Dr Sudipta Paul
MD, FRCOG, DFFP, CCST
Consultant Obstetrician & Gynaecologist, UK
*Ex-Associate Professor, Newcastle University Medicine (Malaysia Campus)
*Specialist in Reproductive Medicine (Infertility) &
Gynaecological Endoscopic Surgery (Microsurgery)
*Fourteen years of UK (National Health Service) experience in Obstetrics & Gynaecology
*Awarded the highly prestigious UK National Health Service “Clinical Excellence Awards” twice for his excellence in the treatment of patients as per the UK standard
Gynaecological problems: Online advice
“Hallmark” of a good quality standard patient care
The Ten Commandments
1. Only Authentic and Evidence Based Treatment as per the international standards should be provided.
2. Clear and open discussions with the patients and their accompanying relatives regarding the patients’ medical problems should occur.
3. Patients should be dealt with as human beings. Patients’ problems should be carefully listened to and the best possible individualised treatment, depending on their circumstances, provided.
4. Patients should always be examined gently in presence of a chaperone.
5. Procedures should be clearly explained to the patients (and their accompanying relatives depending on the situation), including their benefits, side effects/complications and costs, and the benefits, side effects/complications and costs of not doing the procedures.
6. An informed consent must be taken before performing any procedure (such as surgery).
7. Only necessary and relevant investigations should be requested. Patients should be free to do them from any good laboratory.
8. “Junk treatment” should not be provided. Junk treatment is advising medicines, surgery or some other form of treatment that has no proven value in that particular illness. Like “junk food”, “junk treatment” might be harmful.
9. The patients (and their accompanying relatives depending on the situation) should always be involved in the decision making regarding treatment.
10. Gimmick of 100% success must not be provided ever.
“The Doctor is neither God nor a Magician”
Dr Sudipta Paul
Gynaecological problems – Online advice
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World AIDS Day
World AIDS Day, observed on 1 December every year, is dedicated to raising awareness of the AIDS pandemic caused by the spread of HIV infection.
World AIDS Day was first conceived in August 1987 by James W. Bunn and Thomas Netter, two public information officers for the Global Programme on AIDS at the World Health Organization in Geneva, Switzerland. Bunn and Netter took their idea to Dr Jonathan Mann, Director of the Global Programme on AIDS (now known as UNAIDS). Dr Mann liked the concept, approved it, and agreed with the recommendation that the first observance of World AIDS Day should be 1 December 1988.
Government and health officials observe the day, often with speeches or forums on the AIDS topics. Since 1995, the President of the United States has made an official proclamation on World AIDS Day. Governments of other nations have followed suit and issued similar announcements.
AIDS has killed more than 25 million people between 1981 and 2007, and an estimated 33.2 million people worldwide live with HIV as of 2007, making it one of the most destructive epidemics in recorded history. Despite recent, improved access to antiretroviral treatment and care in many regions of the world, the AIDS epidemic claimed an estimated 2 million lives in 2007, of which about 270,000 were children.
Clinical Risk Management
Clinical Risk Management (CRM) has become an integral part of clinical practice. It has been proven that CRM improves the standard of patient care and reduces malpractice. CRM is not merely defensive medicine as it has often been criticised in the past. A thorough understanding of CRM is an essential requirement for all “Good Doctors”. This article discusses the different aspects of CRM comprehensively.
“Clinical Risk Management identifies procedures that may carry actual or legal hazards and minimises them through formal safeguards and protocols.”
*This is equal to 8.3% of the adults population, with equal rates in both women and men. 2, 3
* Worldwide in 2012 and 2013 diabetes resulted in 1.5 to 5.1 million deaths per year, making it the 8th leading cause of death. 4, 5
* Diabetes overall at least doubles the risk of death. 6
* The number of people with diabetes is expected to rise to 592 million by 2035. 7
*The economic costs of diabetes globally was estimated in 2013 at $548 billion and in the United States in 2012 $245 billion. 5
- Williams textbook of endocrinology (12th ed.). Philadelphia: Elsevier/Saunders. pp. 1371–1435.
- Shi, Yuankai; Hu, Frank B. “The global implications of diabetes and cancer”. The Lancet 383 (9933): 1947–8.
- Vos T, Flaxman AD, Naghavi M, Lozano R, Michaud C, Ezzati M, Shibuya K, Salomon JA, Abdalla S, Aboyans V, et al. (Dec 15, 2012). “Years lived with disability (YLDs) for 1160 sequelae of 289 diseases and injuries 1990–2010: a systematic analysis for the Global Burden of Disease Study 2010.”. Lancet 380 (9859): 2163–96.
