GYNECOLOGIC DISORDERS

Mary Lourdes Nacel G. Celeste, RN, MD

Anatomy Recall

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Common Gynecological Complaints
‡ ‡ ‡ ‡ ‡ ‡ ‡ ‡ ‡ Vaginal discharge Vaginal/ Vulvar pruritus Genital ulceration Inguinal lymphadenopathy Pelvic mass Dyspareunia Pelvic pain Vaginal bleeding Amenorrhea
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Diagnostic Tests
‡ Bloodwork - CBC - HCG - LH, FSH, TSH, PRL ‡ Imaging - Ultasound - Hysterosalpingography - Sonohystography ‡ Genital tract biopsy - vulvar - vaginal - endometrial ‡ Vaginal/ endocervical culture ‡ VDRL ‡ Papanicolau Smear ‡ Colposcopy ‡ Laparoscopy
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GYNECOLOGICAL INFECTIONS ABNORMAL UTERINE BLEEDING DYSFUNCTIONAL UTERINE BLEEDING AMENORRHEA ANATOMICAL DISORDERS BENIGN LESIONS of the genital tract MALIGNANT LESIONS of the genital tract FEMALE SEXUAL DYSFUNCTIONS BREAST DISORDERS
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Gynecological Infections
Lower genital tract ‡ Vulvitis ‡ Vaginitis ‡ cervicitis Upper genital tract ‡ Endometritis ‡ Pelvic inflammatory disease (PID) Sexually Transmitted Diseases/ Infections (STD/ STI) ‡ Bacterial ‡ Viral ‡ Others

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VAGINITIS
‡ inflammation of the vagina characterized by an increased vaginal discharge containing numerous WBCs Causes: ‡ Douches ‡ Antibiotics ‡ Hormones ‡ Contraceptives (oral and topical) ‡ Change in sexual partners ‡ In contrast, vaginosis - not associated with WBC
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Signs and Symptoms: ‡ Itching ‡ Burning ‡ Pain ‡ Erythema ‡ Edema

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VULVOVAGINITIS
‡ inflammation of the vulva and vagina ‡ may be caused by vaginal infection or copious amounts of leukorrhea (increased amount of vaginal and cervical discharge consisting of epithelial cells and cervical mucus that can cause maceration of tissue)

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BACTERIAL VAGINOSIS
‡ ‡ ‡ ‡ ‡ nonspecific vaginitis, hemophilus vaginitis, gardnerella) most common cause of abnormal vaginal discharge most common vaginal infection in childbearing women not considered a sexually transmitted disease normally dominant organism lactobacillus is replaced with a high concentration of facultative aerobic and anaerobic bacteria

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Signs and Symptoms: ‡ Fishy odor ‡ Increased thin vaginal discharge (no inflammatory response) Diagnosis (based on Amsel criteria) ‡ White/gray thin adherent discharge ‡ Ph > 4.5 ‡ Positive whiff test (fishy odor will be released when KOH is added to vaginal secretion on a slide or on the lip of the withdrawn speculum ‡ clue cells on wet mount (vaginal epithelial cells coated with bacteria that obscure cell borders)
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Treatment: ‡ Oral agents: Metronidazole 500 mg or Clindamycin 300 mg BID for 7 days ‡ Vaginal agents: Metronidazole gel (.075%) or Clindamycin cream (2%) BID for 7 days ‡ Sexual partner does not need treatment

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Nursing interventions ‡ Teach the importance of completing the course of medication and of not consuming alcohol while taking Metronidazole and 48 hours after completing the treatment ‡ Remind client to avoid intercourse ‡ Instruct good hygiene

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CANDIDA VAGINITIS
‡ vulvovaginitis candidiasis/ yeast vaginitis/ yeast or fungus/ Moniliasis second most common cause of abnormal vaginal discharge common cause: Candida albicans

‡ ‡

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Predisposing factors ‡ Repeated courses of systemic or topical antibiotics ‡ Diabetes especially when uncontrolled ‡ Pregnancy ‡ Obesity ‡ Use of corticosteroids and exogenous hormones ‡ Local allergic or hypersensitivity reaction

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Signs and Symptoms ‡ Thick, curd-like/ cheeselike, white discharge that has no odor ‡ Vaginal erythema, edema and tenderness ‡ Ithchiness of the vulva ‡ Dryness ‡ Painful urination especially when urine flows in the vulva ‡ Dyspareunia

