Health Risks of Underage Drinking in Adolescent Women

As they reach adolescence, many teenage girls will be faced with a multitude of social pressures and personal curiosities. Often, these can involve substances such as alcohol and drugs. According to Drink Aware, the vast majority of teenagers don’t wait until they’re 18 before embarking on the drinking scene and by the time they reach 15, 8 out 10 teenagers have tried alcohol.

Short of locking your teenage daughters in the house, it can be difficult to stop them engaging in this sort of behaviour. However it is important to know the potential risks of underage drinking so that you can educate them on the damage that they could be doing to their physical, mental, emotional and sexual health. Often it can be difficult to make a young person care too deeply about their personal wellbeing – a lot of teenagers feel that they are invincible. But we hope we have compiled a few of the serious and less glamorous side effects of underage drinking that may make them sit up and take heed of your warnings.

INFERTILITY & SEXUAL HEALTH

In a study reported by Livestrong, evidence suggests that even low to moderate alcohol consumption can disrupt the reproductive hormones in women responsible for regulating menstrual cycles. This is particularly relevant during puberty when the body is developing, hormones are circulating and the menstrual cycle is just establishing itself. If a young woman were to disrupt this progress repeatedly then she could find herself suffering from menstrual disorders, irregular bleeding, ovarian problems and even fertility issues in later life.

Research also suggests that girls you binge drink are up to 63% more likely to become teenage mothers. It seems that when the alcohol begins flowing, inhibitions, good judgement and thoughts of safe sex go out of the window. Statistics show that 2007 11% of teenagers have admitted to engaging in unsafe sex after drinking and therefore exposing themselves to unplanned pregnancies and sexually transmitted diseases. With BBC Health suggesting that up to one in ten sexually active people carry Chlamydia, it really only takes one careless encounter to contract a disease that can have all sorts of dangerous side effects including infertility.

GROWTH STUNTING, WEIGHT GAIN & SKIN

Puberty is a busy time with hormonal changes, growth and organ development taking place. Drinking alcohol prior to or during puberty can disrupt the hormonal balance and therefore stunt the growth and development of bones and vital organs. This is particularly relevant in girls as they are generally built smaller then boys and so the alcohol in their systems has a more concentrated effect.

Alcohol is full of empty calories and has no nutritional value. The body seeks to break it down and dispose of it as soon as possible because it has no health benefits and cannot be stored in the body. In the process of metabolising the alcohol, the body doesn’t get chance to break down anything else that has recently been ingested and so weight gain and excess alcohol consumption often go hand in hand.

Alcohol also depletes the body of Vitamin A which is responsible for replenishing new skin cells. To deprive the body of this could mean seeing an unpleasant effect on the complexion which could become dry, dull and prematurely aged.


BRAIN DAMAGE AND MENTAL DISORDERS

Like the rest of the body, the brain also develops throughout puberty and continues to form into a person’s mid 20’s. According to Too Smart To Start, drinking alcohol throughout this period of brain development can affect the structure and functionality of the brain which can have lasting consequences. Each part of the brain is responsible for different things from emotions, memories, rational thought, self regulation and problem solving. To damage a certain part of the brain could permanently impair one of these modes of thought. For example, if the hippocampus (the part of the brain responsible for forming memories) is damaged then a person may find they have trouble remembering things in later life.

Similarly, alcohol has been strongly linked to a variety of mental disorders such as depression and anxiety due to its interference with brain chemistry and the fact that it increases the likelihood of suffering from low mood, insomnia, loss of appetite and social dysfunctional – all of which go hand in hand with depression.


ORGAN DAMAGE AND INCREASE RISK OF DISEASE

Alcohol has a strong, detrimental effect on the liver (particularly a liver that is still developing) as most people are aware of. But it can also increase the risk of mouth, throat and breast cancer, diabetes and heart disease through increased blood pressure and high cholesterol. These conditions are irreversible and can be potentially life threatening.

So if you think that your teenage daughter might be about to start experimenting with binge drinking or alcohol then do make sure that she is aware of the risks involved. It is very difficult to stop young people being curious about things like this but with the right education they can at least know the potential dangers that they are exposing themselves to and hopefully drink responsibly, in moderation and ideally, not at all.

CERVICAL CANCER - A SEXUALLY TRANSMITTED DISEASE !!!.

World wide cervical cancer is the second most common and the 5th deadliest cancer in women. Approximately 80% of cervical cancer now occurs in developing countries such as Nigeria.
Cervical cancer is common among female sex workers. It is rare in Nuns, except for those who had been sexually active before entering the convent. Cervical cancer is more common in the second wives of men whose first wife died from cervical cancer. Cervical cancer is rare in Jewish women.

SIGNS & SYMPTOMS

The early stages of cervical cancer may be symptomless. Vaginal bleeding, contact bleeding or rarely a vaginal mass may indicate the presence of malignancy. Moderate pain during sexual intercourse and vaginal discharge are symptoms of cervical cancer. In advanced disease, spread may be present in the abdomen, lining or elsewhere.
Symptoms of advanced cervical cancer may include loss of appetite, weight loss, fatique, pelvic pain, back pain, leg pain, swollen legs, heavy bleeding from the vaginal, bone fracture and rarely leakage of urine in faeces from vaginal.

