organs and the periphery. Care should be taken to replete intravascular volume before institution of vasoactive agents. Dopamine is a precursor of norepinephrine and stimulates -1, dopaminergic, and -adrenergic receptors in a dose-dependent manner. Dopamine can be expected to increase mean arterial pressure, improve ventricular function, and improve urine output with a low incidence of side effects at doses 10 g/kg/minute. Dobutamine is an analog of dopamine, with predominantly -1 effects and relatively weak -2 and -receptortimulating activity. In comparison with dopamine, dobutamine lacks renal vasodilating properties, has less chronotropic effect (in adult patients), and does not depend on norepinephrine release from peripheral nerves for its effect. There are few published data available concerning the use of dobutamine in neonates, although clinical experience has been favorable. A combination of low-dose dopamine (up to 5 g/kg/minute) and dobutamine may be used to minimize the potential peripheral vasoconstriction induced by high doses of dopamine while maximizing the dopaminergic effects on the renal circulation. B for details of administration of inotropic agents and additional pharmacologic agents (see Chap. After initial stabilization, the neonate with suspected congenital heart disease often needs to be transferred to an institution that provides subspecialty care in pediatric cardiology and cardiac surgery. A successful transport actually involves two transitions of care for the neonate: (i) from the referring hospital staff to the transport team, and (ii) from the transport team staff to the accepting hospital staff. The need for accurate, detailed, and complete communication of information between all these teams cannot be overemphasized. If possible, the pediatric cardiologist who will be caring for the patient should be included in the discussions of care while the neonate is still at the referring hospital. Umbilical lines placed for resuscitation and stabilization should be left in place for transport; the neonate with congenital heart disease may potentially require cardiac catheterization through this route. Neonates with probable or definite congenital heart disease will most likely require surgical or interventional catheterization management during the hospitalization; therefore, it is likely that they will be intubated at some point. Because there is real risk in not intubating these infants, as a general rule, all should be intubated for transport unless there is a compelling reason not to do so. All intubated patients should have gastric decompression by nasogastric or orogastric tube. Acidase status and oxygen delivery should be checked with an arterial blood gas before transport. Although most noncardiac patients are transported receiving supplemental oxygen at or near 100%, this is often not the inspired oxygen concentration of choice for the neonate with congenital heart disease (see V for details of lesion-specific care). This management decision for transport is particularly important for those infants with duct-dependent systemic blood flow and complete intracardiac mixing with single ventricle physiology, and emphasizes the need to consult with a pediatric cardiologist before transport to achieve optimal intratransport patient care. Finally, it is important to remember that in neonates, hypotension is a late finding in shock. Therefore, other signs of incipient decompensation, such as persistent tachycardia and poor tissue perfusion, are important to note and treat before transport. Two-dimensional echocardiography, supplemented with Doppler and color Doppler has become the primary diagnostic tool for anatomic definition in pediatric cardiology. Echocardiography provides information about the structure and function of the heart and great vessels in a timely fashion. Although it is not an invasive test per se, a complete echocardiogram on a newborn suspected of having congenital heart disease may take an hour or more to perform, and may therefore not be well tolerated by a sick and/ or premature newborn. Temperature instability due to exposure during this Cardiovascular Disorders 489 extended time of examination may be a problem in the neonate. Extension of the neck for suprasternal notch views of the aortic arch may be problematic, particularly in the neonate with respiratory distress or with a tenuous airway. Therefore, in sick neonates, close monitoring by a medical staff person other than the one performing the echocardiogram is recommended, with attention to vital signs, respiratory status, temperature, and so on.