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Diagnosis ‡ Vaginal pH is normal (if > 4.5 suspect trichomoniasis or bacterial vaginosis) ‡ KOH wet smear- pseudohyphae Treament ‡ Oral agent: Fluconazole 150 mg (single dose) ‡ Vaginal agents: antifungal preparation (fungicidal azole creams: Clotrimazole, Miconazole) for 3 to 7 days ± Nystatin ±vaginal suppository twice a day for 7 to 14 days or ± Clotrimazole vaginal suppository at bedtime for 7 days or ± Miconazole nitrate vaginal cream applied nightly for 7 days
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Nursing interventions Client teaching: ‡ not wearing underwear to bed ‡ wearing cotton-crotched underwear ‡ completing full course of treatment even during menstruation ‡ avoiding feminine sprays, deodorants, scented pads (allergies and irritation) ‡ Vitamin C, live culture yogurt - increase vaginal acidity ‡ Local application of anti fungal agents (eg, Nystatin) ‡ Inform the patient that the disease can be transmitted to the newborn leading to the development of ORAL THRUSH
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Home Remedies: ± Vaginal douche of two teaspoons ordinary baking powder dissolved in one quart of warm water ± Application of gentian violet to the vagina & perineum. Use sanitary pad to prevent staining of undergarments.

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BARTHOLIN¶S CYST
‡ occlusion of a duct with mucus retention resulting in a nontender mass approx. 1-4cm in size Causes ‡ if the duct becomes blocked for any reason: infection, injury or chronic inflammation ‡ Very rarely, caused by cancer ‡ Unknown (many cases)
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Causative organisms: Staphylococcus aureus (others: S. fecalis, E. coli, N. gonorrhea, C. thromatis) Symptoms: ‡ Bartholyn¶s Cyst (asymptomatic) ‡ Bartholin¶s Abscess - pain or tenderness, dyspareunia Diagnosis ‡ clinical Management ‡ incision and drainage ‡ marsupialization ± entire abscess is incised and sewn open ‡ Word catheter for 2 ± 4 weeks ‡ broad spectrum antibiotic
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Nursing interventions ‡ Teach the importance of completing the course of antibiotic ‡ Teach the importance of good hygiene ‡ Sitz bath ± for both pain relief and to decrease healing time

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SEXUALLY TRANSMITTED DISEASES
‡ ‡ ‡ ‡ ‡ ‡ ‡ Trichomoniasis Chlamydia Gonorrhea Syphilis Herpes simplex Condylomata acuminatum Human Immunodefiency Virus (HIV)

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TRICHOMONIASIS
‡ protozoan infection: Trichomona vaginalis Signs and Symptoms ‡ Frothy yellow-green malodorous vaginal discharge ‡ ³strawberry´ cervix ‡ Vaginal irritation & inflammation ‡ Dyspareunia ‡ Dysuria ‡ Vulvar itching Among males: usually asymptomatic

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Diagnosis ‡ microscopic exam of vaginal discharge -positive motile flagellated protozoa in a saline wet mount ‡ elevated vaginal pH 5.5+ (alkaline) Management ‡ Sexual partner should receive oral treatment. ‡ Metronidazole (Flagyl) 500 mg BID for 7 days or a single 2 g dose (contraindicated during pregnancy)
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Home Remedy ‡ Acidic vaginal douche : 1 tablespoon vinegar with 1 liter water to counteract the alkaline environment of the vagina that favors the growth of Trichomonas vaginalis Nursing interventions ‡ Include sexual partner in treatment. ‡ Advise use of condom during intercourse ‡ Nursing alerts: - Concurrent alcohol ingestion with Metronidazole causes severe GI symptoms (Antabuse-like reaction) - Metronidazole is associated with preterm labor, premature rupture of membranes and postcesarean infection DR CELESTE

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CHLAMYDIA
‡ ‡ ‡ ‡ most common cause of mucopurulent cervicitis most common bacterial STD in women caused by gram (-) bacterium Chlamydia trachomatis Vertical transmission to newborns may result in conjunctivitis and otitis media ‡ Tends to coincide with gonorrhea infection IP: 2-10 days Risk Factors ‡ Sexual activity < 20 years ‡ Multiple sexual partners ‡ Lower socioeconomic status ‡ (+) others STDs DR CELESTE