CAUSES

Infection with some type of Human Papilloma Virus (HPV) is the greatest risk factor for cervical cancer; followed by smoking. Other risk factors include HIV infection. Not all the causes of cervical cancer are known, however and several other combining factors have been implicated.
Human Papilloma Virus (HPV) is the cause of 70% of cervical cancer globally. Women who have many sexual partners or who have sex with men who have had many other partners have a greater risk of the 150 -200 types of HPV known, 15 are classified as high risk types. Types 16 and 18 generally acknowledged to cause about 70% of cervical cancer.
Genital warts are caused by various strains of HPV. The general view is that a patient must have been infected with HPV to develop cervical cancer and is hence viewed as a sexually transmitted disease. Use of condom significantly reduce but does not always prevent transmission. HPV can be transmitted by skin to skin contact with the infected area.

DIAGNOSIS.

Whilst Pap smear is an effective screening test, confirmation of the diagnosis of cancer or precancer requires a biopsy of the cervix. This is often done through colposcopy, a magnified visual inspection of the cervix aided by using diluted acetic acid solution to highlight the abnormal cells on the surface of the cervix. Colposcopic impression, the estimate of disease severity based on visual inspection forms part of diagnosis. Further diagnostic and treatment procedure are loop electrical excision procedure (LEEP) and conisation

PRECANCEROUS LEISONS

Cervical intra epithelial neoplasia (CIN) the precursor to cervical cancer is often diagnosed on examination of cervical biopsy by a pathologist through a cervical smear or Pap smear.
Squamons cell carcinoma (80-85%) is the cervical cancer with the most incidence. The incidence of Aden carcinoma (15%) is on the increase in recent decades especially among women.

PREVENTION

The widespread introduction of cervical screening by Pap smear for cervical cancer has been credited with dramatically reducing the incidence and mortality of cervical cancer in the developed countries.
Cervical smear test every 3- 5 years with incidence by up to 80%. Abnormal result may suggest the presence of precancerous changes allowing examination and possible prevention treatment. If precancerous disease or cervical cancer is detected early, it can be monitored or treated relatively non- invasively with little impairment of infertility.

VACCINATION

There are 2 HPV vaccines which reduce the risk of cancerous or precancerous changes of the cervix and perineum by about 93%. HPV vaccines are typically given to women age 9 to 26 as the vaccine is only effective if given before the infection occurs. The vaccines have been shown to be effective for at least 4 to 6 years. The case for a booster dose is strong. The high cost of this vaccine has been a cause of concern. Many countries have considered programmes to fund HPV vaccination and Nigeria should not be an exception.

CONDOMS

Condoms are thought to offer some protection against cervical cancer. Evidence of whether it offers protection against HPV is mixed, but they may protect against genital warts, and the precursor to cervical cancer. They also protect against other STDs such as HIV and Chlamydia which are associated with greater risk of developing cervical cancer.
Condoms may be useful in treating potentially precancer changes in cervix. Semen increases risk of precancer CIN3 and the use of condoms help to cause this changes regress and help clear HPV.

TREATMENT

Treatment of cervical cancer varies world wide, largely due to a large variance in the disease burden in developed and developing nations, access to surgeons skilled in radical pelvic surgery and emergence of fertility sparing therapy in developed countries. Because cervical cancers are radiosensitive, radiation may be urgent in all stages where surgical options do not exist. Micro invase (stage 1A) is best treated by hysterectomy. A combination of surgery, radiation and Chemotherapy can be used depending on stages of cancer and expertise available.

BREAST CANCER & 21 FACTS

One out of every ten women develops cancer of the bosom (an incidence of 10%)

Among women who are 25 – 74 years of age, bosom cancer is the leading cause of cancer mortality.
Cancinoma of the bosom is more common on the left bosom than the right. It is more common in the outer than the inner quadrant.
Cancer of the bosom is commoner in women who have no children and in women who have not bosom fed.
Cancer of the bosom is 5 times more likely to occur in women who have family history of bosom cancer.
Cancer of the bosom is one of the leading causes of death from all causes of death in women between ages 39 to 44 years.

The typical presentation of bosom cancer is that of a lump in the bosom which in the early stages is isolated, movable and painless.
As the cancer advances, fixation, retraction of skin or Tip, ulceration, pain, redness and ancillary masses may appear.
EARLY detection depends on SELF examination by women at monthly intervals and twice yearly by physicians. bosom self examination (BSE) should be performed monthly, one week after the menses.
To make an early diagnosis the DOCTOR must have a high degree of suspicion regarding all bosom lumps as well as a basic knowledge of bosom problems.

The most common type of bosom lesions and their frequencies are: fibrocystic disease 34% bosom cancer 27% fibroadenoma 19% intraductal papilloma 6%, duct ectasia 4% other types of bosom lesions 11%.

Patients at high risk of bosom cancer are:

• Those over the age of 40 years
• Those with a family history of bosom cancer
• Women who have never been pregnant or never had children.
• Women having their first baby after age 35 years.
• Women with a previous history of cancer in one bosom
• Women with explosure of bosom to excessive ionizing radiation.
• Women with endometrial or ovarian cancer
• Women with high dietary intake of fat.
• Women with chronic psychological stress.
• Women leaving in the western hemisphere of Europe or America.
• White women in the upper socio economic group.

Biopsy is mandatory in bosom lumps, any suspicion found by mammogram or bosom scan even if there are no clinical findings. It is also mandatory in any serous or bloody Tip discharge even if there are no lumps, and mammograms are negative. A woman should have a baseline mammogram between age 35 to 40 years of age. Between 40 and 50 years, mammogram are recommended every other year, after 50 years of age, yearly mammogram are recommended.
15% of patients who survive treatment of the initial bosom cancer for 3 or more years develop cancer in the opposite bosom.