- “The top 10 causes of death Fact sheet N°310”. World Health Organization. Oct 2013.
- IDF DIABETES ATLAS (6th ed.). International Diabetes Federation. 2013. p. 7.
- “Diabetes Fact sheet N°312”. WHO. October 2013.
- “International Diabetes Federation: Diabetes Atlas”.
This woman presented with primary infertility, chronic pelvic pain and dysmenorrhoea in her thirties. The ultrasound scan suggested left endometrioma. Laparoscopy showed left endometrioma with dense adhesions of the uterus to the bladder and anterior abdominal wall, and bilateral kinking of the Fallopian tubes due to advanced endometriosis. The right ovary and the tubes, otherwise, were healthy. The pouch of Douglas was surprisingly clear. The dye test did not show any signs of the dye going in to the tubes. The left endometrioma was removed laparoscopically after division of surrounding adhesions. The adhesions between the uterus and the anterior abdominal wall were divided to make the Fallopian tubes free. Subsequently, there were bilateral spillage of dye. The uterine adhesions to the bladder were left as these were too dense and the risks of injuring the bladder were higher than the potential benefits in improving fertility.
* Endometriosis is a disease where the cells from the endometrium (lining of the womb/uterus) grow in the pelvis outside the womb (or in the womb muscle when it is called adenomyosis).
* Primarily, it is not a disease of the womb/uterus. It affects the organs and tissues outside the womb.
* The commonest site or organ affected is the ovary.
* The incidence of endometriosis in the general female population is 1-2%.
* Its usual symptoms include pain just before and during periods (progressive dysmenorrhoea), painful sexual intercourse (dyspareunia) and pelvic pain, childlessness (infertility) etc (Triad of endometriosis). Other symptoms include heavy periods (10%), lower abdominal pain during passing urine, blood in urine, pain and/or bleeding during opening bowel, pain in and bleeding from surgical scar etc.
* The correlation between the severity of pain and extent of the disease is poor.
* It is found in 15-25% (1 in 4-7) of the infertile women.
* On the other hand, the incidence of infertility in women with endometriosis is 20-65% (2 in 3-10).
* The cause of endometriosis is unknown. There is a familial tendency (more maternal link) suggesting some genetic predisposition.
* Several theories, including implantation of cells from the lining of the womb following retrograde menstruation, have been put forward. In retrograde menstruation the menstrual blood flows backwards through the fallopian tubes into the pelvis.
* Given the fact that retrograde menstruation occurs in the majority (90%, 1 in 9) of women and endometriosis does not develop in all of them suggests strongly towards genetic/immunological predisposition in those who develop it.
* The risk of malignant (cancerous) change in endometriosis is small.
* The diagnosis is usually suspected from the history and examination but confirmed by laparoscopy (the Gold Standard). Ultrasonography cannot exclude endometriosis. Its only usefulness is to detect ovarian endometriotic cyst (endometrioma or chocolate cyst) and adenomyosis or adenomyoma (endometriosis in the womb muscle), but it cannot detect small endometriotic deposits in the pelvis. Blood test such as Serum Ca125 is not useful in making a diagnosis, as it could rise in several other conditions. Its only possible use would be to monitor for recurrence following treatment.
* Endometriosis is usually a progressive disease, and if not treated it would spread to other tissues and organs thereby damaging them. In advanced endometriosis adequate relief from symptoms would be very difficult to achieve due to the extensive damage to the tissues and organs.
* It usually regresses after menopause as it is estrogen (female hormone) dependent.
* The treatment of endometriosis depends on the stage of the disease, symptoms, whether the woman wishes to have more babies, her age, previous treatment etc.
* Its treatment includes Surgical (such as laparoscopic surgery or open surgery) and Medical (such as GnRh analogue, Danazol etc).
Q. How endometriosis causes damage to tissues and organs?
* During periods the endometrotic tissues (anywhere) bleed as the lining of the womb does. The bleeding behaves like a foreign body in the areas affected and causes local inflammation which the body’s defence mechanism tries to control and heal (natural process). With the process repeating every periods scar tissue forms. Eventually the disease extends and greater number of organs (such as ovaries, tubes, bowel, bladder etc) and area of tissues get involved in the scar tissue (adhesions) that might cause persistent pain.
Q. Why endometriosis causes pain just before and during periods?
* It causes pain in the areas affected due to local inflammation. Therefore the pain is relieved by anti-inflammatory drugs (such as Ibuprofen, Mefenamic acid, Diclofenac etc).
Q. Why endometriosis causes pain during sexual intercourse?
* Due to the areas in the pelvis affected, mainly the area behind the womb.