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Signs and symptoms ‡ May be asymptomatic ‡ Gray white/ yellowish vaginal discharge ‡ Burning and itchiness ‡ Bleeding between periods ‡ Mucopurulent cervicitis ‡ Painful and frequent urination Diagnosis ‡ (+) culture/ antigen detection test on cervical smear ‡ Polymerase chain reaction (PCR)
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Management ‡ Doxycycline 100 mg PO BID for 7 days (causes fetal long bone deformity if used in pregnancy) ‡ Azithromycin (Zithromax) 1 g PO in a single dose ‡ Erythromycin 500 mg QID for pregnant patient ‡ Patient may also be treated for gonorrhea with a single IM shot of Ceftriaxone 250 mg ‡ Infant treated with Erythromycin ophthalmic ointment Nursing interventions Client teaching: ‡ Teach the importance of completing the course of antibiotic ‡ Use condom during sex ‡ Sexual partner should receive treatment DR CELESTE

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Complications ‡ Pelvic inflammatory disease (PID) ‡ Ectopic pregnancy ‡ Fetus transmittal (vaginal birth); may cause conjunctivitis (also associated with premature rupture of membranes, preterm labor and endometriosis, low birth weight and perinatal mortality due to placental transmission)

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GONORRHEA
‡ Morning drop, Clap, Jack ‡ Sexually transmitted disease caused by gram (-) Neisseria gonorrhea, which causes inflammation of the mucus membrane of the genito urinary tract IP: 3-7 days Signs and Symptoms ‡ Females: may be asymptomatic; may have purulent vaginal discharge, pelvic pain and fever; dyspareunia Males: Painful urination; purulent yellow penile discharge; urethritis (decreased sperm count) ‡ Newborn: yellow discharge, both eyes
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Diagnosis ‡ gram stain and culture of cervical secretions on Thayer Martin medium Complications ‡ PID ‡ ectopic pregnancy ‡ infertility ‡ Chorioamnionitis ‡ ophthalmia neonatorum in newborns (associated
with severe eye infection and blindness)

‡ preterm delivery ‡ sterility & pelvic inflammatory disease
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Management (single dose only) ‡ Ceftriaxone (Rocephin) 125 mg IM (drug of choice for pregnant women) ‡ Ofloxacin (Floxin) 400 mg orally ‡ Treat concurrently with Doxycycline or Azithromycin for 50% infected w/ Chlamydia ‡ Ophthalmic ointment is routinely given as Crede¶s prophylaxis to prevent opthalmia neonatorum (0.5% Erythromycin or 1% Tetracycline ointment for newborn DR CELESTE babies)

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Nursing interventions Health Teachings: ‡ Avoid sexual intercourse until cured of the infection or use condom to prevent transmitting the infection. ‡ Examination and treatment of sexual partner to prevent reinfection is necessary. ‡ Return to clinic for check-up in 4 to 7 days after completion of treatment. ‡ Monitor treatment

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SYPHILIS
‡ caused by motile anaerobic spirochete Treponema pallidum ‡ ³ beautiful´ fast moving but delicate spiral thread ‡ can cross the placental barrier IP: 7-14 days ‡ can cause 100% fetal infection if primary and secondary infection is untreated, and 6-14% fetal infection in latent syphilis ‡ 2nd trimester infections cause spontaneous abortion, preterm labor, stillbirth and congenital anomalies ‡ 3rd trimester infection causes enlarged liver,spleen, skin rash and jaundice in a newborn

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Signs and Symptoms
‡ Primary Stage - painless chancre on genitalia, anus or mouth; most infectious stage ‡ Secondary Stage - about 2 months after primary syphilis resolves; generalized maculopapular skin rash including palms and soles - painlesscondylomata lata on vulva - hepato/ splenomegaly - headache; anorexia; fever ‡ Latent syphilis ± asymptomatic ‡ Tertiary Stage ±most destructive stage; neurosyphilis/permanent damage (insanity); gumma (necrotic granulomatous lesions), aortic aneurysm

