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  • Professor Emeritus, Department of Cellular & Molecular Pharmacology, University of California, San Francisco

http://cmp.ucsf.edu/faculty/bertram-katzung

The most common cause of thyroid hyperfunctioning in premenopausal women is Graves disease cheap 20 mg valif visa, which occurs four to purchase 20 mg valif overnight delivery five times more often in women than men best valif 20 mg. Hyperthyroidism can result in oligomenorrhea or amenorrhea proven valif 20 mg, and it can lead to elevated levels of plasma estrogen (155). Other causes of anovulation include hypothalamic dysfunction, hyperprolactinemia, premature ovarian failure, and primary pituitary disease (Table 14. These conditions often are considered causes of amenorrhea, and they may cause irregular bleeding (see Chapter 30). Women should be encouraged to track their menstrual cyclicity and to consider that the menstrual cycle can be a “vital sign” that reflects overall health (61). Diabetes mellitus can be associated with anovulation, obesity, insulin resistance, and androgen excess. Androgen disorders are very common among women of reproductive age and should be evaluated and managed accordingly. Because androgen disorders are associated with significant cardiovascular disease, the condition should be diagnosed promptly and treated. This condition becomes of more immediate concern in older women of reproductive age. Management of bleeding disorders associated with androgen excess consists of an appropriate diagnostic evaluation followed by the use of oral contraceptives (in the absence of significant contraindications or the desire for conception) or the use of insulin-sensitizing agents, coupled with dietary and exercise modification (159–161). Anatomic Causes Anatomic causes of abnormal bleeding occur more frequently in women of reproductive age than in women in other age groups. Uterine leiomyomas and endometrial polyps are common conditions that most often are asymptomatic; however, they remain important causes of abnormal bleeding (162). Uterine leiomyomas occur in as many as one-half of all women older than age 35 years and are the most common tumors of the genital tract (151,152,162). The incidence varies from 30% to 70%, depending on criteria for study, whether clinical symptoms, ultrasound, or histologic assessment (163). One study of a randomly selected population estimated a cumulative prevalence of greater than 80% in black women and nearly 70% in white women (164). Although the number and size of uterine leiomyomas do not appear to influence the occurrence of abnormal bleeding, submucosal myomas are the most likely to cause bleeding. The mechanism of abnormal bleeding related to leiomyomas is not well established (see Chapter 15 for further discussion of uterine fibroids). Endometrial polyps are a cause of intermenstrual bleeding, heavy menstrual bleeding, irregular bleeding, and postmenopausal bleeding and are associated with the use of tamoxifen and with dysmenorrhea and infertility. The incidence of endometrial polyps increases with age throughout the reproductive years (162). The diagnosis may be suspected on the basis of endometrial thickening on transvaginal pelvic ultrasound, and patterns of feeder blood vessels may aid in distinguishing endometrial polyps from intracavity fibroids and from endometrial malignancy (162,165,166). Visualization with hysteroscopy or sonohysterography or the microscopic assessment of tissue obtained by a biopsy done in the office or a curettage specimen is required for confirmation. Whether and when to recommend removal is not well established, particularly if a polyp is asymptomatic and is found incidentally. One study of randomly selected Danish women using transvaginal ultrasound and sonohysterography found polyps in 5. Endometrial polyps can regress spontaneously, although it is not clear how frequently this occurs. Smaller polyps are more likely to resolve, and larger polyps may be more likely to result in abnormal bleeding (169). Whereas polyps may resolve spontaneously over time, a clinically important question is whether they are likely to undergo malignant transformation. Because even asymptomatic polyps usually are removed at the time of identification, this question is difficult to answer. The chance of malignancy or premalignant changes in endometrial polyps appears to be quite low in premenopausal women and higher among postmenopausal women, with bleeding reports range from premalignant change in 0. Abnormal bleeding, either intermenstrual or postcoital, can be caused by cervical lesions. Bleeding can result from endocervical polyps and infectious cervical lesions, such as condylomata, herpes simplex virus ulcerations, chlamydial cervicitis, or cervicitis caused by other organisms. Other benign cervical lesions, such as wide eversion of endocervical columnar epithelium or nabothian cysts, may be detected on examination but rarely cause bleeding. Coagulopathies and Other Hematologic Causes of Abnormal in Reproductive Age Women As with adolescents, hematologic causes of abnormal bleeding should be considered in women with heavy menstrual bleeding, particularly in those who had abnormal bleeding since menarche. Of all women with menorrhagia, 5% to 20% have a previously undiagnosed bleeding disorder, primarily von Willebrand’s disease (171). Abnormal