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However menopause symptoms icd 9 order estrace canada, if the thrombocytopenia becomes severe and/or persists 10 days menopause 51 generic 1 mg estrace with visa, further investigation is necessary breast cancer awareness bracelets buy discount estrace 1mg online. Guidelines for the evaluation of neonates with early-onset thrombocytopenia (72 hours of life). In these patients, thumb abnormalities are frequently found, and the diepoxybutane test is nearly always diagnostic. Infants that survive the first year of life generally do well, since the platelet count then spontaneously improves to low-normal levels that are maintained through life (11). Radiologic examination of the upper extremities in these infants confirms the proximal synostosis of the radial and ulnar bones (12). Other genetic disorders associated with early-onset thrombocytopenia include trisomy 21, trisomy 18, trisomy 13, Turner syndrome, Noonan syndrome, and Jacobsen syndrome. The presence of hepato- or splenomegaly is suggestive of a viral infection, although it can also be seen in hemophagocytic syndrome and liver failure from different etiologies. Other diagnoses, such as renal vein thrombosis, KasabachMerritt syndrome, and inborn errors of metabolism (mainly propionic acidemia and methylmalonic acidemia), should be considered and evaluated based on specific clinical indications. However, thrombocytopenia can be the presenting sign of these processes and can precede clinical deterioration. If the infant has or has recently had a central venous or arterial catheter, thromboses should be part of the differential diagnosis. Finally, drug-induced thrombocytopenia should be considered if the infant is clinically well and is receiving heparin, antibiotics (penicillins, ciprofloxacin, cephalosporins, metronidazole, vancomycin, and rifampin), indomethacin, famotidine, cimetidine, phenobarbital, or phenytoin, among others (13,14). Other less common causes of late-onset thrombocytopenia include inborn errors of metabolism and Fanconi anemia (rare). Novel tools to evaluate platelet production and aid in the evaluation of thrombocytopenia have been recently developed and are likely to become widely available to clinicians in the near future. Guidelines for the evaluation of neonates with late-onset thrombocytopenia (72 hours of life). Immune thrombocytopenia occurs due to the passive transfer of antibodies from the maternal to the fetal circulation. The maternal autoantibody also crosses the placenta, resulting in destruction of fetal platelets and thrombocytopenia. If blood cannot be collected from the parents in a timely fashion, neonatal serum may be screened for the presence of anti-platelet antibodies. However, to confirm the diagnosis, it is important to follow the platelet count frequently until a normal count is achieved. If the patient is clinically stable and does not have evidence of an intracranial hemorrhage, platelets are usually given when the platelet count is less than 30 103/mcL, although this is arbitrary. If the patient has evidence of an intracranial hemorrhage, the goal is to maintain a platelet count greater than 100 103/mcL. Platelets can also be washed to eliminate the plasma, but this induces more damage to the platelets than concentrating them (19). Other large studies confirmed an incidence of severe neonatal thrombocytopenia in this population ranging from 8. If the infant has mild thrombocytopenia, however, the platelet count should be repeated in 2 to 3 days, since it usually reaches the nadir between days 2 and 5 after birth. Cranial imaging should be obtained in all infants with platelet counts 50 103/mcL to evaluate for intracranial hemorrhage. There is in general little correlation between fetal platelet counts and either maternal platelet counts, platelet antibody levels, or history of maternal splenectomy. However, attempts to measure the fetal platelet count before delivery are not recommended due to the risk associated with such attempts. In regard to the mode of delivery, there is no evidence that cesarean section is safer for the fetus with thrombocytopenia than uncomplicated vaginal delivery. Recent studies have shown that there is great variability in neonatal transfusion practices in the United States and worldwide (28,29). To a large extent, this is attributable to the paucity of scientific evidence in the field. A more recent retrospective study evaluated whether platelet counts 50 103/mcL could be safely tolerated in neonates. This study concluded that using a platelet count of 30 103/mcL as a transfusion threshold was a safe practice for stable neonates with no prior hemorrhages (31). Based on this limited evidence, we currently propose administering platelet transfusions to neonates according to the criteria shown in Table 47. There is more consensus in regard to the platelet product that should be transfused. Most experts agree that neonates should receive 10 to 15 mL/kg of a standard platelet suspension, either a platelet concentrate ("random-donor platelets") or apheresis platelets. Each random-donor platelet unit has approximately 50 mL of volume and contains approximately 10 109 platelets per 10 ml (32). When making platelet transfusion decisions, it is important for neonatologists to be aware of the risks associated with these transfusions. In the case of platelet suspensions, the risk of bacterial contamination is higher than the combined risk of all viral infections for which platelets are routinely tested. It is unclear from these studies whether this association simply reflects sicker patients receiving more platelets or whether platelet transfusions adversely affect outcomes. Nevertheless, while we await for data from well-designed randomized controlled studies, platelet transfusion decisions in neonates should be made thoughtfully, carefully balancing the risks and benefits in each individual patient. Platelet reference ranges for neonates, defined using data from over 47,000 patients in a multihospital healthcare system. Thrombocytopenia among extremely low birth weight neonates: data from a