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Primary ± painless chancre

Secondary ± generalized rash

Tertiary - gumma

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Diagnosis ‡ VDRL (venereal disease research laboratory test) or RPR (rapid plasmin reagin) ± nonspecific tests - for screening and to follow treatment course (decrease fourfold in 3-6 months) ‡ Fluorescent Treponemal Antibody AbsorptionTest (FTA-ABS) or Microhemagglutination Assay for Antibodies to TP (MHA-TP)± specific tests for syphilis ‡ Dark-field microscopic examination of lesion- 1st and 2nd stage

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Management ‡ Primary and secondary and early latent disease Pen G (Benzathine Penicillin G 2.4 M U IM) - Alternatives: Tetracycline 500 mg orally QID or Doxycycline 100 mg orally BID ‡ Tertiary - IV Pen G ‡ Erythromycin & Cefriaxone are the drugs of choice for pregnant women Complications ‡ Congenital syphilis in newborn if untreated in late pregnancy ‡ Late abortion ‡ Stillbirth
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Health Teachings : ‡ Educate women to recognize signs of syphilis. ‡ Educate women to seek immediate treatment if known exposure occurs. ‡ Encourage women to wear cotton underwear. ‡ Use condom during intercourse.

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Sexual partners must also be treated to prevent re-infection. ‡ No sexual intercourse until lesions disappear ‡ After completion of treatment, the woman is treated monthly & the sexual partner at 3 months, 6 mos & 12 mos. ‡ Fetus will not be affected if the mother is treated before the 5th month. Emphasize the importance of screening for syphilis during the first prenatal visit for early detection & treatment. ‡ Inform patients treated with penicillin about Jarish Herxheimer reaction, a reaction to penicillin characterized by: fever, chills, malaise, headache, nausea, & tachycardia. This is a normal reaction that subsides within 24 DR CELESTE hours.

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HERPES GENITALIS
‡ Sexually transmitted disease caused by the Herpes Simplex Virus 2 (HSV 2) Signs and Symptoms ‡ Flulike symptoms (malaise, myalgia, nausea, fever) ‡ Vulvar burning and pruritus ‡ Painful vesicles (cervix, vagina, perineum, glans penis) 2 - 20 days after exposure ‡ Painful genital ulcer ‡ Recurrent episodes 1-6x a year (during stress, fever, menstruation) ‡ Dyspareunia Diagnosis ‡ Viral culture ‡ Pap smear (shows cellular changes) ‡ Tzanck smear (scraping of ulcer for staining) ± multinucleated giant cells
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Management ‡ Antiviral agents ± Acyclovir 200 mg PO q 4 hrs for 5 days ‡ Sitz bath ‡ Analgesics
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Complications: Health teachings ‡ Meningitis ‡ NO sexual activity in the presence of lesions and 10‡ Neonatal infection 14 days after lesions (vaginal birth) subsided ‡ Trigeminal herpes zoster (facial muscle paralysis) ‡ Keep vulva clean and dry in the presence of lesions (wearing of cotton underwear) ‡ Sitz bath ‡ use foley catheter if retention persists ‡ Povidone- iodine douche and acyclovir NOT used during pregnancy
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CONDYLOMA ACUMINATUM ‡ Genital warts ‡ Genital or venereal warts caused by Human Papilloma Virus (HPV) ‡ May be a precursor to cervical cancer ‡ HPV types 6 & 11 ± condyloma acuminatum ‡ HPV types 16, 18 and 31 ± cervical cancer Signs and Symptoms: Single or multiple dry soft, fleshy painless (wartlike) growths on the vulva, vagina, cervix, urethra, or anal area; penis ‡ Can evolve into larger cauliflower-like growths ‡ Vaginal bleeding, discharge, odor and dyspareunia

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Diagnosis ‡ Clinical ‡ Pap smear-shows cellular changes (koilocytosis) Acetic acid swabbing (will whiten lesion) Management ‡ Small lesions ± treated topically with podophyllin or trichloroacetic acid ‡ Larger lesions ± ablated with cryotherapy, laser vaporization or surgical excision. ‡ Recurrence rate : 20%

Complications ‡Neoplasia ‡Neonatal laryngeal papillomatosis (vaginal birth)

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Health Teachings ‡ Inform the patient that infection with the virus increases the incidence of CERVICAL CANCER ‡ Therefore: Annual PAP smear is indicated