liver function, which can be seen with alcoholism or other chronic liver diseases, results in inadequate production of clotting factors and can lead to excessive menstrual bleeding. Infections Causes As in adolescents, menorrhagia can be the first sign of endometritis in women infected with sexually transmissible organisms. Women with cervicitis, particularly chlamydial cervicitis, can experience irregular bleeding and postcoital spotting (see Chapter 18). Neoplasia Abnormal bleeding is the most frequent symptom of women with invasive cervical cancer. A visible cervical lesion should be evaluated by biopsy rather than awaiting the results of cervical cytology testing, because the results of cervical cytology testing may be falsely negative with invasive lesions as a result of tumor necrosis. Unopposed estrogen is associated with a variety of abnormalities of the endometrium, from cystic hyperplasia to adenomatous hyperplasia, hyperplasia with cytologic atypia, and invasive carcinoma. Although vaginal neoplasia is uncommon, the vagina should be evaluated carefully when abnormal bleeding is present. Attention should be directed to all surfaces of the vagina, including anterior and posterior areas that may be obscured by the vaginal speculum on examination. Diagnosis of Abnormal Bleeding in Reproductive-Age Women For all women, the evaluation of excessive and abnormal menses includes a thorough medical and gynecologic history, the exclusion of pregnancy, the consideration of possible malignancy, and a careful gynecologic examination.

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Sensation over the inner thigh valif 20 mg without a prescription, vulva buy generic valif 20 mg on-line, and perirectal areas should be tested for symmetry to purchase 20mg valif with visa light touch and pinprick valif 20mg online. Muscle Strength the integrity of the pelvic floor muscles should be assessed at rest and with voluntary contraction to determine strength, duration, and anterior lift. The ability to relax these muscles and tenderness on palpation should also be evaluated. Several standardized systems have been described to objectively measure muscle strength, but none has been accepted as a standard. The puborectalis muscle should be readily palpable posteriorly as it creates a 90-degree angle between the anal and rectal canals. Voluntary contraction of this muscle “lifts” the examining finger anteriorly toward the pubic rami. An intact external anal sphincter muscle that has decreased tone and contractility often indicates pudendal neuropathy. Similarly, neuropathy affecting the puborectalis can be recognized by an obtuse anorectal angle and weak voluntary contraction. Similar to the urethral axis, the anorectal angle can also be tested using a cotton-tipped swab, although this test is rarely performed. Deflection is measured in the supine position at rest, with strain, and with squeeze. Vaginal Support the salient points of pelvic organ prolapse (see Chapter 27 for patients with defecatory dysfunction are the support of the vaginal apex, posterior wall, and perineal body, although some experts believe anterior wall defects can also affect defecatory dysfunction. The posterior wall is assessed while supporting the vaginal apex and anterior wall with a Sims speculum. This permits the examiner to focus on identifying specific locations of rectovaginal fascial defects. A rectovaginal examination aids in identification of defects in the rectovaginal fascia or perineal body. Loss of vaginal rugation has also been reported overlying the site of a rectovaginal fascial tear (84). This technique is especially useful for enteroceles, which have a smooth, thin epithelium over the enterocele sac or peritoneum. Normally, the perineum should be located at the level of the ischial tuberosities, or within 2 cm of this landmark. A perineum below this level, either at rest or with straining, represents perineal descent. Subjective findings of perineal descent include widening of the genital hiatus and perineal body, as well as a flattening of or a convex appearance of the intergluteal sulcus. An increase in the length of the perineal body and genital hiatus consistent with straining suggests perineal descent. Mark’s perineometer, although a thin ruler placed in the posterior introitus at the level of the ischial tuberosities also can be used. Descent is measured as the distance the perineal body moves when the patient strains. Although pelvic floor fluoroscopy is the standard technique for measuring perineal descent, this technique is most useful in patients with symptoms of severe defecatory dysfunction and evidence of perineal descent on pelvic examination. Anorectal Examination Visual and digital inspection of the vagina and anus will help to identify structural abnormalities such as prolapse, fistulas, fissures, hemorrhoids, or prior trauma. As previously mentioned, a rectovaginal examination provides useful information regarding the integrity of the rectovaginal septum and can demonstrate laxity in the support of the perineal body. The rectovaginal examination is helpful in the diagnosis of enteroceles, which can be felt as protrusion of bowel between the vaginal and rectal fingers with straining. Digital rectal examination should be performed at rest, with squeeze, and while straining. The presence of fecal material in the anal canal may suggest