multihospital healthcare system. Circulating megakaryocytes and their progenitors in early thrombocytopenia in preterm neonates. Endogenous thrombopoietin levels and effect of recombinant human thrombopoietin on megakaryocyte precursors in term and preterm babies. Inherited thrombocytopenia: congenital amegakaryocytic thrombocytopenia and thrombocytopenia with absent radii. Immature platelet fraction as novel laboratory parameter predicting the course of neonatal thrombocytopenia. Immature platelet values indicate impaired megakaryopoietic activity in neonatal early-onset thrombocytopenia. Clinical and diagnostic comparison of neonatal alloimmune thrombocytopenia to non-immune cases of thrombocytopenia. Current approaches to the evaluation and management of the fetus and neonate with immune thrombocytopenia. A retrospective 11-year analysis of obstetric patients with idiopathic thrombocytopenic purpura. Estimation of the risk of thrombocytopenia in the offspring of pregnant women with presumed immune thrombocytopenic purpura.
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Describe the microscopic appearance of the endometrium during the various phases of the menstrual cycle menstrual emotions purchase 2 mg estrace mastercard. Describe the rheological properties of cervical mucus during different phases of the normal menstrual cycle menstruation at 8 purchase 2 mg estrace fast delivery. The arcuate nucleus and the control of the gonadotropin and prolactin secretion in the female rhesus monkey women's health clinic yeovil generic 2mg estrace free shipping. Pituitary and gonadal desensitization after continuous luteinizing hormone releasing hormone infusion in normal females. Nocturnal slowing of pulsatile luteinizing hormone secretion in women during the follicular phase of the menstrual cycle. All these can cast their shadow on future reproductive health of the individual during adult life. The understanding of the role of the gynaecologist in the timely detection of these problems, instituting preventive and timely therapeutic interventions to correct the same if possible and counselling the parents about the likely sequelae as well as measures to mitigate their consequential illeffects can all contribute towards improving the future quality of life. Reproductive Endocrinology of the Growing Girl Child During childhood, the endocrine changes in the growing female child are directed towards preparing her for the maturation of the hypothalamusituitaryvarianuterine axis to achieve full reproductive potential. With the birth and expulsion of the placenta, its inhibitory effect ceases and there is once again a transient rise in circulating levels of gonadotropins and a gradual decline to nadir by the age of 2 years. This results in rise in levels of circulating gonadotropins, which promote follicular development in the ovaries. The ovaries in response to the above stimulus produce oestrogens that act on the uterine endometrium to initiate proliferation and endometrial growth, a prelude to menarche. The positive feedback to oestrogen develops and the cyclic pattern of gonadotropin release and normal menstrual cyclicity gets establishedures 4. The Newborn Female Infant History and physical examination-the newborn: the best time to begin documenting clinical observations is at birth. Repeated attempts to squeeze breast secretions should be stoutly resisted as this may result in bruising, infection and breast abscess formation. The external genitalia should be examined under a good light keeping the newborn supine with the thighs well flexed against the abdomen. Once again oestrogen effects on the genitalia are apparent, the labia majora appear thick and full and tend to cover the labia minora, the clitoris appears prominent-the clitoral index (glans width 3 length) should not exceed 6. Values exceeding this call for further investigations as clitoromegaly may be due to a serious underlying cause such as congenital adrenal hyperplasia, which demands immediate attention and treatment in contrast to other causes such as true hermaphroditism and maternal exposure to androgens (teratogens-drugs having androgenic side effects or androgen-secreting tumours of the adrenals or ovaries). On separation of the labia, it is not uncommon to observe a white mucoid discharge/blood which may persist for about 70 days. The vaginal orifice may be somewhat difficult to visualize, pressure on the vestibule often results in expression of mucus discharge, which confirms patency of the outflow tract; ultrasound examination of the pelvis clarifies the doubt. Chapter 4 Puberty, Paediatric and Adolescent Gynaecology 53 the Growing Girl Child A young prepubertal girl child may be brought with complaints related to her private parts such as swelling, itching, offensive vaginal discharge, bleeding or injury. Examination of the prepubertal child calls for patient persuasion, gentleness, reassurance and skill and goes a long way in accomplishing a satisfactory examination. Distension of the vagina with saline can be accomplished by holding the labia tightly around the vulval introitus; this may allow sufficient distension for satisfactory inspection of the cervix, vaginal vault, health of the vaginal walls, detection of any neoplasm or presence of any foreign body inserted inadvertently into the vagina. Endoscopic examination may be a satisfactory