Contralateral hidden cancers are seen in about 25% of patients with bosom cancer recently proved on one side.35% of women with untreated bosom cancer are known to survive for 5 years.
Irrespective of all diagnosis, techniques including mammogram, some cancers still unfortunately still elude early detection. Reliance for early detection of bosom cancer must be placed on self examination.
Recommendations for surgery, radiation and chemotherapy depends on the type, size, location and the extent of the tumour, the patient’s age, relation to the menopause and other factors.
bosom monthly self examination (BSE), bosom scan and mammogram in those of high risk group aids early detection and treatment.

What is bosom Cancer?

bosom cancer is a malignant tumour (a collection of cancer cells) arising from the cells of the bosom. Although bosom cancer predominantly occurs in women, it can also affect men.
What Causes bosom Cancer

There are many risk factors that increase the chance of developing bosom cancer. Some of the bosom cancer risk factors can be modified (such as alcohol) while other cannot be influenced (such as age).

Age: -
The chances of bosom cancer increases as you get older.

Family: -
The risk of bosom cancer is higher among women who have relatives with the disease. Having a close relative with the disease (sister, mother, daughter) doubles a woman’s risk.

Previous bosom Cancer: -
Having been diagnosed with bosom cancer in one bosom increases the risk of cancer in the other bosom or a recurrence in the same bosom.

Menstruation: -
Women who started their menstruation as a younger age (before 12) or went through menopause later (after 55 years have a slightly increased risk.

Bosom Tissue: -
Women with dense bosom tissue on mammogram have a higher risk of bosom cancer.

Race:-
White women have a higher risk of developing bosom cancer, but African Americans and black women have more aggressive tumours when they do develop bosom cancer.
Exposure to previous chest radiation increases the risk of bosom cancer.
Having no children or the first child after age 30 increases the risk of bosom cancer.
bosom feeding for one and a half to 2 years slightly lowers the risk of bosom cancer.
Being overweight or obese increases the risk of bosom cancer.

Bosom Cancer Symptoms and Signs

The most common signs of bosom cancer are a new lump or mass in the bosom. In addition, the following are possible signs of bosom cancer:
Tip discharge or redness
bosom or Tip pain
Swelling of part of the bosom or dumpling.


How is bosom Cancer Diagnosed?

Although bosom cancer can be diagnosed by the above signs and symptoms, the use of screening MAMMOGRAM has made it possible to detect many of the cancers early before they cause any symptoms.
Women age 40 years and older should have a screening MAMMOGRAM every year and should continue to do so as long as they are in good health.
Women in their 20s and 30s should have a clinical and self bosom examination regularly by their gynaecologist during any gynaecological encounters.


What is Treatment of bosom Cancer?

Patients with bosom cancers have many treatment options. Most treatments are adjusted to the type of cancer and the staging group.

Surgery: -
Most women with bosom cancer will require surgery. The surgery could be bosom conserving surgery or mastectomy.
bosom conserving surgery will only remove part of the bosom. (Partial Mastectomy) and usually followed by radiation therapy.
Mastectomy means all the bosom tissues are removed.
Radical mastectomy means the whole bosom tissue is removed in addition to the axillary lymph nodes and the chest wall muscles.

Radiation Therapy: -
Destroys cancer through external beam radiation or through branchy therapy.

Chemotherapy: -
chemotherapy is the treatment of bosom cancers with medications given either through intravenous injections or orally.

Adjuvant Chemotherapy means chemotherapy is given after the surgery.
Neo adjuvant Chemotherapy means it is given before the surgery.

Hormone Therapy: -
This is usually used to prevent or reduce the risk of bosom cancer recurrence. Tamoxifen prevents oestrogen from binding to oestrogen receptors on the bosom cells. Other hormones that can be used are Fulvestrant, Aromatase inhibitors such as letrozole, anatrozole and exemestane.

FIBROID

Uterine fibroid is the most common benign (not cancerous) tumour of a woman uterus (womb). Fibroids are tumours of the smooth muscle that is normally found in the wall of the uterus. 
They can develop within the uterine wall or attaché to it. They may grow as single tumours or in clusters.
Uterine fibroids can cause excessive menstrual bleeding, pelvic pain and frequent urination. Even though they are called benign (not cancerous) tumours, fibroids potentially can cause many health problems.
Fibroid growth occurs in up to 50% of all women and they are a leading cause of hysterectomy (removal of uterus) in Europe and America.
Fibroids starts in muscle tissues of the uterus they can grow into uterine cavity (submucosal) into the thickness of the uterine wall (intramural) or on the surface of the uterus (subserosal) into the abdominal cavity. Some may occur as pedunculated masses.

Uterine Fibroid Causes.

The exact reasons why some women develop fibroids are unknown. Fibroids tend to run in families. Women of Africa descent (blacks) are 2 0r 3 times more likely to develop fibroids than women of other races.
Fibroids grow in response to stimulation by the female hormone (oestrogen) produced naturally in the body. These growths can show up as early as 20 and shrink after menopause when the body stops producing large amount of oestrogen.
Fibroids can be small and cause no problems, but they can also grow to weigh several kilograms. Fibroids generally grow slowly.

The following factors have been associated with the presence of fibroids:

• Being overweight (obesity).
• Never having given birth to a child.
• Onset of menstruation period before age 10.
• African and African heritage (3 – 9 times often than in Caucasian women). 
• Uterine Fibroid Symptoms.

