What are Urogynecologic Disorders?

 

Lily Arya, MD, MS:
Sacral nerve stimulation is a minimally invasive outpatient procedure for the treatment of urge incontinence and urinary frequency. It is performed in two parts. Part one involves testing to see if patient is eligible for the procedure. It is performed under local anesthesia. Two weeks later, if the patient is eligible, the placement of the pulse generator is done under sedation and local anesthesia. Studies show that it is successful in 75-85% women in curbing the "urgency" to urinate

 

 

FIRST TRIMESTER PREGNANCY

Definition:

The first trimester of pregnancy begins when a fertilized egg implants into a woman's uterus. This occurs about 7 days after the egg is fertilized.
The first trimester ends when the fetus is about 12 weeks old. (This is about 14 weeks from the first day of the last normal menstrual period.)

Alternative Names:

Early pregnancy; Pregnant - first trimester

Causes, incidence, and risk factors:

Pregnancy is a normal condition and, in most situations, should not be approached as a problem or disease. Any fertile female engaged in a sexual relationship with a fertile male is at risk of becoming pregnant.

Symptoms:

Signs and tests:

The health care provider will perform an examination, which may reveal:

  • an enlarged uterus -- the top of the uterus (the fundus) may be felt by touch
  • a bluish or purple coloration of the vaginal walls and cervix
  • softening of the cervix
  • weight changes (usually weight gain, although weight loss could occur if nausea and vomiting are significant).
  • increased size of the abdomen

Tests include:

Pregnancy may also alter the results of numerous laboratory tests.

Treatment:

Prior to modern medicine, many mothers and their babies did not survive pregnancy and the birth process. Today, good prenatal care can significantly improve the quality of the pregnancy and the outcome for the infant and mother.
Good prenatal care includes:

  • Good nutrition and health habits before and during pregnancy
  • Frequent prenatal examinations to detect early problems
  • Routine ultrasounds to detect fetal abnormalities and problems
  • Routine screening for:
    • Sexually transmitted diseases
    • Rubella immunity
    • Blood type problems (Rh and ABO)
    • Diabetes
    • Genetic disorders -- if there is a family history or the age of the mother indicates the need
    • Blood pressure abnormalities
    • Urine protein

Women who choose to have an abortion usually do so in the very early stages of the pregnancy (usually before 12 weeks gestation). Abortion is legal through the 24th week of pregnancy. The abortion procedure, however, becomes more difficult with advancing gestational age, and many providers do not perform pregnancy terminations in the second trimester.
Women who plan to continue a pregnancy to term need to choose a health care provider who will provide prenatal care, delivery, and postpartum services. Provider choices in most communities include:

  • physicians specializing in obstetrics and gynecology (OB/GYN)
  • certified nurse midwives (CNMs)
  • some family practice physicians
  • some family nurse practitioners (FNPs) or physician assistants (PAs) who work in conjunction with a physician

Family health care providers, or generalists, are proficient in managing women throughout normal pregnancies and deliveries. If a problem in the pregnancy is identified, a generalist will refer the patient to obstetric specialist.
The goals of prenatal care are to:

  • monitor both the pregnant woman and the fetus throughout the pregnancy
  • identify anything that could change the outlook for the pregnancy from normal to high-risk
  • explain nutritional requirements throughout the pregnancy and postpartum period
  • explain activity recommendations or restrictions
  • address common complaints that may arise during pregnancy (for example, backache, joint pain, nausea, heartburn, headaches, urinary frequency, leg cramps, and constipation) and how to manage them, preferably without medications

Women who are considering becoming pregnant, or who are pregnant, should eat a balanced diet and take a vitamin and mineral supplement that includes at least 0.4 milligrams (400 micrograms) of folic acid. This level of folic acid supplement has been shown to decrease the risk of certain abnormalities (such as spina bifida).
Pregnant women are advised to avoid all medications, unless the medications are necessary and recommended by a prenatal health care provider. Women should discuss all medication use with their providers.
Pregnant women should avoid all alcohol and drug use. They should not smoke. They should avoid herbal preparations and common over-the-counter medications that may interfere with normal development of the fetus.
Prenatal visits are typically scheduled:

  • every 4 weeks during the first 32 weeks of gestation
  • every 2 weeks from 32 to 36 weeks gestation
  • weekly from 36 weeks to delivery

Weight gain, blood pressure, fundal height, and fetal heart tones (as appropriate) are usually measured and recorded at each visit, and routine urine screening tests are performed.