fecal impaction or neuromuscular weakness of the anal continence mechanism. Circumferential protrusion of the upper rectum around the examining finger during straining suggests intussusception, which often occurs in combination with laxity of the posterior rectal support along the sacrum. The integrity of the external anal sphincter and puborectalis muscle can be evaluated by observation and palpation of these structures during voluntary contraction. Evidence of dovetailing of the perianal skin folds and the presence of a perineal scar with an asymmetric contraction often indicates a sphincter defect. When a patient is asked to contract her pelvic floor muscles, two motions should be present: the external anal sphincter should contract concentrically, and the anal verge should be pulled inward. As mentioned previously, the 90-degree angle created by the puborectalis should be readily palpable posteriorly and, with voluntary contraction, the examining finger should be lifted anteriorly toward the pubic rami. Both the puborectalis and external anal sphincter should relax during Valsalva effort. Patients with anismus may experience a paradoxical contraction of these muscles during straining. Finally, defects in the anterior aspects of the external anal sphincter may be detected by digital examination. Testing Sophisticated diagnostic testing is currently being used in clinical research and in anorectal physiology laboratories to quantify the function of the colon and anorectum. Following is a description of these techniques as they relate to the management of fecal incontinence and disordered defecation. Fecal Incontinence Endoanal Ultrasonography Endoanal ultrasonography permits accurate imaging of both the internal and external anal sphincters. It can assess the continuity and thickness of the muscle and currently is considered the single best method for detecting anal sphincter defects. Endoanal ultrasonography is performed using a Bruel-Kjaer (Copenhagen, Denmark) ultrasound scanner with a 360-degree rectal endoprobe (type 1850) with a 7. Location and severity of the defect can be described by circumferential distance in degrees, percentage of thickness, and distance from the anal verge (Fig.

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In addition buy cheap valif 20mg line, ongoing visits for counseling and support are essential and may include practical counseling and assistance with problem-solving skills and social support during and after treatment purchase 20mg valif visa. Relapse prevention is important purchase valif 20mg otc, with congratulations for any successes and encouragement to order 20 mg valif overnight delivery remain abstinent. Patients who use tobacco but are unwilling to quit at the time of the visit should be treated with the “5 Rs” motivational intervention: Relevance, Risks, Rewards, Roadblocks, and Repetition (48). Obstetrician-gynecologists and primary care: training during obstetrics gynecology residency and current practice patterns. Characteristics of office-based physicians and ther practices: United States, 2003–04. Women’s patterns of provider use across the lifespan and satisfaction with primary care coordination and comprehensiveness. The database focuses on the effects of interventions used in health and social care. Clinical preventive services for adolescents: Position paper of the society for adolescent medicine. Clinical preventive services for adolescents: position paper of the Society for Adolescent Medicine. The role of obstetrician-gynecologist in the assessment and management of obesity. The practical guide: identification, evaluation, and treatment of overweight and obesity in adults. Harmonizing the metabolic syndrome: a joint interim statement of the International Diabetes Federation Task Force on Epidemiology and Prevention; National Heart, Lung, and Blood Institute; American Heart Association; World Heart Federation; International Atherosclerosis Society; and International Association for the Study of Obesity. Use of supplements containing folic acid among women of childbearing age—United States, 2007. Nolan Empiric therapy for women with pneumonia should be based on the specific patient profiles and the severity of their pneumonia. All patients with possible community-acquired pneumonia should have a chest radiograph to establish the diagnosis and the presence of complications. Most patients with hypertension will require two or more antihypertensive medications to achieve optimal blood pressure control less than 140/90 or less than 130/80 mm Hg for patients with diabetes or kidney disease, respectively. There is an increased use of cholesterol-lowering drugs, including the “statins,” a class of drugs that lower cholesterol by blocking a liver enzyme necessary to produce cholesterol, and they are very effective in reducing the risk of heart attacks and deaths. Type 2 diabetes is frequently not diagnosed until complications appear, and approximately one-third of all people with diabetes may be undiagnosed: individuals at risk should be screened and a comprehensive plan of care initiated for those diagnosed with diabetes. As health care providers for women, gynecologists are responsible for providing care that extends beyond diseases of the reproductive organs to include much of the general medical care of their patients. Broadening the spectrum of care requires adjustments