alternative to a difficult clinical examination. The preschool girl child is best examined supine with her hips well abducted and the feet apposed (frog leg position), older child is best examined supine with her legs supported in stirrups. In young prepubertal girls, the labia majora appear flattened, the labia minora are thin and relatively prominent and the clitoris is small. On parting the labia or drawing the lower parts of the labia downwards and outwards, the vaginal orifice can be well visualized. The vaginal walls appear thin and congested, the transverse rugae present in adults are not seen, a midline longitudinal ridge may be present. If vaginal discharge is required for testing, this should be collected with a moist cotton tipped applicator, rubbing should be avoided as this not only causes discomfort but can be traumatic to the thin and delicate vaginal epithelium. In the young prepubertal girl child, the vagina measures 4 cm, the cervix is twice the length of the uterus; the ovaries are located high up at the pelvic brim. Endocrine activity of the pituitary, ovaries and adrenal glands becomes increasingly manifest between the ages of 7 and 10 years when increases in oestrogen effects on the genitalia become evident clinically. In case of suspected child sexual molestation or rape, the child may be better examined in the knee chest position. In this position, the vagina balloons out and the introitus and hymen are easily visualized, the trauma of forced sexual assault is often apparent as laceration or tear of the introitus posteriorly. In this position it is easier to collect discharge from the vagina for culture and forensic tests. The pelvic examination should be avoided in an adolescent girl, but when required, it is done under sedation of anaesthesia. The vagina lengthens to 102 cm in a fully grown adolescent, the vagina becomes more capacious, the vaginal epithelium is thick with presence of rugae and covered with a white acidic discharge and the vagina shows presence of a mixed flora of nonpathogenic organisms. The cervix feels like a knob at the top of the vaginal vault and the uterus to cervix ratio reverses to 2:1. With approaching puberty, the ovaries descend into the pelvis and the ovaries show evidence of commencing follicular function. Common Paediatric Gynaecologic Problems the prepubertal girl child: the common problems for which medical opinion is sought include broadly: n n n n n n Vulvovaginal infections and leucorrhoea Vaginal bleeding Ambiguous genitalia Abdominal neoplasms Sexual abuse Sex education-sexuality the common gynaecologic problems affecting the prepubertal girl child for which consultation may be sought usually involve vulval pruritus, vaginal bleeding or discharge, developmental anomalies, suspected abdominal lump, precocious or late puberty and suspected sexual assault. Although the genital structures are in the resting state during early childhood, they are not immune to diseases. The prepubertal female genitals are delicate and are prone to infection and bleeding. Vulvovaginal infections, pruritus and discharge: Irritation or inflammation of the vulva may result from numerous causes. Infections (molluscum contagiosum, condylomata acuminata, herpes genitalis and gonorrhoea) may be transmitted through sexual or nonsexual close contact with the child. Poor personal hygiene may lead to candidal vulvovaginitis, vulval irritation may follow worm infestation such as pin worms or thread worms secondary to anorectal contamination. Poor sexual hygiene may lead to chronic nonspecific vulvovaginitis and irritation leading to vulvitis causing labial adhesions. Exposure to chemicals (deodorants/antiseptics) may cause atopic dermatitis leading to a chronic discharge, vulvar skin excoriation and over time cause labial adhesions, or eczematoid changes. Vaginal discharge: this is generally the result of infection caused by nonspecific causes, generally resulting from poor hygiene or as a result of specific infections. Nonspecific vulvovaginitis: this is best treated by initially improving perineal hygiene such as warm sitz baths, cleaning the perineal area with bland olive oil followed by soap and water, keeping the parts dry, and the use of clean cotton undergarments. Vulvar medications should be prescribed sparingly as the skin of the genital region is very sensitive in children. In case of unsatisfactory response in 2 weeks, consider topical application of an oestrogenic cream (Premarin/Dienesterol/Evalon).
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Long-term treatment of hypoparathyroidism involves administering vitamin D menstruation through the ages buy estrace 1 mg with amex, preferably as 1 pregnancy fatigue purchase estrace overnight,25-dihydroxyvitamin D and calcium menopause and insomnia buy estrace australia. Therapy is adjusted to keep the serum calcium in the lower half of the normal range to avoid episodes of hypercalcemia that might produce nephrocalcinosis and to avoid pancreatitis. In older infants, poor linear growth, bowing of the legs on weight bearing (which can be painful), thickening at the wrists and knees, and prominence of the costochondral junctions (rachitic rosary) of the rib cage occur. In nutritional vitamin D deficiency, calcium is not absorbed adequately from the intestine (see Chapter 31). Poor vitamin D intake or avoidance of sunlight