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HIV and AIDS
‡ Retrovirus (HIV1 & HIV2) ‡ Attacks and kills CD4+ lymphocytes (T-helper) ‡ Capable of replicating in the lymphocytes undetected by the immune system ‡ Immunity declines and opportunistic microbes set in ‡ No known cure
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MOT: ‡ Sexual intercourse ( vaginal and anal) ‡ Exposure to contaminated blood, semen, breast milk and other body fluids ‡ Blood Transfusion ‡ IV drug use ‡ Transplacental ‡ Needlestick injuries

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HIGH RISK GROUP ‡ Homosexual or bisexual ‡ Intravenous drug users ‡ BT recipients before 1985 ‡ Sexual contact with HIV+ ‡ Babies of mothers who are HIV+ ‡ THE INFECTED MOTHER CAN PASS THE VIRUS TO THE FETUS DURING PREGNANCY & CHILDBIRTH OR VIA THE BREAST MILK

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s/sx: 1. Acute viral illness (1 mo after initial exposure) ±Sx: fever, malaise, lymphadenopathy 2. Clinical latency ± 8 yrs w/ no sx; towards end, bacterial and skin infections and constitutonal sx ± AIDS related complex; CD4 counts 400-200 3. AIDS ± 2 yrs; CD4 T lymphocyte < 200 w/ (+) ELISA or Western Blot and opportunistic infections
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Effects on the Infant: ‡ ‡ ‡ ‡ ‡ ‡ Microencephaly CNS lymphomas CVA¶s Respiratory failure Lymphadenopathy Developmental anomalies

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HIV CLASSIFICATION
‡ CATEGORY 1 ± CD4+ 500 OR MORE ‡ CATEGORY 2 ± CD4+ 200-499 ‡ CATEGORY 3 ± CD4+ LESS THAN 200

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HIV TEST
‡ Elisa ± Enzyme Link Immunosorbent Assay ( first test conducted) ‡ Western Blot - confirmatory ‡ Rapid hiv test
± Suds hiv-1 ± Results are obtained in less than 10 minutes ± Color indicator similar to pregnancy test ± Positive result needs a confirmatory test
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How to Diagnose
‡ HIV+ 2 consecutive positive ELISA and 1 positive Western Blot Test ‡ AIDS+ HIV+ CD4+ count below 500/ml Exhibits one or more of the ff: (next slide) ‡ Full blown AIDS CD4 is less than 200/ml
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Exhibits one or more of the ff:
‡
‡ ‡ ‡ ‡ ‡ ‡ ‡ ‡ ‡ ‡ ‡ ‡ ‡ Extreme fatigue Intermittent fever Night sweats Chills Lymphadenopathy Enlarged spleen Anorexia Weight loss Severe diarrhea Apathy and depression PTB Kaposis sarcoma Pneumocystis carinii DR CELESTE AIDS dementia

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Treatment
‡ Anti-retroviral Therapy (ART) ± ziduvirine (AZT) ( Azidothymidine) a. Prolong life b. Reduce risk of opportunistic infection c. Prolong incubation period

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For infected persons: ‡ 1. Avoid infections ‡ 2. Use latex condom to protect partner during sexual intercourse ‡ 3. Do not donate blood, sperm, organs or other body tissues ‡ 4. Do not share items with other persons that may be contaminated with blood & other body fluids ‡ 5. Do not breastfeed infant
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Health teachings

For non-infected persons: ‡ 1. Stick to one partner, practice monogamous relationship ‡ 2. Use condoms ‡ 3. Avoid anal & oral sex ‡ 4. Practice good personal hygiene ‡ 5. Practice healthful living: exercise, adequate rest, nutritional diet, safe sex
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‡ 6. Be aware of the signs & symptoms of infections:
± Weight loss of greater than 10% of body weight ± Chronic diarrhea, more than one month ± Prolonged fever, lasting more than one month ± AIDS cannot be transmitted by sharing foods, eating utensils, toilet, swimming pools, water

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Precautionary measures for health workers: ‡ Handle all sharp instruments with care, use disposable needles & do not reuse as much as possible ‡ Protect yourself, increase resistance to infection by proper diet, exercise, rest & sleep ‡ Avoid body fluids ± label blood & other specimens of a person known or suspected with AIDS properly, clean blood spills with disinfectant ‡ Practice strict aseptic technique ± handwashing,wear gloves, clean, disinfect & sterilize ‡ Wear, protective clothing when necessary ± gloves, masks, goggles
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DRUGS
‡ 1. Nucleoside Reverse Transcriptase Inhibitors NRTI¶s
± INTERFERES WITH DNA CHAIN