in practice, with less emphasis placed on the surgical aspects of the specialty. Early diagnosis and treatment of medical illnesses can have a major impact on a woman’s health. Although timely referral is important for complex and advanced diseases, many conditions can be recognized and treated initially by gynecologists. Respiratory problems are the most common reasons patients seek care from a physician, so gynecologists should be aware of their pathophysiology. Cardiovascular disease has a significant impact on overall morbidity and is the main cause of death in women. Cardiovascular disease is associated with cigarette smoking, hypertension, hypercholesterolemia, and diabetes mellitus. These conditions are responsive to screening, behavior modification, and control to lower risk factors. Because of the interaction of hormones and the overall effect on the endocrine system, thyroid disease can be of special significance in women. The gynecologist should provide screening and initial therapy for these conditions and assess the need for referral. Respiratory Infections Infections of the respiratory system can range from the common cold to life-threatening illness. Sinusitis A problem frequently encountered in women is self-diagnosed “sinus problems. The sinuses are not an isolated organ, and diseases of the sinuses are often related to conditions that affect other portions of the respiratory system. The entire respiratory system can be infected by one particular virus or pathogen (the sinobronchial or sinopulmonary syndrome); however, the most prominent symptoms are usually produced in one anatomic area. Therefore, during the evaluation of symptoms attributable to sinusitis, the presence of other infections should be investigated. Multiple infectious and chemical agents or reactions to nervous, physical, emotional, or hormonal stimuli may cause an inflammatory response in the respiratory system (1). Systemic diseases such as connective tissue syndromes and malnutrition may contribute to chronic sinusitis. Factors contributing to the development of sinus disease include atmospheric pollutants, allergy, tobacco smoke, skeletal deformities, dental conditions, barotrauma from scuba diving or airline travel, and neoplasms. Most acute infections (lasting less than 4 weeks) begin with a viral agent in the nose or nasopharynx that causes inflammation, blocking the draining ostia (1). The location of the symptoms varies by anatomic site of infection—maxillary sinus over the cheeks, ethmoid sinus across the nose, frontal sinus in the supraorbital area, and sphenoid sinus to the vertex of the head—and typically last 7 to 10 days, clearing with nothing more than a decongestant.

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Katsambas stress generic 20mg valif free shipping, and cosmetics in acne purchase 20 mg valif fast delivery, and Department of Dermatology cheap valif 20 mg without prescription, Andreas Syngros informing the patient on expected side Hospital discount valif 20mg without prescription, National and Capodistrian University of Athens, Athens, Greece effects. Married Employed Nonsmokers Nondrinkers Not paying for prescription (no cost) Disease-related First-time users of oral isotretinoin 53. This chapter will review strategies to study, indicating that younger patients and those improve patient compliance including patient more psychologically affected by acne are less education, the advent of new formulations, and likely to comply with proposed treatments [3 ]. Factors that had a positive effect on improve compliance, we should first be able to adherence included more severe acne, use of cos recognize the responsible factors that infiuence it. It has been shown that a range of disease-related Patient compliance is greatly infiuenced by and social factors may infiuence compliance with the dermatologist, and strategies about educating treatment in acne (Table 53. Being female, married, employed, and not paying for prescription were characteristics associated with 53. Also, Patient Compliance: the Role patients receiving oral isotretinoin for the first of the Dermatologist time were most compliant (increased medication adherence) compared with patients who had 53. This finding was attributed to the loss of faith in the effectiveness of isotreti Treatment has to be tailored according to the noin after the failure of a first course [3 ]. If the recommended treatment studies have also suggested that first-time use interferes significantly with the patient’s lifestyle, 53 Improving Compliance with Acne Therapy 391 patient compliance will be minimal and the result Table 53. Moreover, patient compliance might be Improving patient compliance What to do enhanced by taking into account patient prefer General approach Tailor treatment to the individual ences for acne medications [6]. Adolescents often patient abandon acne treatments prematurely because of Select a treatment that will not a slow onset of action, irritation, or inconve interfere with the patient’s lifestyle nience in use. Male patients generally do not like Take into account patient’s using many different products, so a simple regi preferences men consisting of a cleansing soap and one topi Educating the Discussion before treatment patient Provide clear instructions cal combination treatment should suffice for cases of mild acne. Explain the rhythm of