in infants exclusively breastfed may contribute to the development of rickets. Fat malabsorption resulting from hepatobiliary disease (biliary atresia, neonatal hepatitis) or other causes (cystic fibrosis) also may produce vitamin D deficiency because vitamin D is a fat-soluble vitamin. Defects in vitamin D metabolism by the kidney (renal failure, autosomal recessive deficiency of 1-hydroxylation, vitamin Dependent rickets) or liver (defect in 25-hydroxylation) also can cause rickets. In familial hypophosphatemic rickets, the major defect in mineral metabolism is failure of the kidney to adequately reabsorb filtered phosphate so that serum phosphate decreases and urinary phosphate is high. The diagnosis of this X-linked disease usually is made within the first few years of life and is typically more severe in males. The etiology of rickets usually can be determined by an assessment of the mineral and vitamin D status (25-hydroxyvitamin D <8 ng/mL suggests nutritional vitamin D deficiency) (see Table 176-1). Further testing of mineral balance or measurement of other vitamin D metabolites may be required. Several chemical forms of vitamin D can be used for treatment of the different rachitic conditions, but their potencies vary widely. In hypophosphatemic rickets, phosphate supplementation (not calcium) must accompany vitamin D therapy, which is given to suppress secondary hyperparathyroidism. Adequate therapy restores normal skeletal growth and produces resolution of the radiographic signs of rickets. Nutritional rickets is treated with vitamin D given as one large dose, in weekly larger doses, or multiple smaller replacement doses. Surgery may be required to straighten legs in untreated patients with long-standing disease. The internal and external genitalia are formed between 6 and 13 weeks of gestation. Fetal gonad and external genitalia are bipotential and have the capacity to support development of a normal male or female phenotype. Genes usually determine the morphology of internal organs and of gonads (gonadal sex); this directs the appearance of the external genitalia that form the secondary sex characteristics Genital tubercle Urethral folds Urogenital slit Labioscrotal swelling Anal pit Tail 16. Testosterone acts at 9 to 13 weeks of gestation to virilize the bipotential anlage. Testicular production and secretion of mrian-inhibitory substance by Sertoli cells cause the regression and disappearance of the mrian ducts and their derivatives, such as the fallopian tubes and uterus. In the presence of testosterone, the wolffian ducts develop into the vas deferens, seminiferous tubules, and prostate. In the absence of fetal testicular secretion of mrian-inhibitory substance, a normal uterus, fallopian tubes, and posterior third of the vagina develop out of the mrian ducts, and the wolffian ducts degenerate. The degree of virilization can range from mild clitoral enlargement to the appearance of a male phallus with a penile urethra and fused scrotum with raphe. Congenital virilizing adrenal hyperplasia is the most common cause of female ambiguous genitalia; it is most commonly the result of an enzyme deficiency that impairs synthesis of glucocorticoids but does not affect androgen production. Classification the terms intersex, hermaphroditism, and pseudohermaphroditism are not useful. The testes should be sought carefully in the inguinal canal or labioscrotal folds by palpation or ultrasound. Rarely a palpable gonad in the inguinal canal or labioscrotal fold represents a herniated ovary or an ovotestis. The latter patients have ovarian and testicular tissue and usually ambiguous external genitalia. Testosterone production can be reduced by specific deficiencies of the enzymes needed for androgen biosynthesis or by dysplasia of the gonads. In the latter, if mrian-inhibiting substance production also is reduced, a rudimentary uterus and fallopian tubes are present. The complete form of androgen resistance or androgen insensitivity syndrome is the most dramatic example of resistance to hormone action by defects in the androgen receptor. At the time of puberty, testosterone concentrations increase to normal or above normal male range. Because a portion of the testosterone is normally converted to estradiol in peripheral tissues and the estrogen cannot be opposed by the androgen, breast development ensues at the normal age of puberty without growth of pubic, facial, or axillary hair or the occurrence of menstruation. Gender identity and gender role are significant psychological issues with these patients if diagnosed at puberty. The laboratory evaluations required might take days or weeks to complete, delaying a sex assignment and naming of the infant, such that choice often precedes diagnosis. Beyond infancy and childhood, and to offset any gender uncertainty in the patient and confusion in the parents, health care providers must help families come to an appropriate closure and gender choice. On physical examination, it is essential to note where the urethral opening lies and whether there is fusion of the anterior portion of the labioscrotal folds. If the vaginal opening is normal, and there is no fusion, but the clitoris is enlarged without ventral fusion of the ventral urethra, the patient had later exposure to androgens. A patient with a fully formed scrotum, even if small, and a normally formed but small