‡ Zidovudine (AZT) ‡ SE ± NEUROPATHY AND RASH

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DRUGS
2. Non-nucleoside Reverse Transcriptase Inhibitors NNRTI¶s - BINDS TO REVERSE TRANSCRIPTASE AND BLOCKS RNA AND DNA REPLICATION

‡ Ritonavir (Norvir) ‡ SE ± RASH, HEPATOTOXICITY, BONE MARROW DEPRESSION
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DRUGS
‡ 3. Protease Inhibitors PI ‡ BLOCK VIRUS ABILITY TO BREAK DOWN LARGER PROTEIN MOLECULES ‡ Indinavir (Crixivan) ‡ SE ± HEPATOTOXICITY, NV, ABDOMINAL PAIN, RENAL CALCULI

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PREVENTION
A ± ABSTINENCE B ± BE FAITHFUL C ± CONDOMS D ± DON¶T USE DRUGS

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OTHERS ‡ Pelvic inflammatory disease (PID) ‡ Toxic shock syndrome (TSS)

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Pelvic Inflammatory Disease
‡ Caused by microorganisms colonizing endocervix ascending to endometrium and fallopian tubes ‡ Due to sexually transmitted microorganisms ie Neisseria, Chlamydia, Haemophilus influenza, peptostreptococci

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Risk Factors
‡ ‡ ‡ ‡ ‡ Multiple sexual partners History of PID Early onset sexual activity Recent gyne procedure IUD

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Manifestations
‡ ‡ ‡ ‡ ‡ ‡ ‡ pelvic pain ± sharp and cramping Fever Excessive vaginal discharge Menorrhagia Metrorrhagia Urinary symptoms Cervical uterine tenderness with movement

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Diagnostics
‡ ‡ ‡ ‡ ‡ ‡ ‡ History and PE CBC Vaginal and endocervical culture VDRL Endometrial biopsy - endometritis Sonography ± tubo-ovarian abscess Laparoscopy - salpingitis
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Management
‡ ‡ ‡ ‡ ‡ Antibiotics IV fluids/increase oral fluid Pain medications Remove IUD Evaluation of sexual partners

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Toxic Shock syndrome
‡ Reproductive age, near menses or postpartum period ‡ D/t S. Aureus ‡ R/t use of tampons, cervical cap or diaphragm Manifestations: fever, rash on trunk, desquammation of skin, hypotension, dizziness, vomiting, diarrhea, myalgia, inflamed mucous membranes

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Diagnostics: Elev BUN, Crea Elev AST, ALT, total bilirubin Dec platelets Management: IV fluids Antibiotics renal dialysis Client education ± change tampons 3-6 hours, avoid tampons 6-8 wks after childbirth, do not leave diaphragms>48 hours
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‡ AUB- diagnosis referring to any uterine bleeding that is irregular in amount, duration, or timing ‡ DUB- most common type of AUB and is frequently defined as irregular uterine bleeding unrelated to organic pathology, medication, pregnancy related disorders, systemic condition,
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‡ causes of AUB: 1. pregnancy-ectopic, spontaneos abortion 2.endocrine problem- cushing syndrome,diabetes 3.medicationamphetamines,anticoagulants,steroids,IN H,SSRIs 4. systemic dse.- thyroid dysfunction,leukemia,ITP
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‡ Types:
± 1.anovulatory DUB- due to lack of progesterone in the luteal phase of anovulatory cycles leads to unstable ,excessively vascular endometrium,often lead to abnormal cycle interval, or abnormal amount of bleeding ± 2. ovulatory DUB- are regular and tend to be cyclic,although the bleeding pattern are often abnormal,menorrhagia is commonly observed and is commonly associated with pelvic pathology

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‡ Causes of anovulation:
± Physiologic:
‡ ‡ ‡ ‡ Pregnancy Lactation Perimenarche Perimenopause

± Pathologic causes:
‡ Hyperandrogenic disorder ‡ Hyperprolactinemia ‡ Extreme stress
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‡ s/sx: uterine bleeding ‡ Physical Examination:
± 1. pelvic examination ± 2.Speculum examination ± 3. bimanual examination