Most fibroids, even large ones, produce no symptoms. These masses are often found incidentally during a normal pelvic examination.

When women do experience symptoms, the most common are the following:
Irregular vaginal bleeding or an increase in menstrual bleeding known as menorrhagia, sometimes with blood clots.
Pressure on the bladder which may cause frequency in urination and a sense or urgency to urinate and very rarely inability to urinate.
Pressure in the rectum, resulting in constipation.
Pelvic pressure, resulting in lower abdominal pain.
Increase in size around the waist and abdominal swelling. Some women need to increase their cloth size but not because of significant weight gain.
Infertility
Pelvic mass during a physical examination.

When to Seek Medical Help

If a woman has any of the following, she should see her gynaecologist.
Irregular heavy menstrual bleeding. Menstrual bleeding soaking though more than 3 pads per hour requires your gynaecologist attention.
Severe or prolonged pelvic or abdominal pain.
Dizziness, light headedness, shortness of breath or chest pain associated with excessive vaginal bleeding.
Vaginal bleeding associated with pregnancy.
Infertility with long standing fibroid.
Uterine Fibroid Diagnosis
When uterine fibroid is suspected, your gynaecologist can arrive at a diagnosis by various methods:
A physical examination including a pelvic examination can reveal an irregularly shaped uterus when fibroids are present.
An abdominal, or transvaginal ultrasound san can help indentify the numbers, size and shape of most fibroid.
A hysteroscopic look at the uterus by passing a small fibreoptic camera through the cervix can confirm a submucous fibroid.
Hystero salpingogram (HSG) during infertility working sometimes gives an indication about the presence of a fibroid. It helps in distinguishing those fibroids that cause tubal blockage from those that do not.
Laparscopy is a minor surgical procedure to have a direct view of the pelvic. It is procedure done during routine infertility work up to confirm tubal patency. It can detect subserous and intra mural fibroids sometimes incidentally.

Uterine Fibroid Treatment

Uterine fibroid treatment depends on the symptoms, the size, and the location of the fibroids, the age (How close to menopause) and the patients desire to have children and the patients’ general health.

Medical Treatment

In most cases of fibroid, treatment is not necessary particularly if the woman has no symptoms, has small tumours, or has gone through menopause.
Abnormal vagina bleeding caused by fibroids may require surgical scrapping of the uterine cavity by D&C (Dilatation & Curettage). If no malignancy found, the bleeding can be controlled by hormonal medications. Observation every 6 months to check for changes in the size and symptoms is advisable.

Medication

Women with heavy bleeding, pains and fibroids may be given non-steroidal anti inflammatory drugs (NSAIDs) oral contraceptive (birth control pills) gonadotrophin releasing hormone agonists and anti hormonal drug mifepristone.
Non steroidal drugs such as ibuprofen have been shown to relieve pelvic pain associated with fibroids.
Oral contraceptive pills are also commonly used in women with fibroids. They often decrease perceived menstrual blood flow and help with pelvic pain.
Gonodotrophin releasing hormone agonists are medications that act on the pituitary gland to decrease oestrogen produced by the body. A decrease in oestrogen causes fibroids to decrease in size. These medications are usually used prior to surgery to shrink the fibroid, to decrease the amount of blood loss during surgery to improve pre-operative blood count. The size of fibroid can be reduced up to 50% in 3 months, but the fibroids can re-grow once treatment is stopped.
Long term treatment with these drugs is limited by the side effects of low oestrogen (much like menopause) which includes decreased bone density (osteoporosis) hot flushes and vaginal dryness.
Mifepristone has also been shown to reduce fibroid size by about half. It has also been shown to reduce pelvic pain, bladder pressure and lower back pain. Mifepristone can induce miscarriage so it should be used with caution if a woman is trying to conceive.
Danazol has been used to reduce bleeding in women with fibroids. It causes the menstruation to stop but does not shrink the size of the fibroid. Danazol is an androgenic (male hormone) drug that can cause side effects such as weight gain and muscular cramps decreased breast size, acne (oily skin) mood changes depression etc.

Surgery

Myomectomy is the surgical removal of the fibroid only. It can be accomplished by open surgery, hysteroscopy or laparoscopically depending on the size and location of the fibroid.
The uterus is left intact and the patient may be able to become pregnant. It is the most common surgical procedure in the treatment of fibroid in Nigeria.
Hysterectomy is the surgical removal of the uterus (and fibroids). It is the most common performed surgical procedure in the treatment of fibroid in the UK and USA and it is considered a cure, but at the expense of fertility. Depending on the size and location of the fibroid, it can be performed abdominally, vaginally or laparoscopically.
Uterine artery embolization or clotting of the arterial blood supply to the fibroid is an innovative approach that has shown promising results. This procedure is done by inserting a catheter (small tube) into an artery of the leg (femoral artery) using special X-ray video to trace the arterial blood supply to the uterus, then clotting the artery with tiny plastic or gelatine sponge particles the size of grains of sand. This material blocks blood flow to the fibroid and shrinks it. Interventional radiologist performs their procedures.

Uterine Fibroid Prevention

Women should avoid weight gain after age 18 and maintain a normal body weight compared to height. Body weight tends to increase oestrogen production thus aggravating fibroid growth.
Exercise can help women control weight and additionally decrease hormone production that stimulates fibroid growth.
In conclusion, treatment success and future outcome in fibroid depends on the severity of the fibroid prior to treatment and the chosen treatment. Fibroids may affect fertility, but it depends on the size and location of the fibroids.
Many women with fibroids are older than 35 years. This and other factors such as decreased egg quality and decreased ovulation contribute to their inability to become pregnant.
Fibroids rarely turn into cancer.