penis, termed a microphallus, must have had normal exposure to and action of androgen during 9 to 13 weeks of gestation. Although the classic approach to sex assignment has been based on the feasibility of genital reconstruction and potential fertility rather than on karyotype or gonadal histology, the effects of prenatal androgen must be considered. Chapter 178 resistance) traditionally has been raised as a female because surgical construction of a fully functional phallus is difficult. Present management of ambiguous genitalia involves extensive open discussion with parents involving the biology of the infant and the likely prognosis. Treatment should be individualized and managed by a team, including an experienced pediatric endocrinologist, urologist or gynecologist, psychologist, geneticist, and the primary care physician. Reconstructive surgery is usually performed by 2 years of age so that genital structure reflects gender of rearing. This recommendation for reconstructive surgery is controversial; some advocate that surgery not be performed in infancy or early childhood so that the child or young adolescent can be involved in the decision. Diagnosis the first step toward diagnosis is to determine whether the disorder represents virilization of a genetic female (androgen excess) or underdevelopment of a genetic male (androgen deficiency) (see. Inguinal gonads that are evident on palpation usually are testes and indicate that incomplete development of a male phenotype has occurred; this pattern is not consistent, and ovaries and ovotestes may feel similar. Similarly absence of female internal genitalia (detected by ultrasound) implies that mrian-inhibiting substance was present and secreted by fetal testes.
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Information about reporting hotlines and the clinician must decide whether a problem requires referral for further diagnostic workup and management or whether management in the primary care setting is appropriate menopause 43 purchase estrace uk. When a child is young menstruation knee pain discount estrace 1mg overnight delivery, much of the counseling interaction takes place between the parents and the clinician womens health boise buy estrace 2 mg with visa, and, as the child matures, direct counseling shifts increasingly toward the child. By assuming the role of a nonjudgmental, supportive listener, the clinician creates a climate of trust, allowing the family to express difficult or painful thoughts and feelings. Expressing emotions may allow the parent or caregiver to move on to the work of understanding and resolving the problem. Early detection allows intervention before the problem becomes entrenched and associated problems develop. The severity of developmental and behavioral problems ranges from variations of normal to problematic responses to stressful situations to frank disorders. Counseling Principles For the child, behavioral change must be learned, not simply imposed. It is easiest to learn when the lesson is simple, clear, and consistent and presented in an atmosphere free of fear or intimidation. Parents often try to impose behavioral change in an emotionally charged atmosphere, most often at the time of a behavioral violation. Similarly clinicians may try to teach parents with hastily presented advice when the parents are distracted by other concerns or not engaged in the suggested behavioral change. Apart from management strategies directed specifically at the problem behavior, regular times for positive parent-child interaction should be instituted. Frequent, brief, affectionate physical contact over the day provides opportunities for positive reinforcement of desirable child behaviors and for building a sense of competence in the child and the parent. Most parents feel guilty when their children have a developmental/behavioral problem. If possible and appropriate, the clinician should find ways to alleviate guilt, which may be a serious impediment to problem solving. The primary care physician should monitor the progress of the child and continually reassess that the requisite therapy is being accomplished. Educational intervention for a young child begins as home-based infant stimulation, often with an early childhood specialist. For the school-age child, special services may range from extra attention in the classroom to a self-contained special education classroom. Psychological intervention may be directed to the parent or family or, with an older child, primarily child-directed. Examples of therapeutic approaches are guidance therapies, such as directive advice giving, counseling to create their own solutions to problems, psychotherapy, behavioral management techniques, psychopharmacologic methods (from a psychiatrist), and cognitive therapy. Sensory integration therapy is also used by occupational therapists to structure sensory experience from the tactile, proprioceptive, and vestibular systems to allow for adaptive motor responses. Speech-language intervention by a speech and language therapist/pathologist (oral-motor therapist) is usually part of the overall educational program and is based on the tested language strengths and weaknesses of the child. Children needing this type of intervention may show difficulties in reading and other academic areas and develop social and behavioral problems because of their difficulties