improvement Strategies to improve adherence and the Explain the role of cosmetics Explain the role of sunlight, diet, resulting outcomes of topical therapies include stress simplifying the treatment regimen and identify Explain potential side effects ing cues that remind patients to use the medica Use of maintenance therapy tion. Also, it should be taken into account that New formulations Micronized isotretinoin the compliance reported by patients often Extended-release minocycline greatly exceeds reality, and it has been proposed New topical combination to question patients on the quantity of oral med formulations ication they have used, in order to maximize Minimizing side Short-contact topical retinoids compliance [2]. On the other hand, there are cases when acne persists beyond the expected age, and thus, no patient is “too old to have acne. A discussion before any treatment proposal is Patients often have questions concerning the mandatory. The dermatologist should spend at potential role of diet, sunlight, or stress on their least 20 min with an acne patient in the first coun acne, which should be adequately answered (see seling visit. A the natural course of acne has to be explained review of the literature reveals that there is not in simple, understandable phrases and terms. We good-quality patient-oriented evidence on this suggest the use of a simple figure (Fig. It remains to be seen showing the expected severity and duration of whether certain foods (especially saturated fats acne. The patient should understand that acne or foods with a high glycemic index) may cause usually presents at the age of 12–14 years old, hyperinsulinemia in humans. We feel that more gradually progresses during adolescence, and systematic controlled studies are warranted so finally resolves by the age of 23–27 years old in that a final conclusion on the diet–acne hypothe the majority of patients [2 ]. Also, neuroactive substances Exposure to sunlight has a beneficial effect on within the epidermis, such as substance P, have acne in the majority of cases, especially when been incriminated to upregulate lipid synthesis in acne is localized on the back and chest, but dete sebaceous cells and to stimulate the proliferation rioration may be noted in 20 % of patients. Before starting any therapy for acne, it is neces Stress has traditionally been the main culprit sary to advise the patient to apply topical thera in aggravating acne according to our patients. A significant association between acne In order to minimize irritation associated with severity and increased stress levels during exami the use of topical retinoids, short durations of nation periods has been reported in a prospective application should be adopted at first, with grad study of 22 patients, even after controlling for ual increments in application time as tolerated changes in diet and sleep habits. Also, patients should be advised to use a authors pointed out that the association observed gentle cleanser and a moisturizer [1 ]. Sometimes an aggravation treatment should be explained to patients or par may be experienced during the first few weeks of ents of minors. Some patients are reassured to therapy, but in most patients acne will improve by learn that isotretinoin is a naturally occurring 60 % in 4 months and by at least 80 % in 6 months endogenous compound [1, 18]. Furthermore, the patient should be aware that isotretinoin results in dryness of the lips that systemic treatment should be continued for a (100 %), skin (50 %), nasal passages (30–50 %), sufficient period of time in order to achieve opti and eyes (20 %), it may cause dermatitis, cheilitis, mal results: 6–8 months for isotretinoin, 6 months epistaxis, and conjunctivitis. The frequent appli to 1 year for hormonal treatments, and up to 6 cation of moisturizers is usually sufficient and months for oral antibiotics [2]. They are also suggested in order to counteract the drying effect of topical retinoids, benzoyl peroxide, azelaic acid, and oral 53. Noncomedogenic and nonacnegenic cosmetics and makeup should be recommended the desire for acne treatments associated with a for acne patients [2, 17]. An explanation of the most frequent side effects New and emerging systemic antibiotics include to expect with a proposed acne treatment should lymecycline, azithromycin, anti-infiammatory be provided to the patient, together with simple dose doxycycline, and a new extended-release advice on how to handle them. A lower starting dose of isotretinoin has bacterial resistance (anti-infiammatory dose doxy been recommended in order to avoid this adverse cycline) [7]. Efficacy relies on good dosing compliance and good compliance results from convenience in use Conclusions and treatment tolerability [1, 5]. Since acne is a chronic disease, it may Once-daily use of a micronized and more bio necessitate treatment for months or years. This new formulation can be taken with dermatologists is central in considering food at a single daily dose of 0. When the relationship between doctor and patient has been built on trust and confidence, 53. The development of side effects during treatment and hence diminished patient tolerability can References lead to decreased compliance. Patient compliance: enhancing clini patients treated with low-dose isotretinoin com cian abilities and strategies.

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