Advanced OB-GYN News

ENDOMETRIOSIS

By Joseph Hazan,M.D., FACOG

Endometriosis affects females of the

reproductive age.

The inner lining ofthe uterus is called

endometrium.

This inner lining is normally

built up monthly and shed during the period.

Endometriosis consists of this type

of endometrial tissue being found outside

the uterus, in various areas.

It usually manifests itself as nodules,

lesions, implants or growths.

More commonly the locations are in

the pelvic area.

However they can be

found in the abdomen or outer genital

areas.

Rarely they can be located in

distant areas such as the arm, chest,

thigh or lungs.

The problem with having endometrial

lining tissue in various locations is due

to the pain.

This pain is caused by the

breakdown and bleeding in these areas.

There is inflammation and scarring also.

Adhesion formation, obstruction and

hemorrhage are possible.

The pain is usually associated with periods,

intercourse and sometimes with bowel

movements.

Infertility can result in 35% of cases.

Diagnosis of endometriosis early in

its progression can help prevent

infertility.

Treatment is by surgery and medications

to help eliminate endometriosis. The

following can be beneficial:

Combined oral contraceptives

Levonorgestrel Intrauterine system

Medroxyprogesterone acetate

injection every 3 months.

Nonsteroidal antiinflammatory drugs

GnRH agonist Lupron

Danazole(Danocrine)

Treatment will depend on the individual

situation.

BIBLIOGRAPHY

1) Schenken RS. Pathogenesis. In:

Schenken RS,ed. Endometriosis:

Contemporary

Concepts in Clinical Management.

Philadelphia: JB Lippincott;1989.

2) Kennedy S,et al. ESHRE guideline

for the diagnosis and treatment of

endometriosis. Hum Reprod. 2005;

20(10):2698-2704.

RESOURCES

www.endo-online.org

endo@endometriosisassn.org

http://www.EndometriosisAssn.org

DYSPAREUNIA

By Joseph Hazan,M.D.,FACOG

Dyspareunia is painful intercourse.

It can occur due to physical or

psychological factors. It can be

occasional or persistent.

It can also occur after intercourse.

Causes:

1) Infection:

Herpes

Bacterial vaginosis

Pelvic Inflammatory Disease

Yeast

Trichomonas

Sexually Transmitted Infection

Urinary Tract Infection

2) Endocrine

Menopause

Breastfeeding

Estrogen lowering medications

3) Trauma

4) Medications that reduce libido

Antipsychotic medications

Some antidepressants

Some heart medications and

antihypertensives

5) Various:

Fibroids

Pelvic floor spasms- vaginismus

Vulvitis

Atrophic vaginitis

Vulvar Intraepithelial Neoplasia

Vulvar vestibulitis

Lichen sclerosus

Lichen planus

Endometriosis

Irritable Bowel Syndrome

Interstitial Cystitis-

Painful Bladder Syndrome

Constipation

Trigger point

Ovarian or tubal mass

Chronic pelvic pain

After a diagnosis is made

the treatment will be directed

to the specific situation.

PAINFUL PERIODS

Joseph Hazan,M.D.,FACOG

This problem, also known as

DYSMENORRHEA is the most

common female health issue.

70% of teenagers have this problem.

15% of those have severe symptoms.

10 % of women with severe symptoms

have pelvic abnormalities

( e.g. endometriosis).

We will address this topic separately.

These are the primary reasons for

painful periods:

1) Smoking

2) Heavy periods

3) Low fish intake

4) Depression and anxiety

5) Sexual abuse

The following are secondary causes:

1) Pelvic inflammatory disease

2) Endometriosis

3) Fibroids

4) IUD’s that do not

contain medication

5) Polyps of the uterus

6) Stenotic cervix ( narrow

cervical opening)

7) Adhesions

Treatment depends on the cause.

RESOURCES

http://www.acog.org

MORE ON PELVIC PAIN

By Joseph Hazan,M.D., FACOG

The other causes of pelvic pain are

as follows:

Constipation

Colon cancer

Irritable bowel bowel

Inflammatory bowel disease

Colitis

Chronic intermittent bowel

obstruction

Diverticular disease

(including diverticulitis)

Abdominal wall muscle

and fascial ( myofascial)

pain

Chronic coccygeal pain

Back pain

Fibromyalgia

Pain from incorrect posture

Neuralgia of pelvic nerves

Herniated disc

Spinal cord or sacral nerve

malignancy

Compression of vertebrae in

the lumbar area

Degenerative osteoarthritis

Fibromyalgia

Hernias in abdomen and groin

Spondylosis

Surgical scar pain due to trapped skin

nerve

Depression

Psychosomatic disorder

Celiac disease

Abdominal migraine

Bipolar disorder

Sleep disorders

We will begin to look into some of these

tomorrow.