MENSTRUAL CRAMPS (DYSMENORRHEA)

 

Menstrual cramps are pain in the belly and pelvic areas that are experienced by a woman as a result of her menstrual period. Menstrual cramps are not the same as the discomfort felt during premenstrual syndrome (PMS). Although the symptoms of both disorders can sometimes be experienced as a continual process. Many women suffers from both PMS and menstrual cramps

How Common is Menstrual Cramps?

Menstrual cramps of some degree affects more than an estimated 50% of women and among these up to 15% would describe their menstrual cramps as severe. Nearly 90% of adolescent girls report having menstrual cramps.

What is Dysmenorrhea?

The medical term for menstrual cramps is dysmenorrhea. There are 2 types of dysmenorrhea primary and secondary.
In primary dysmenorrhea, there is no underlying gynaecological problem causing the pain. This type cramping may begin within 6 months to a year following menarche (the beginning of menstruation), the time when a girl starts having menstrual periods. Menstrual cramps typically do not begin before the onset of ovulation. Therefore, an adolescent girl may not experience dysmenorrhea until months to year following the onset of menstruation.
In secondary dysmenorrhea, some underlying abnormal conditions (usually involving a womans reproductive system), contributes the menstrual pain. Secondary dysmenorrhea may be evident at menarche, but more often the condition develops later.

What causes menstrual cramps

Each month the inner lining of the uterus (the endometrium) normally builds up in preparation for a possible pregnancy. After ovulation, if the egg is not fertilised by a sperm, no pregnancy will result and the current lining of the uterus is no longer needed. The woman oestrogen and progesterone  hormone and levels decline and the lining of the uterus becomes swollen and eventually shed as a menstrual flow and is replaced by a new lining in the next monthly cycle. When the old uterine lining begins to breakdown, molecular compounds called prostaglandins are released. These compounds cause the muscle of the uterus to contract. When the uterine muscles contract, they constrict the blood supply (vasoconstriction) to the endometrium. These contractions blocks the delivery of oxygen to the tissue of the endometrium which in turn breaks   down and dies and are shed as menstrual flow. Other substances known as leukotrieries are released and elevated at this time and may be related to the development of menstrual cramps.

Why are some Cramps so Painful?

Menstrual cramps are caused by uterine contractions that occur in response to prostaglandins and other chemicals. The cramping sensation is intensified when clots or pieces of bloody tissue from the lining of the uterus pass through the cervix, especially if a woman’s cervical canal is narrow.
The difference in pain may be due to the woman prostaglandins level. Women with menstrual cramps have elevated level of prostaglandins in the endometrium compared to women who do not experience cramps. Menstrual cramps are very similar to those pregnant woman experiences when she is given prostaglandin as an induction agent for labour.

What other Factors Influence Menstrual Cramps?

An unusually narrow cervical canal tends to increase menstrual cramps
A backwards tilting of the uterus (a retroverted uterus)
Lack of exercise is now recognised to contribute to painful menstrual cramps
It has long been taught that psychological factors also play a role. For example it is widely  accepted that emotional stress can increase the discomfort of menstrual cramps

What are the Symptoms of Menstrual Cramps?

Menstrual cramps are pains that begin in the lower abdomen and pelvis. The discomfort can extend to the lower back or legs. The cramps can be a quite painful or simply a dull ache. They can be periodic or continual. Menstrual cramps usually starts shortly before the menstrual period, peak within 24 hours after the onset of the bleeding and subside again after a day or two.
Menstrual cramps may be accompanied by a headache and or nausea which can lead to vomiting. Menstrual cramps can also be a accompanied by either constipation or diarrhea because the prostaplandins which cause the smooth muscles to contract are found in both the uterus and the intestinal tracts. Some women experience an urge to urinate more frequently.

How are Menstrual Cramps Diagnosed?

The diagnosis of menstrual cramps is usually made by the woman herself, and reflects her individual perception of pain once a woman has experienced menstrual cramps, usually with the adolescent onset of her monthly flow, she becomes well aware of the typical symptoms if there are other medical conditions contributing to menstrual cramps (secondary dysuenorrhea), the doctor may suggest diagnostic testing including imaging studies.

What is the Treatment for Menstrual Cramps?

Currently recommendation includes not only adequate rest and sleep but also regular exercise (walking). Some women find that abdominal message, yoga, or orgasmic sexual activity may bring relief. A heating pad applied to the abdominal area may relieve the pain and congestion and decrease the symptoms.
A number of non prescription drugs can help to control the pain as well as actually prevent the menstrual cramps themselves. For mild cramps, aspirin or paracetamol may be sufficient.
The main agent for treating moderate cramps are the non steroidal anti inflawattun of prostaglandins and lessen the effects. Such NSAIDS include ibuprofen, naproxen, ketoprofen.
A woman should start taking this medications before her pains becomes difficult to control. This might mean starting the medications 1 to 2 days before her period is due to begin and continue the medication 1-2 days into her period. The best results are obtained by taking the NSAIDs on a scheduled basis and not waiting for the pain to begin.

What if Cramps are very Severe?