in being understood and in understanding others. Hearing intervention, performed by an audiologist (or an otolaryngologist), includes monitoring hearing acuity and providing amplification when necessary via hearing aids. Social and environmental intervention generally includes nursing or social work involvement with the family. Medical intervention for a child with a developmental disability involves providing primary care as well as specific treatment of conditions associated with the disability. Although curative treatment often is not possible, functional impairment can be minimized through thoughtful medical management. Certain general medical problems are found more frequently in delayed and developmentally disabled people (Table 10-5), especially if the delay is part of a known syndrome. Supporting the family through palliative care, hospice, and bereavement is another important role of the primary care pediatrician. Behavioral problems Seizures Infectious diseases Gastrointestinal problems Sexuality Other syndromespecific problems Advocacy for services and enhancing access to care perinatal insults, acquired childhood disease, and environmental and social factors (Table 10-7). The earlier the cognitive slowing is recognized, the more severe the deviation from normal is likely to be. A history and physical examination may suggest a diagnostic approach that, then, may be confirmed by laboratory testing and/or imaging. Frequently used laboratory tests include chromosomal analysis and magnetic resonance imaging of the brain. Caution must be exercised in interpretation because these categories do not reflect actual functional level of the tested individual. Partial vision (defined as visual acuity between 20/70 and 20/200) occurs in 1 in 500 school-age children in the United States. Legal blindness is defined as distant visual acuity of 20/200 or worse and affects about 35,000 children in the United States. The most common cause of severe visual impairment in children is retinopathy of prematurity (see Chapter 61). Cataracts also are associated with other ocular abnormalities and developmental disabilities. Amblyopia is a pathologic alteration of the visual system characterized by a reduction in visual acuity in one or both eyes with no clinically apparent organic abnormality that completely accounts for the visual loss. Amblyopia is due to a distortion of the normal clearly formed retinal image (from congenital cataracts or severe refractive errors); abnormal binocular interaction between the eyes as one eye competitively inhibits the other (strabismus); or a combination of both mechanisms. Albinism, hydrocephalus, congenital cytomegalovirus infection, and birth asphyxia are other significant contributors to blindness in children. Fixation and visual tracking behavior can be seen in most infants by 6 weeks of age. The eyes also should be examined for red reflexes and pupillary reactions to light. Optical alignment (binocular vision with both eyes consistently focusing on the same spot) should not be expected until the infant is beyond the newborn period. If ocular abnormalities are identified, referral to a pediatric ophthalmologist is indicated. During the newborn period, vision may be assessed by physical examination and by visual evoked response. This test evaluates the conduction of electrical impulses from the optic nerve to the occipital cortex of the brain. The eye is stimulated by a bright flash of light or with an alternating checkerboard of black-and-white squares, and the resulting electrical response is recorded from electrodes strategically placed on the scalp, similar to an electroencephalogram. Perception of body image is abnormal, and imitative behavior, such as smiling, is delayed. Delays in mobility may occur in children who are visually impaired from birth, although their postural milestones (ability to sit) usually are achieved appropriately. Classroom settings may be augmented with resource-room assistance to present material in a nonvisual format. Fine motor activity development, listening skills, and Braille reading and writing are intrinsic to successful educational intervention for a child with severe visual impairment. The most common cause of mild to moderate hearing loss in children is a conduction abnormality caused by acquired middle ear disease (acute and chronic otitis media).
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Progestogens cause bloated feel breast cancer quilt buy estrace toronto, weight gain and depression and may adversely alter the lipid profile women's health clinic bowling green ky order estrace overnight delivery. A dose of 3 mg combined with 30 mcg oestradiol (yasmin women's health center danvers ma discount 1 mg estrace fast delivery, janya, tarana) has been tried in menopausal women, but more research is desirable. Testosterone implant and combined tablet with oestrogen are used to improve libido. Yohimbine resembles reserpine, an indole alkyl amine alkaloid derived from the bark of tree Rauwolfia. Tibolone (Livial) is a synthetic derivative of 19-nortestosterone and has a weak oestrogenic, progestogenic and androgenic action. It also elevates the mood, relieves the vasomotor symptoms, improves the sex drive and reduces bone resorption. It is mainly beneficial in reducing osteoporosis and is given 60 mg daily with calcium and vitamin D. It is