PELVIC PAIN

By Joseph Hazan, M.D., FACOG

In this series we will look into

some of the useful information

regarding major entities that

cause pelvic pain.

The type of pain we will address

will be chronic pain.

Most acute causes

for pain such as ectopic pregnancy,

ruptured or torsioned ovarian cyst,

appendicitis or kidney stones result

in acute ( sudden onset and very severe)

pain which have to be treated as emergencies.

The Chronic Pelvic Pain Syndromes we will

be addressing here are prolonged, at times

for weeks and months. They are characterized

by noncyclicity.

For instance painful menses are cyclic and

recur at regular intervals.

Painful intercourse

is recurring in character and causes significant

discomfort.

It is estimated that about one in

five women aged 18-50 years are suffering

from chronic pelvic pain for over one year.

The most important gynecologic causes

of chronic pain are

Endometriosis

Pelvic inflammatory disease

Fibroids

Ovarian cysts

Pelvic congestion

Adhesions

Adenomyosis

Ovulation pain

Cervical stenosis

Cancer

Pelvic prolapse

There are urologic causes of

chronic pelvic pain also:

Interstitial cystitis

Urethral syndrome

Detrussor dyssynergia

Urethral diverticulum

Chronic UTI

(Urinary tract infection)

Urolithiasis ( stone)

Urethral caruncle

Tommorrow we will address other

pelvic systems

also:

ABOUT CHEST PAIN

By Joseph Hazan, M.D., FACOG

There is vital information on this subject.

Some of the causes of chest pain need

to be differentiated from heart disease.

Anxiety and indigestion could produce

chest pain.

THE DIFFERENCE

1) If the chest pain is mostly sharp,

it is usually not related to the heart.

Heart disease related chest pain is

mostly described as discomfort,

pressure, burning, squeezing or

heavy feeling.

2) Heart related pain usually is

aggravated with activity.

3) Heart disease related pain is

not relieved by drinking water,

eating food breathing fresh air.

4) Heart disease related pain is

not relieved or aggravated

by taking deep breaths

or rubbing your chest.

5) Heart disease related pain

keeps getting worse and is

prolonged.

6) Heart disease related pain is

usually diffuse and not only at a

specific spot. It could radiate to

the back, arm, shoulder or abdomen.

In case of the above findings

call 911.

MORE ON THE FLU

Here is a list of web resources

on updated information on

this timely topic:

1) 2009 H1N1 Flu ( Swine Flu)

www.cdc.gov/h1n1flu

2) 2009 H1N1 Influenza Vaccine and

Pregnant Women

www.cdc.gov/h1n1flu/vaccination/pregnant_qa.htm

3) 2009 H1N1 Influenza Virus

www.acog.org/departments/department_notice.cfm?recno=

20&bulletin=4866

4) 2009 H1N1 Vaccination Recommendations

www.cdc.gov/h1n1flu/vaccination/acip.htm

5) Updated Interim Recommendations for the

Use of Antiviral Medications in the Treatment

and Prevention of Influenza for the 2009-2010

Season

www.cdc.gov/h1n1flu/recommendations.htm

BIBLIOGRAPHY

1) Neuzil KM.Pandemic influenza vaccine policy:

considering the early evidence.

N Engl J Med.2009 Sep 10; ( epub ahead of print).

2) Lu P, Bridges CB, Euler GL, Singleton JA.

Influenza vaccination of recommended adult

populations, US,1989-2005.

Vaccine.2008;26(14):1786-1793.

3) Jamieson DJ, Honein MA, Rasmussen SA,

et al. H1N1 2009 Influenza virus infection

during pregnancy in the USA.

Lancet.2009;374(9688):451-458.

H1N1 IN PREGNANCY

By Joseph Hazan, M.D., FACOG

Influenza viruses are a group of

RNA viruses. They belong to

the viral family Orthomyxoviridae.

This group is divided into

Influenza A, B and C.

Influenza C generally causes

only mild respiratory illness.

A and B strains cause seasonal

viral flu and the main strains

are included in the yearly flu

shots.

Influenza A is divided into subtypes

based on the expression patterns of

two viral antigens, H and N.

H stands for Hemagglutinin and this

is the viral antigen that causes the

virus to attach itself.

There are 16

H variants.

On the other hand the N stands for

Neuraminidase which is the viral

antigen that causes the virus to be

released.

There are 9 of the N variants.

H1N1 refers to a subtype of Influenza A.

THE CURRENT PANDEMIC started in

early April 2009 in Mexico as a

disease that mostly affected the young

and caused symptoms of pneumonia.