Q. Why endometriosis causes pain outside the period as well?
* When the disease extends to a greater number of organs (such as ovaries, tubes, bowel, bladder etc) and area of tissues that get involved in the scar tissue (adhesions) it might cause persistent pain outside the period as well.
Q. Why endometriosis causes infertility?
* It might cause infertility due to the release of toxic chemicals that kill the sperm, egg or embryo, or change the motility of the hair-like structures (cilia) inside the Fallopian tubes; or damage to the ovaries (direct or due to adhesions) or tubes (due to adhesions); or painful sexual intercourse (dyspareunia).
Q. Could Hormone Replacement Therapy (HRT) be used in women with endometriosis?
* It is a debatable issue as endometriosis is estrogen (female hormone) dependent. There are HRTs that do not contain estrogen such as Tibolone. The issue should be discussed with a Gynaecologist before deciding to take HRT.
Updated on 25.01.2014.
Gynaecological malignancies include a vast and heterogenous group of malignancies that affect the female reproductive tract. These are associated with significant morbidity an mortality in the female primarily due to delayed diagnosis. The aim should be early detection and appropriate management, and taking preventive measures where available and feasible. The outcome of management is usually expressed in 5-year survival, but the quality of survival is equally important.
Conception <———– Genetic Predisposition
Pregnancy/Intrauterine Life/Life before birth <———– ?Intrauterine factors
Life after birth <———– Environmental factors
What are the issues that would affect someone with a diagnosis of cancer?
What would they want to know?
What do you have to take into account in relation to diagnosis of cancer?
Issues in relation to diagnosis of female genital tract cancer
1. Breaking the bad news
3. Psychological impact
4. Impact on the Family
5. Impact on the Sexual life
6. Impact on the Fertility
7. Cost implications (in developing countries/countries where treatment is not free)
Principles of Management
* Diagnosis to treatment should be undertaken within 2 weeks (UK), urgent referral and treatment elsewhere.
* Multidisciplinary Team (MDT – General Gynaecologist/Gynaecological Oncologist, Medical Oncologist, Oncology Nurse, Pain management team member etc) discussion / treatment plan
* Treatment options
iv> Palliative therapy (symptomatic treatment, pain management etc) for terminal cancer
* Treated by
i> General Gynaecologist
ii> Gynaecological Oncologist (Gynaecologist specialising in Gynaecological Oncology)
* Follow up at intervals
* Hospice (special hospital for patients with terminal cancer)/Palliative care (at home/hospital)
FIGO Staging – General Principles
* Stage 1 – cancer is confined to the organ
* Stage 2 – cancer has involved adjacent organs/areas
* Stage 3 – cancer has spread further/beyond adjacent organs/areas
* Stage 4 – Distant metastases
Organs involved and the methods of staging
HIV transmission through mosquito bites
*Human immunodeficiency virus, or HIV, is a human retrovirus that infects lymphocytes and other cells bearing the CD4 surface marker.1
*The virus is transmitted primarily by sexual and parental routes.1
*Could HIV be transmitted through mosquito bites?
*Surveys to determine knowledge regarding HIV have shown in many countries, including Papua New Guinea, that a large proportion of the literate population still believe that mosquitoes can transmit the HIV virus from one person to another. Since AIDS was first recognized, many have reported on the possibility of mosquito involvement in the transmission of the virus. In 1988, almost half of 6625 men and women interviewed in Zaire and nearly half of 4189 teacher-trainees interviewed in Zimbabwe believed in the transmission of HIV by mosquitoes. A survey involving 1500 high school students from 14 schools in 4 different provinces in Papua New Guinea revealed that 34% of them considered mosquitoes to be carriers of HIV.2
*There are two ways blood feeding arthropods can spread disease, mechanically, by simple transfer of virus between hosts by contaminated mouth parts, or, biologically that would require virus replication in arthropod tissues (especially salivary glands).1
* Studies with HIV have shown clearly that the virus disappears in the mosquito after about 1-2 days, the time required for the mosquito to digest the blood-meal. Since the virus does not survive to reproduce and invade the salivary glands, biological transmission of HIV is not possible.2 The evidence that indicates that HIV is not transmitted by mosquito bite include: i> HIV virus can not replicate inside the mosquito, bed bug, flea, or other blood sucking insect and the lack of replication of HIV in arthropod cells due to lack of T4 antigen on cell surface, and ii> it is unlikely that HIV is transmitted by insects, given the low infectivity of HIV and the short survival of the virus in the mosquito. HIV appears to be much less easily transmitted probably due to lower titers of virus in body fluids. So, on the basis of experimental evidence and probability estimates, it has been concluded that the likelihood of mechanical or biological transmission of HIV by insects is virtually nonexistent.1
* It has been calculated that, for mechanical transmission, an HIV-free individual would have to be bitten by 10 million mosquitoes that had been feeding on an HIV carrier to receive a single unit of HIV from contaminated mosquito mouthparts. In short, there is still no evidence of arthropod transmission of the HIV virus.2
* Although mosquitoes are carriers of malaria, filaria, yellow fever, dengue, chikungunya and Japanese encephalitis, there is no evidence that mosquitoes can transmit HIV.