absorbed from the gastrointestinal tract (60%), and glucuronidation occurs in the liver and is excreted in the faeces. Side effects are hot flushes, cramps, increased incidence of venous thrombosis and retinopathy. About 11 g soya contains 2 mg phytoestrogens, which is strongly oestrogenic, though it is a nonsteroidal plant product. About 450 mg soya daily is protective without the potential risk of breast cancer, liver disease and other side effects of oestrogen. Bisphosphonates such as etidronate and tiludronate reduce bone resorption through the inhibition of osteoclastic activity. Etidronate 10 mg/kg body weight (approximately 400 mg orally daily) is given for 2 weeks followed by a gap of 2 months (3-month course), and this course is repeated for 10 such cycles. Calcium should be taken in the morning and etidronate swallowed (not chewed) in the afternoon, on an empty stomach with a glass of water in the upright position; stay upright for half an hour. Risedronate has reduced gastric side effects and is effective in a dose of 5 mg daily or 35 mg once a month. Subcutaneous injection of calcitonin is also available, but gastrointestinal symptoms, anaemia and inflammation of joints cause poor compliance so also the high cost. About 20 mcg once-daily subcutaneous injection decreases vertebral fracture by 65% and others by 50% if used less than 2 years. Combined oestrogen and progesterone provides a better protection against endometrial cancer. Alendronate is the third generation of bisphosphonates (nonhormonal) and is 1000 times more potent than etidronate with no side effects. Before the age of 30 years the incidence is 1:1000, at 35 it is 1:250 and just before 40 years it is 1%. Genetic disorders such as chromosomal abnormalities are reported in 100% of cases involving X sex chromosomes. Mumps, thyroid dysfunction, hypoparathyroidism and Addison disease may account for a few cases. The ovarian biopsy shows infiltration of the follicles with plasma cells and lymphocytes. Tuberculosis of the genital tract involving the ovaries can cause secondary amenorrhoea and ovarian failure. Smoking is known to induce premature menopause, and the age when it occurs depends upon the degree of smoking. Chapter 5 Perimenopause, Menopause, Premature Menopause and Postmenopausal Bleeding 5. Radiation and chemotherapy can cause premature menopause, but the effect is reversible and the ovary may resume ovulation and menstruation after about a year of amenorrhoea. Radiation of up to 40000 rads restores normal ovarian function in 50% cases after a period of 1 year or 2, and pregnancies have occurred. Ovarian failure following hysterectomy is known to occur in 150% cases and is caused by kinking and blockage of ovarian vessels. Enzyme defects such as 17-a-hydroxylase deficiency and galactosaemia have adverse effect on oocytes, but more often cause primary amenorrhoea. Resistant ovary: this terminology is used less frequently these days and it is presumed that the follicles fail to respond to gonadotropin stimulation. Induction of multiple ovulations in infertility can cause premature menopause when the follicles get exhausted. Progestogen challenge test will indicate if menstruation can be induced, provided endometrium is primed with oestrogen. Corticosteroid therapy is effective in autoimmune disease if antibodies to sex hormones are present in the blood. Specific management according to the need: Pathophysiology Lack of receptors is explained as the cause of nonresponse of follicles. Clinical Features Hot flushes and sweating occur in 75% cases and may be more severe than seen in natural menopause. A woman not interested in pregnancy, but requests for restoration of menstrual cycles, should receive oestrogen progesterone cyclical therapy or cyclical progesterone alone. A young woman interested in pregnancy should be offered either ovulation induction therapy (if ovarian reserve present) or be offered donor eggs in in vitro fertilization. Late menopause occurs in women with fibroids and is seen in women who develop endometrial cancer. Beyond 52 years, endometrial biopsy is required to rule out endometrial pathology. Benefits of late menopause are: n n Late ageing-better quality of life Cardioprotective, delay in osteoporosis Complications the risks of osteoporosis and cardiovascular diseases increase in premature menopause. Postmenopausal Bleeding Normally a 1-year period of amenorrhoea after the age of 40 is considered as menopause. However, vaginal bleeding occurring anytime after 6 months of amenorrhoea in a Management 1. Speculum and bimanual examination may reveal an obvious cause in the lower genital tract. Even without amenorrhoea or irregular bleeding, if a woman over the age of 52 years continues to menstruate, she needs investigations to rule out endometrial hyperplasia and malignancy of the genital tract. Ultrasound-endometrial thickness of more than 4 mm indicates the need of endometrial biopsy. Several methods are now available to obtain endometrial tissue for histological examination. Although many endometrial benign lesions cause bleeding, the main objective is to exclude malignancy: n Aetiology Several causes account for genital tract bleeding in a postmenopausal woman: 1. Vagina-foreign body such as ring pessary for prolapse, senile vaginitis, vaginal tumour (benign as well as malignant) and postradiation vaginitis.