By the time the WHO ( World Health

Organization) raised the pandemic

level to 5 on April 29 there were 2

fatalities in the U.S.

On May 20, 2009 the CDC (Centers for

Disease Control and Prevention), published

the 20 cases and 1 fatality and drew attention

to the severity of shortness of breath in

pregnant cases.

Also, fever, sore throat,

cough, runny nose, headaches, aches,

pains,nausea, vomiting, diarrhea were seen.

By May 20, 2009 there were 10.000

cases of H1N1 globally.

On June 6, 2009 the WHO announced

a level 6 pandemic which is the highest

level in 41 years. By then there were

about 94.000 cases in over 100 countries.

Pregnant women are more susceptible

to more severe symptoms, higher

complication and mortality from H1N1.

It is also more dangerous to the fetus.

TESTING is done by a rapid influenza

antigen test.

To confirm the diagnosis,

a RT-PCR ( Reverse Transcription-

Polymerase Chain Reaction) test is

done.

TREATMENT is done with antivirals and

ISOLATION face masks are used.

PREVENTION is also with antivirals.

Vaccination has recently become

available.

COLD VS H1N1

By Joseph Hazan, M.D., FACOG

There are several differences in the way

these two entities present clinically.

Here we will list the differences in symptoms

of the cold versus H1N1.

1) FEVER is rare with a cold.

However in 80% of all flu cases fever

is present. Temperature over 100 for

a few days is seen with the flu.

2) COUGH

With a cold there is usually a mucus

producing cough.

With the flu, there is a dry, non-mucus

producing cough.

3) ACHES

With a cold there are slight body aches.

With the flu body aches are severe.

4) STUFFY NOSE

With a cold a stuffy nose is usual and clears up

in a week.

With the flu stuffy nose is not usually seen.

5) CHILLS

With a cold chills are not common.

With the flu the incidence of chills is 60%.

6) FATIGUE

With a cold there is mild tiredness.

With the flu tiredness is mostly severe.

7) SNEEZING

With a cold it is very common.

With the flu sneezing is uncommon.

8) SUDDEN ONSET

With a cold symptoms start over a few days.

The flu starts suddenly over a few hours and

hits hard with sudden symptoms of fever and

body aches.

9) HEADACHE

Unusual with a cold.

Found in 80% of the flu cases.

10) SORE THROAT

Common with a cold.

Usually not seen with the flu.

11) CHEST DISCOMFORT

With a cold it is mild or moderate.

With the flu it is usually severe.

FLU FACTS

By Joseph Hazan,M.D., FACOG

More new facts are emerging in

the quest to conquer the flu virus.

Initially, the H1N1 virus appeared

in 1918

as it spawned the most dangerous

pandemic on record.

This strain of virus in its weakened

form returned every year for about

30 years until it reassorted its genetic

structure and appeared as the Asian flu

pandemic in 1957.

This reassortment was due to a patient

who was infected with both the H1N1 and

H2N2 avian virus came up with a new

immunological type of virus which resulted

from the reassortment of the genes of those

two viruses.

This was the initial emergence of the new

H2N2 virus.

This pandemic in 1957 was not as

widespread or severe as the one in

1918, “the Spanish influenza”.

Later, in 1968 the ” Hong Kong flu”

emerged when a patient who had the

seasonal H2N2 virus was also infected

with the H3 avian, “bird” flu.

This was not as severe as the 1918 flu either.

Subsequently, the H3N2 and H1N1

combinations have appeared

since the 70’s.

The yearly flu vaccines target those

two viruses and the influenza B virus.

However, the H5N1 avian, “bird” flu

started in 1997 and starting in

Hong Kong caused 433 human cases

with 262 fatalities.

The current H1N1″ so called

-swine flue- started in 1998 in the U.S.

It was first detected in pigs.

This virus has the genetic make up

of genes from the human, bird and swine

flu viruses.

Pigs can catch viral illness from

humans and birds.

This Spring this virus resurfaced in

Mexico and is

found to be highly transmissible and

virulent.

It spread from Mexico to California

and by June it became a pandemic.

It infects the young and pregnant

women appear more vulnerable.

The high mortality rate among the

young appears to be due to the strong

immune response the young people are

able to mount,resulting in

a “cytokine storm”

which could be an immune response

that devastates the host.

Finally, the long awaited H1N1

vaccine has now arrived and will

be available starting this week.

Advanced OB-GYN News

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ENDOMETRIOSIS

DYSPAREUNIA

PAINFUL PERIODS

MORE ON PELVIC PAIN

PELVIC PAIN

ABOUT CHEST PAIN

MORE ON THE FLU

H1N1 IN PREGNANCY

COLD VS H1N1

FLU FACTS

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