Pelvic Infection and Infertility
* The incidence of pelvic infection in the general female population is about 10-15%.
* It most commonly occurs in the younger age groups (15-24 years).
* The risk factors for pelvic infection include young age at first sexual intercourse, a high frequency of sexual intercourse, multiple sexual partners, not using condom or spermicide, abortion (termination of pregnancy, both medical and surgical), miscarriage, insertion of coil (IUCD), intra-uterine instrumentation (e.g. D&C), appendicitis, tubal/pelvic surgery etc.
* The likelihood of tubal factor infertility depends on the severity and number of episodes of pelvic infection.
* The possibility of tubal factor infertility after one episode of mild pelvic infection is about 0.6% (1 in 167) but following an episode of severe disease that rises to about 21.4% (1 in 4.67, 3467% increase).
* The overall possibility of tubal factor infertility after one episode of pelvic infection is about 8%, that rises to about 19.5% after two episodes (144% increase) and to as high as about 40% after three episodes (105% increase compared with two episodes and 400% increase compared with one episode).
Q. What are the symptoms of pelvic infection?
* The usual symptoms of acute pelvic infection include vaginal discharge, pelvic or lower abdominal pain, fever etc. In chronic pelvic infection persistent pelvic or lower abdominal pain, persistent or recurrent vaginal discharge, painful sex, heavy periods, painful periods etc might be present. Vaginal spotting in between periods (intermenstrual bleeding) is a feature of pelvic infection due to Chlamydia trachomatis.
Q. How is the diagnosis of pelvic infection made?
* It is usually suspected from the symptoms and examination findings. Genital swabs could confirm the nature of infection (such as bacterial, protozoal or fungal). Laparoscopy is diagnostic. Ultrasonography is helpful in excluding other problems, but cannot diagnose pelvic infection.
Q. How the incidence of tubal factor infertility due to pelvic infection could be reduced?
* The incidence of tubal factor infertility could be reduced by changes in behaviour, taking appropriate precautionary measures and use of appropriate antibiotics when indicated.
* Simple measures like using condom and prompt treatment of pelvic infection would have a significant impact in reducing the incidence of tubal damage and pelvic adhesions, and consequent infertility and pelvic pain. Women should be particularly careful while having abortion, and should ensure that it is done in an appropriate environment.
Q. Are there any other risks associated with pelvic infection?
* The risk of pregnancy in the Fallopian tube (ectopic pregnancy, a potentially life-threatening condition due to rupture of the tube and bleeding inside abdomen) also increases to 9.1% following pelvic infection (a 6.5-fold increase).
* Pelvic infection may result in chronic pelvic pain due to adhesions that increases the risk of having a hysterectomy (removal of the womb) by 10-fold.
Pregnancy & Folic acid supplementation
☺Marginal to severe folate deficiency is present in 5% of the general population and in early pregnancy.
☺Folic acid supplementation around the time of conception and up to 12 weeks’ pregnancy reduces the risk of having a baby with neural tube defects (NTDs, which affect the spinal cord and brain) by 3/4th (RR* 0.28, 95% CI** 0.13- 0.58). Neural tube defects include spina bifida (commonest, about 2/3rd of all), anencephaly (the second most common, about 1/3rd of all) and encephalocele (<1/10th of all). The prevalence varies from 1 in 100-2000 pregnancies depending on the geographical location (highest in certain northern provinces in China and lowest in the Scandinavian countries). The risk of recurrence is 3-5% after one affected baby and 8-10% after two affected babies. The risk is 3-4% if one of the parents is affected by multifactorial NTD.
☺The recommended dose of folic acid is 0.4 mg per day. For women who have previously had a baby with a neural tube defect or who are receiving anti-epileptic medication, a higher dose of 5 mg per day is recommended. This higher dose has also been suggested for women with a BMI of >35, although the benefit is yet to be proven.