If a woman’s menstrual cramps are too severe to be managed by the above strategies, then the oral contraceptive pills containing oestrogen and progesterone in a regular or extended cycle can be prescribed.
This type of approach can prevent ovulation which in turn reduces the severity of cramping and causes a light menstrual flow.
The use of intrauterine device that releases small amounts of progesterone directly into the uterine cavity has also been associated with a 50% reduction in the prevalence of menstrual cramps, in contrast, intrauterine devise that contains only copper may worsen the menstrual cramps.

Are there Surgical Solutions?

In the past, many women with menstrual cramps had an operation known as D&C to remove some of the lining of the uterus, some women even resort to the ultimate solution to menstrual problems by having a hysterectomy surgery that removes the entire uterus.

What is Treatment of Secondary dysmenorrhea

The treatment of secondary dysmenorrhea depends on the cause. There are a number of under of underlying conditions which can contribute to the pain, including endometriosis, uterine fibroids, adenonuyosis, PID, adhesions, use of intrauterine contraceptive devises (IUCD)
All of these conditions should be first diagnosed by the gynaecologist who will then recommend the optimal treatment.
If a woman notices changes in the severity of her menstrual cramps, the timing, or location, she should consult her gynaecologist especially if the changes are of sudden onset.

Prognosis for menstrual cramps

In general, a woman’s menstrual cramps do not worsen during her lifetime, infact the menstrual cramps usually diminish with age and after pregnancy.
Where there is secondary dysmenorrhea with an underlying condition contributing to the pain, the prognosis depends on the successful treatment of the underlying condition.

ENDOMETRIOSIS AND POLYCYSTIC OVARIAN SYNDROME (PCOS)

ENDOMETRIOSIS

Endometriosis is a condition where the endometrial tissue from the lining of the uterus forms and grows in places outside the uterus. Theses growth leads to pain and infertility. Up to 50% of women who have endometriosis experience infertility.
The lost endometrial cells respond to the body hormones the same way they would inside the uterus.
Normally the endometrium within the uterus thickens to prepare for an embryo. When pregnancy does not occur, the extra lining breaks down and is shed during menstruation.
With endometriosis, the endometrial tissue that is outside the uterus also thickens, break down and bleeds, except that it cannot be expelled vaginally like the endometrial tissue. Instead the endometrial tissue outside the uterus builds up over time and forms patches, scar tissues, cyst and adhesions.
Usually, these endometrial growth form in the pelvis region, near the ovaries, but can also appear in rectum, vagina, fallopian tube, urinary tracts, bowels and rarely in the lungs, arms, thighs, umbilicus e.t.c.
Beside infertility, it causes painful period and painful sexual intercourse. Other women experience no symptoms, and it is only discovered accidentally during infertility evaluation.

How Endometriosis Cause infertility

Endometriosis is believed to be involved in up to 30% of female infertility. However, not every woman with endometriosis will have trouble in conceiving, and ironically, pregnancy may help alleviate the symptoms and reduce the progress of the disease.
The connection between endometriosis and infertility isn’t completely understood. Even when there is no obvious barrier to fertilisation and the number of implants are small or not blocking the egg or sperm from meeting, infertility can still result.

However, some other ways that endometriosis can affect fertility are:-

Endometriosis scar, adhesions or cysts around the ovaries may prevent the eggs from entering the fallopian tubes and may also prevent ovulation from occurring.
Endometriosis inside the fallopian tubes may form scar and adhesions, blocking the tubes.
The cause of endometriosis is not fully known, but some researchers suspect, it is related to the body immunity, so whatever it is that causes endometriosis may also cause infertility.
Endometriosis can make sexual intercourse painful, and pain may be more around ovulation period hence interfering with ability to conceive.

How is Endometriosis Diagnosed?

The only way to confirm a diagnosis of endometriosis is with a direct view diagnostic laparoscopy or accidentally during open pelvic surgery for other ailments.
Laparoscopy is an outpatient procedure that involves making a small incision in the abdomen, through which the gynaecologist inserts a tube with special camera and instruments to see the pelvis.
Because the use of laparoscopy is not widespread in Nigeria, the diagnosis of endometriosis is underreported. Its symptom is similar to that of pelvic infection (PID), hence pelvic infection (PID) is over diagnosed instead.

How is Endometriosis Treated?

Treatment of endometriosis is dependent on its severity, if the patient is experiencing pain, the patient’s age, and whether pregnancy is desirable.
Some treatment of endometriosis will lead to decreased fertility, which would not be an option if pregnancy is desirable are:
Laparoscopic surgery to remove the endometrial growth, scar, and adhesions caused by the endometriosis.
This is not a cure as the endometriosis may return later.
However, some women will have increased fertility for up to 9 months after the surgery.
IVF treatment is an option pre or post surgery.
In mild to moderate endometriosis, intrauterine insemination (IUI) along with fertility drugs may be used. The pain of endometriosis may be treated with pain relieving medications, acupuncture, and lifestyle changes such as regular exercises and diet changes.
If you do not wish to get pregnant, the treatment options may include hormonal treatments which stops ovulation and prevents pregnancy.
In severe cases the removal of the womb (Hysterectomy) and ovaries might be the only solution.