Expectations (prognosis):

About 10% of known pregnancies terminate spontaneously -- usually during the first trimester. (See miscarriage.) As many as 50 - 70% of all conceptions terminate spontaneously before the woman is even aware of pregnancy. Many of these occur because there is a problem with the developing fetus.

Complications:

Abnormal or high-risk situations, which may prove dangerous to the health of the mother or fetus, may occur in up to 20% of pregnancies.

Calling your health care provider:

Call for an appointment if you suspect you are pregnant, are currently pregnant and are not receiving prenatal care, or if you are unable to manage common complaints without medication.
Call your health care provider if you suspect you are pregnant and are on medications for diabetes, thyroid disease, seizures, or high blood pressure.
Notify your health care provider if you are currently pregnant and have been exposed to a sexually transmitted disease, chemicals, radiation, or unusual pollutants.
Call your health care provider if you are currently pregnant and you develop fever, chills or painful urination.
It is urgent that you call your health care provider if you are currently pregnant and notice any amount of vaginal bleeding, the membranes rupture (water breaks), or you experience physical or severe emotional trauma.

Prevention:

There are a variety of birth control methods designed to prevent pregnancy. These include the condom, female condom, IUD, birth control pill, hormone injections/implants, diaphragm, and family planning.
For example, women who use Depo-Provera injections or progestin implants have less than 1 pregnancy per 100 women per year. Couples who use the rhythm or calendar methods have between 20 to 30 pregnancies per 100 women per year.
The only 100% effective means of contraception is complete abstinence.

 

What is menopause?

Menopause is the permanent end of a woman's monthly period. A woman has reached menopause when she has ceased having periods for one year. In North America, women usually go through menopause between the ages of 45 and 55. When menopause occurs before age 40, it is considered premature.
As menopause nears in a healthy woman, the ovaries begin to gradually reduce the amount of estrogen, progesterone and androgens they produce.
Estrogen is the main female sex hormone, and it controls the development of a woman's secondary sex characteristics. Estrogen also prompts the growth of a uterine lining during a woman's menstrual cycle and maintains that lining during pregnancy. However, estrogen is far more than a reproductive hormone, as it has wide-ranging effects on other parts of a woman's body, including her:

  • Urinary tract
  • Heart
  • Blood vessels
  • Bones
  • Breasts
  • Skin
  • Portions of the brain

Progesterone is important in maintaining a regular menstrual cycle.
The role of androgens is less well documented. A reduction in androgen levels may contribute to the decline in energy levels and sexual desire that women sometimes experience during menopause

Symptoms

As a woman's hormone levels decline, she may begin to notice signs that her hormones are fluctuating. Common symptoms include:

  • Hot flashes
  • Night sweats
  • Erratic monthly periods, often combined with unusually heavy menstrual bleeding
  • Vaginal dryness and thinning of the tissues of the vagina and urethra
  • Increase in facial hair and thinning of hair on scalp

Every woman has a different experience through menopause. Some women have very few of these symptoms and find them easy to manage. Other women, though, have such bad symptoms that they lose sleep and their mood suffers.
If you're struggling with symptoms of menopause, talk to your health care provider about hormone replacement therapy or alternative remedies to ease symptoms of menopause. And talk to your health care provider immediately if your bleeding occurs more frequently than every 21 days or if there is heavy bleeding that lasts more than seven days.

Alternative Therapies to Ease Symptoms

Today, women are seeking herbal and nutritional therapies to ease hot flashes and other symptoms of menopause. While many herbal remedies may help ease those discomforts, these therapies have not been proven to reduce risk of heart disease or osteoporosis. If you're considering alternative therapies, talk to your health care provider. Note, though, that not all doctors feel comfortable recommending herbal or nutritional therapies for symptoms of menopause.

Female Herbs
These leading female herbs, deemed safe by the FDA, appear to balance estrogen in the body when the human hormone level becomes too low or too high. They are available dried, as capsules or tinctures, or in teas:

  • Dong quoi (Angelica sinesis) -- To quell hot flashes and regulate hormonal production. Investigators have confirmed dong quoi's pain-relieving, antispasmodic and anti-inflammatory activity.
  • Ginseng -- A tonic that increases energy and endurance.
  • Feverfew -- To relieve migraine headaches triggered by perimenopausal hormone fluctuations.
  • St. John's wort -- Scientifically shown to relieve mild depression and anxiety.
  • Valerian -- To promote sleep and relieve anxiety.
  • Motherwort -- To relieve vaginal dryness.
  • Wild yam -- Regarded as a progesterone-producing herb to ease hot flashes and breast tenderness.
  • Garlic -- Whether eaten or taken in deodorized capsules, may lower harmful lipids and protect the heart.