☺To achieve maximum benefit, the folic acid should be started at least before becoming pregnant and continued up to 12 weeks’ pregnancy as the neural tube in the baby is formed around 3-4 weeks of its embryonic age (5-6 weeks of pregnancy).
☺Maternal folic acid supplementation is associated with decreased risk of other congenital anomalies, including cardiovascular defects (OR*** 0.61, 95% CI 0.40- 0.92) and limb defects (OR 0.57, 95% CI 0.38- 0.85), and some paediatric cancers including leukaemia, paediatric brain tumours and neuroblastoma.
☺Whether periconceptional folic acid supplementation increases the incidence of twin births is yet to be proven. (NICE 2004 & RCOG SACOP 16, 2009)
*RR = Relative Risk (is the ratio of the number of a group in which the event of interest occurs to the number in which it does not)
**95% CI = 95% Confidence Interval (a range that includes the true value with a probability of 0.95)
***OR = Odds Ratio (is the ratio of the number of a group who develop the outcome of interest to the number who do not)
Pregnancy and its Mechanism
To become pregnant naturally the following must happen
(The Five Pillars of Natural Conception, Paul S 2009)
1. The woman must ovulate (release an egg)
The egg (ovum) develops in the ovary and is subsequently released at ovulation. This function is controlled by several hormones released by the brain including GnRh (Gonadotrophin Releasing Hormone) from the hypothalamus, and FSH (Follicle Stimulating Hormone) and LH (Luteinising Hormone) from the pituitary gland, and ovary (estrogen and progesterone). Ovulation (release of the egg) is also controlled by other local factors including chemicals in the ovary. There are two ovaries, and in a healthy female of reproductive age*, ovulation usually occurs from one of them in each menstrual cycle. The notion that ovulation occurs alternately from each ovary in consecutive months may not be correct.
*Reproductive age – It starts around the time of first menstrual period (Menarche) and finishes with the complete stoppage of menstrual periods (Menopause). The usual range of reproductive age is 12-50 years (variable). The first few years after the menarche and last few years preceding the menopause (peri-menopause) are not that useful in relation to reproduction because of lack of regular ovulation. Therefore, for practical purposes, 15-45 years of age is generally considered as reproductive age in the female.
2. The Fallopian tube(s) (reproductive channels) must be functional
The egg, once released from the ovary, enters the Fallopian tube and meets the sperm there. Following fertilisation in the Fallopian tube the fertilised egg enters the uterus (womb) after 3-4 days where it implants and grows in to the baby. The Fallopian tubes are not mere channels for the passage of the sperm and egg, these have important functional roles in collecting the egg from the ovary, and transport of the egg and fertilised egg. Hair-like structures (cilia) in the endosalpinx (lining of the Fallopian tubes) play important role in the transport of the egg and fertilised egg. Damage to the Fallopian tube(s) is associated with infertility and would increase the risk of ectopic pregnancy in the tube. For natural conception to occur at least one Fallopian tube must be open and functional. One cannot drive a car along the road unless the road is open and drive-worthy!
3. The uterus and endometrium (lining of the womb) must be receptive and capable of carrying a pregnancy
Abnormalities of the uterus and its lining may affect implantation of the fertilised egg leading to failure of implantation or miscarriage at a later stage. Ageing of the female and some diseases might affect normal functioning of the uterus and its lining.
4. The man must produce good quality sperm in adequate numbers
Only one healthy (normal with good progressive motility) sperm is required to fertilise an egg, however, millions of healthy sperm are initially required to complete the process of fertilisation. The process of the sperm reaching the egg in the Fallopian tube, from the front passage through the neck of the womb and womb is an enormously difficult task for the sperm. Majority of the sperm die/fail to reach the egg during the process. Only few healthy sperm reach the egg and one of them fertilises it. Thereby, Nature ensures that only the best quality sperm (vigorous enough to reach the egg) would fertilise the egg.
5. Regular unprotected sexual intercourse without any sexual dysfunction
Unprotected sexual intercourse should take place regularly without any sexual dysfunction (at least 2-3 times/week, preferably without a gap of more than 1 day in between) to deposit sperm high in the front passage around the time of ovulation (usually occurs between 12-16 days of a 28 days menstrual cycle). The egg lives for about 24 hours while the sperm survives for about 3 days (up to 7 days has been reported) inside the female genital tract. Therefore, sexual intercourse, at least 2-3 times/week, usually provides some living sperm inside the female genital tract for most of the time. This significantly improves the chance of a pregnancy happening. With regular intercourse, 94% and 77% of fertile women aged 35 years and 38 years respectively conceive within three years of trying.
© Dr Sudipta Paul, themedideas.com, 2013