POLYCYSTIC OVARIAN SYNDROME (PCOS)

Polycystic ovarian syndrome is an endocrine disorder and a common cause of infertility in women.
In PCOS, hormones that affect the reproductive system are abnormal leading to irregular or absent ovulation. PCOS is a common disorder affecting up to 10% of women.
Women with PCOS often have polycystic ovaries. This means that the ovaries have many tiny, benign and painless cysts. During an ultrasound examination, the tiny cysts resemble a string of PEARLS.
A common finding with PCOS is abnormal high levels of Androgens (male) hormones. Whilst Androgens are found in both men and women, they are considered to be primarily male hormone.
High Androgen (male hormone) levels are associated with some of the more distressing symptoms of PCOS such as ACNE, and abnormal hair growth in women.
What are the Symptoms of Polycystic Ovarian Syndrome (PCOS)?
Some of the symptoms of PCOS include:

• Infertility
  
• Irregular or absent ovulation
  
• Absence of monthly menstrual cycle (Amenorrhea)
  
• Irregular monthly cycle (Oligomenorrhea)
  
• Recurrent miscarriage
  
• Abnormal hair growth on upper lip, chin, around nipple or on abdomen (Hirsutism)
  
• Acne
  
• Especially oily skin and hair
  
• Male pattern balding
  
• Obesity
  
• Insulin resistance
  
• High level of androgens
  
• Elevated LH hormone level (making ovulation prediction kits unreliable)
  

PCOS does not present in the same way for all women. A woman does not need all those symptoms to be present, before a diagnosis of PCOS is made.
For example, many women with PCOS do not have abnormal hair growth or obesity.

How Does PCOS Cause Infertility?

The abnormal hormone level associated with PCOS leads to problems with ovulation. These irregularities in ovulation are the main cause of infertility.
PCOS is associated with a higher risk of early miscarriages, which may be as high as 20-40%, nearly twice as high as in the general population.
Some of the reasons for the higher miscarriage rate are; poor egg quality related to premature or late ovulation. A less favourable environment for an embryo to implant in the uterine lining due to the abnormal hormone levels is another reason for the higher miscarriage rate.
Another reason has to do with the insulin resistance associated with PCOS.

How is PCOS Diagnosed?

Not every doctor agrees on the criteria for diagnosing PCOS. Its definition has been changed over the years.
However, the commonly used diagnostic criteria currently used require 2 out of the 3 of the following:

• Irregular or absent menstrual cycle caused by chronic anovulation.
• Either blood test confirmation or outward signs of high level of androgens (abnormal hair growth)
• The presence of polycystic ovaries as seen by ultrasound scan.

Taking a detailed history is an important part of PCOS diagnosis. Your doctor will want to know about how regular your menstrual cycles are and will ask about any unwanted hair growth. You may be tempted not to mention the unwanted hair growth because of embarrassment, but it is important you tell your doctor this problem if you have it.

Treatment of PCOS

Treatment of PCOS will depend on whether or not you are trying to get pregnant. If pregnancy is not a priority, the birth control pill (contraceptive) will help to regulate your cycle and help to reduce ACNE and unwanted hair growth.
For those trying for pregnancy, the treatment of PCOS is similar to the treatment used for treating anovulation.
The first line of treatment is ovulation drugs such as CLOMID which is used to help stimulate ovulation.
Metformin (Glucophage) a drug usually used to treat insulin resistance is sometimes used for treatment, even if you do not have insulin resistance.
If these medications do not help, then Gonadotrophins injections may be tried.
If drugs alone do not work or there are other factors leading to infertility, IVF treatment may be recommended.
Studies have shown that women who are overweight with PCOS may be able to restart ovulation naturally by loosing just 10% of their current weight. A healthy diet and regular exercise may also help to restore ovulation in some but not all women with PCOS.

GUILDE TO INFERTILITY INVESTIGATIONS

The philosophy of care in any infertility clinic should be a success oriented approach (getting infertile couples pregnant) rather than the usual problem oriented approach (doing endless, useless and unnecessary investigations) as is the norm in our environments these days.
In a problem oriented approach, a lot of time, money and effort would be wasted by the doctors concentrating on a long list of useless and fanciful tests and investigations. Many of these investigations do not affect the treatment or the outcome of the treatment options.
It is bad enough being infertile, but for the infertile couples to go through endless tests and investigations that add no value to the outcome of any treatment option DRAINS them emotionally and financially.
Keeping the investigations complex however helps some clinics to justify the abnormally high fees they charge to reach a diagnosis.
Couples that come to doctors for infertility want to have babies, not unnecessary extended investigations and having to wait too long in achieving their objectives.
Every infertility investigations protocol should ideally be easy, simple, safe and less stressful with a proper diagnosis and successful treatment (having babies) achieved.

Criteria for Getting Pregnant Naturally.

There are basically 5 criteria for achieving pregnancy naturally.

• The sperm of the man must be of adequate quantity and quality.

• Sex should occur around the ovulation period (fertile period) of the woman.

• The inside of the woman’s womb should be able to keep and maintain a pregnancy. Nothing inside should be able to disrupt a pregnancy.

• The fallopian tubes should be open on both sides, so that the eggs produced on the ovary can meet with the sperm.

• The ovaries must be producing quality eggs regularly (monthly)

From the above criterion, it would be easy to see that the essence of any infertility investigation is to check out these 5 requirements and confirm they are all working well.
About 95% of infertile couples would first see their general practitioners before seeing an infertility expert. It is therefore important that there is a guide on what the GP should do at this level as frontline doctors.
About 45% of infertile couples will get pregnant by themselves, by changes in their lifestyles and by the standard gynaecological treatment. However, 60% will require some form of assisted conception such as Intrauterine Insemination (IUI), Invitro fertilisation (IVF) etc at a specialised infertility centre. It is important for the GP to know when to refer to an infertility specialist so that time, money and effort are not wasted.