These alternative therapies also may ease symptoms:

  • Black cohosh (Cimicifuga racemosa) roots and stems -- Reduces hot flashes and relieves depression and vaginal thinning. It is the main ingredient in Remifemin, a widely used German product, and in "menopause" teas and capsules. Note: do not use if you might be pregnant or are having heavy bleeding.
  • Vitex or chasteberry (Vitex agnus-castus) fruit -- May regulate progesterone levels that contribute to fluid retention, bloating, breast tenderness, headache and fatigue. It is often included with black cohosh in menopausal products. Note: do not use this if you might be pregnant.

Soybeans
Interest in soybeans has been sparked by the theory that a soy-rich diet may explain why Asian woman don't experience symptoms of menopause. Lab studies reveal soy can significantly boost the high-density lipoproteins that protect the heart -- a significant finding given that heart disease is the leading cause of death in post-menopausal women. Soy also may prevent bone loss.

Tips on Natural Herbs
Natural isn't always safe. Some herbal remedies may have harmful side effects in people with certain medical problems. Stop taking herbs and see your physician if you develop uterine bleeding, a rash or any adverse reaction.

  • Seek guidance. Contact a licensed herbalist or talk to your health care provider if you are considering alternative therapies.
  • Seek reputable herbal preparations. Herbal products are not uniform. To make sure the ingredients you want are in the jar, read labels to learn genus and species, known active ingredients and the amounts.
  • Results may not be instant. It can take about six to eight weeks for most herbs to work.
  • Start with a lower dose. There is a therapeutic dosing range that may vary with each individual, just as there is with drugs. If the dose is three capsules three time a day, you may want to start with one capsule three times a day.

 

 

Miscarriage

Why do miscarriages occur?
The reason for miscarriage is varied and most often, the cause can not be identified. During the first trimester, the most common cause of miscarriage is chromosomal abnormality-meaning that something is not correct with the baby's chromosomes. Most chromosomal abnormalities are the cause of a faulty egg or sperm cell or due to a problem at the time that the zygote went through the division process. Other causes for miscarriage include (but are not limited to):

  • Hormonal problems, infections or health problems in the mother
  • Lifestyle (i.e. smoking, drug use, malnutrition, excessive caffeine and exposure to radiation or toxic substances)
  • Implantation of the egg into the uterine lining does not occur properly
  • Maternal Age
  • Maternal trauma

What are the Warning signs of Miscarriage ?
If you experience any or all of these symptoms, it is important to contact us o to evaluate if you could be having a miscarriage:

  • Mild to severe back pain (often worse than normal menstrual cramps)
  • White-pink mucus
  • True contractions (very painful happening every 5-20 minutes)
  • Brown or bright red bleeding with or without cramps
  • Tissue with clot like material passing from the vagina
  • Sudden decrease in signs of pregnancy

The different types of Miscarriage :
Miscarriage is often a process and not a single event. There are many different stages or types of miscarriage. There is also a lot of information to learn about healthy fetal development so that you might get a better idea of what is going on with your pregnancy. Understanding early fetal development and first trimester development can aide you in knowing what things your health care provider is looking for when there is concern of a miscarriage occurring.
Most of the time all types of miscarriage are just called Miscarriage, but you may hear your health care provider refer to other terms or names of miscarriage such as:

  • Threatened Miscarriage: Some degree of early pregnancy uterine bleeding accompanied by cramping or lower backache. The cervix remains closed. This bleeding is often the result of implantation.
  • Inevitable or Incomplete Miscarriage: Abdominal or back pain accompanied by bleeding with an open cervix. Miscarriage is inevitable when there is a dilation or effacement of the cervix and/or there is rupture of the membranes. Bleeding and cramps may persist if the miscarriage is not complete.
  • Complete Miscarriage: A completed miscarriage is when the embryo or products of conception have emptied out of the uterus. Bleeding should subside quickly, as should any pain or cramping. A completed miscarriage can be confirmed by an ultrasound or by having a surgical curettage performed.
  • Missed Miscarriage: Women can experience a miscarriage with out knowing it. A missed miscarriage is when embryonic death has occurred but there it not any expulsion of the uterus. It is not known why this occurs. Signs of this would be a loss of pregnancy symptoms and the absence of fetal heart tones found on an ultrasound.
  • Recurrent Miscarriage (RM): Defined as 3 or more consecutive first trimester miscarriages. This can affect 1% of couples trying to conceive.
  • Blighted Ovum: Also called an anembryonic pregnancy. A fertilized egg implants into the uterine wall, but fetal development never begins. Often there is a gestational sac with or without a yolk sac, but there is an absence of fetal growth.
  • Ectopic Pregnancy: A fertilized egg implants itself in places other than the uterus, most commonly the fallopian tube. Treatment is needed immediately to stop the development of the implanted egg. If not treated rapidly, this could end in serious maternal complications.
  • Molar Pregnancy: The result of a genetic error during the fertilization process that leads to growth of abnormal tissue within the uterus. Molar pregnancies rarely involve a developing embryo, but often entail the most common symptoms of pregnancy including a missed period, positive pregnancy test and severe nausea.

Treatment of Miscarriage :
The main goal of treatment during or after a miscarriage is to prevent hemorrhaging and/or infection. The earlier you are in the pregnancy, the more likely that your body will expel all the fetal tissue by itself, and will not require further medical procedures. If the body does not expel all the tissue, the most common procedure performed to stop bleeding and prevent infection is a dilation and curettage, known as a D&C. Drugs may be prescribed to help control bleeding after the D& C is performed. Bleeding should be monitored closely once you are at home and if you notice an increase in bleeding or the onset of chills or fever, it is best to call your physician immediately.
Prevention of Miscarriage :
Since the cause for most miscarriages is due to chromosomal abnormalities, there is not much that can be done to prevent them. One vital step is to get as healthy as you can before conceiving to provide a healthy atmosphere for conception to occur.

  • Exercise regularly
  • Eat healthy
  • Manage stress
  • Keep weight in healthy limits
  • Take folic acid daily
  • Do not smoke

Once you find out that you are pregnant, again the goal is to be as healthy as possible, to provide a healthful environment for your baby to grow in:

  • Keep your abdomen safe
  • Do not smoke or be around smoke
  • Do not drink alcohol
  • Check with your doctor before taking any over-the-counter medications
  • Limit or eliminate caffeine
  • Avoid environmental hazards such as radiation, infectious disease and x-rays
  • Avoid contact sports or activities that have risk of injury

Emotional Treatment :
Unfortunately, miscarriage is not prejudice in whom it touches. It can affect any couple or family. Often women are left with unanswered questions regarding their physical recovery, their emotional recovery and trying to conceive again. It is very important that women try to keep the lines of communication open with family, friends and health care providers during this time.

 

 

 

 

Weight and Fertility

Body mass index and its effect on in vitro fertilization pregnancy rates

Background
A woman's weight can affect her fertility. We know that at both extremes, very thin and obese, that there can be disruption of the normal process of regular, consistent ovulation. Anovulation can often result. Medications can be used to induce ovulation in these women in an attempt to become pregnant.
Body mass index, or BMI, is an index of a person's relative "skinniness or fatness". The BMI factors in a person's weight as well as their height to give an overall "index". A high BMI indicates obesity.

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A standard medical definition of "normal" body weight is a BMI of about 18.5 - 24.9

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A BMI under 18.5 indicates that the person is "underweight"

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A BMI of 25.0 - 29.9 indicates that the individual is "overweight", but not obese

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A BMI over 30 indicates obesity

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A BMI over 40 indicates extreme obesity

Obesity is associated with increased risk for several serious disease processes. Extreme obesity is associated with a dramatically increased risk for many serious diseases. The web site weight.com is a good place to start learning more about those risks, as well as weight loss issues, etc.
Body mass index is calculated with this formula:
weight (in kilos) divided by height (in meters) squared
Therefore, if someone weighs 100 kilos and is 1.8 meters tall, their BMI is 100 divided by 1.8 X 1.8 = 100/3.24 = 30.9
To convert from pounds to kilos, take the weight in pounds and divide it by 2.2
To convert from inches to meters, take the height in inches times 0.0254

 

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