GP Guideline in Infertility Management

The frontline general practitioner should try as much as possible to see the couples together. Both should be involved in the management of their infertility.
A detailed history including drug and examination of the couple is mandatory.
The GP should advise every woman presenting with infertility to take folic acid as a supplement whilst they are trying to conceive and at least during the first 12 weeks of a pregnancy in order to prevent neural tube defects. The dose should be increased in women who have previously had an infant with neural tube defect or who have epilepsy and are on medications.
Environmental factors can affect infertility and therefore an occupational history should be taken as part of infertility investigations.

General Advice GP Should Give to Infertile Couples.

Women complaining of infertility should be advised to give up smoking if they do smoke.
Men who smoke should be advised to stop in order to remove one variable that may affect their infertility.Women should be advised not to drink more than one or two units of alcohol once or twice a week when trying to become pregnant.
In men there is evidence that excessive drinking can adversely affect reproductive function and general health, therefore men who drink excessively should be advised to limit their drinking.Any woman with a body mass index > 30 should be advised to loose weight whether ovulating or not.
Although weight loss in overweight men will improve their general health, there is little evidence to suggest that this will improve fertility.
Men with poor quality sperm should be advised to wear loose fitting underwears and trousers and avoid occupational or social situations that might cause testicular overheating.There is no evidence that the use of temperature charts and ovulation kits to time intercourse improves infertility outcome. There use should be discouraged. Couples should be advised instead to have REGULAR intercourse 2-3 times a week throughout their cycle.

Initial Investigation at GP Clinic

The male partner should have 2 semen analysis performed during the initial investigation. The laboratory that performs the semen analysis should undertake the analysis according to recognised WHO methodology. The laboratory should also practice internal quality control. The GP should try and send the sample to the same laboratory used by specialist infertility clinics.
Whilst regular menstruation is strongly suggestive of ovulation, this should be confirmed by the measurement of serum progesterone in the mid luteal phase (Day 21 progesterone)
There is no VALUE in measuring thyroid function or prolactin in women with a regular menstrual cycle, in the absence of galactorrhea (milk from the breast)
or symptoms of thyroid diseases.

When Should a GP Refer to Infertility Specialist?

For the sake of the infertile couples a general practitioner should consider an early referral to infertility specialist if the woman is aged 35 years and above. An early referral to an infertility specialist is required when the woman is not seeing her periods, or when her period is scanty and irregular (amenorrhea & oligomenorrhea). The GP should refer if the woman has a previous history of abdominal or pelvis surgery (e.g. fibroid opx), if there is a history of sexually transmitted diseases and if there is an abnormal pelvic examination.
The GP should consider early referral when the man has a previous genital disease, a previous urinary or genital surgery. A previous sexually transmitted disease, a varicocele or any significant systemic illness and if there is an abnormal genital examination.
Further Investigation in a Specialised Infertility Clinic
Further management of infertile couple should be in a specialised infertility clinic staffed by an appropriately trained multi professional team with facilities for investigating and managing problems in both partners.
GPs should endeavour to refer patients to such clinics and patients should request that they be referred to such clinics. GPs should continue to offer ongoing support to the couples after the referral.
The female should normally have a test of tubal patency. A Hysterosalpingogram (HSG) or a salime Sono Hysterogram may be used as a screening test for tubal patency. A diagnostic laparoscopy and dye test is however the procedure of choice to properly evaluate the pelvis.
Before any uterine instrumentation at the GPs or infertility centres, a screening for sexually transmitted diseases especially Chlamydia should be performed and any infection should be appropriately treated.
An Ultrasound scan (Abdominal and Vaginal) to properly evaluate the uterus and the ovaries is very essential.

Non Essential Investigation in Routine Infertility Management

An endometrial biopsy (D&C) to evaluate luteal phase should not be performed as part of routine investigation of the infertile couple.
The so called “Tubal flushing” or Hydrotubation has no place in the modern investigation or treatment of infertile couple. Apart from the fact that it is rarely successful, it causes discomfort and could actually disseminate genital infection into full blown PID
The post coital test is not recommended in the routine investigation of infertile couples.
Sperm function test are specialised tests and should not be used in routine investigations of infertile couple (Routine semen analysis is sufficient)
Routine testing for antisperm antibodies in semen is not recommended.
Hysteroscopy should not be considered in routine investigation.

Guide to Semen Collection and Normal Values

Before the man goes for his semen collection, he should have abstained for 2 to 3 days. The sample is preferably produced by masturbation, rather than by coitus interruptus. The sample should not be collected in condoms. A wide mouthed sterile plastic specimen pot should be used in the collection. The plastic container should be marked with the name, date and time of production. Delivery of the specimen to the laboratory as soon as possible within one hour is essential. The sample should be protected from the extreme of temperatures e.g less than 15oc or above 38oc during the transportation.

WHO values for ‘normal’ semen analysis
The WHO values should be the basis of any referrals from GP to the infertility specialist.
The volume should be between 2 to 5 mils.
The liquefaction time should be within 30mins.
The sperm concentration (or count) should be above 20 million per ml.
The sperm motility should be over 50% having progressive motility.
The shape (morphology) of the sperm should at least be over 30% with normal forms.
The white blood cells suggestive infections should be less than 1 million per mil.
In conclusion, with these basic investigations a diagnosis of the cause of infertility should easily be reached and an appropriate management options outlined for the couples. There is no need for endless repetitive investigations that wear out the couples and sometimes the medical team.
The philosophy of care must always remain success oriented rather than problem oriented.