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‡ Management:Goal:1. normalize the bleeding 2. correct any anemia 3. restore quality of life 4.prevent cancer 1. medication ± oral contraceptives 2. surgery- D and C, Hysterectomy
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Endometriosis Endometrial tissue outside the uterine cavity Pelvis most common location Bleeding results to inflammation, scarring of peritoneum and adhesions Cause unknown Common in 20-45 yrs old

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Common Sites 0f Endometriosis Formation

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Risk Factors:

Physiologic disruption after gyne surgery or cesarean birth Hereditary Possible immunologic effect

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Manifestations: 1. Pelvic pain dull/cramping, r/t menstruation 2. Dyspareunia 3. Abnormal uterine bleeding 4. Fixed tender retroverted uterus 5. Palpable nodules in the cul de sac Diagnostics: laparoscopy

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Management: OCP-combination contraceptives to induce amenorrhea Analgesics NSAIDS Danazol antiprogesterone; suppresses GnRH, low estrogen and high androgens to suppress ovulation, promote amenorrhea and decrease endometrial support GnRH agonists ie leuprolide suppress the menstrual cycle through estrogen antagonism Progestins ie Medroxyprogesterone antiendometrial effect
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amenorrhea
‡ Absence of menstruation ‡ Can be primary and secondary amenorrhea

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‡ Primary amenorrhea
± Pregnancy ± Upper genital tract causes(mullerian agenesis, testicular feminization ± Lower genital tract causes( imperforate hymen) ± Hypergonatropichypogonadism( gonadal dysgenesis)

‡ Secondary amenorrhea
± ± ± ± ± ± ± ±
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Pregnancy ashermans syndrome Cervical stenosis Hormonal contraception Hypothyroidism PCOS Pituitary tumor menopause
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‡ Management:
± Progestational challenge- administered progesterone 300mg OD for 5 days or provera 10 mg OD for 5 days ± Prolactin and TSH level to rule out pituitary and thyroid pathology

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Cystocele
‡ Downward displacement of bladder, w/c appears as a bulge in the anterior vaginal wall ‡ R/t genetics, childbearing, obesity, age ‡ S/s: incontinence, vaginal fullness ‡ Mx: Kegel¶s exercises, estrogen, surgery

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Rectocele
‡ Posterior vaginal wall is weakened ‡ Anterior wall of rectum sags forward into the vagina ‡ S/sx:constipation ‡ Mx: surgery

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Uterine Prolapse
‡ Cervix may prolapse into vagina ‡ S/sx: dragging sensation in groin, backache in sacrum ‡ Mx: estrogen, surgery

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Nabothian cyst
‡ ‡ ‡ ‡ Common findings Cause is unknown Diagnosis is made clinically Treatment: no treatment

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Cervical polyps
‡ Are a result of benign hyperplasia of the glandular tissue arising from the mucosa ‡ Causes: unknown ‡ Treatment: removal of polyps

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Uterine fibroids
‡ Myomas or leiomyomatas, are benign growth that arise from the smooth muscle of the uterus ‡ Types: subserosal( external surface of the uterus intramural (within the myometrium) submucosal (with in the endometrial layer)
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Benign Ovarian masses
‡ Ovarian cysts ± physiologic variations in menstrual cycle ‡ Dermoid cysts - (cystic teratomas) ± cartilage, bone, teeth, skin or hair can be observed ‡ Endometriomas (chocolate cysts)

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Manifestations
‡ Sensation of fullness, cramping, dyspareunia, irregular bleeding Diagnostics: USG Management: OCP to suppress ovarian function DR CELESTE surgery

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Leiomyoma
‡ ‡ ‡ ‡ Fibroid tumors 40 yrs old Potential for cancer is minimal Smooth muscle cells present in whorls and arise from uterine muscle

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Manifestations
‡ ‡ ‡ ‡ ‡ ‡ Frequently asymptomatic Lower abdominal pain Fullness or pressure Menorrhagia Metrorhaggia dysmenorrhea

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Diagnostics: USG Management: Routine pelvic exam every 3-6 months surgery

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Vaginal Cancer ‡ Upper 1/3 most common site ‡ S/S: painless vaginal bleeding and discharge, urinary retention, bladder spasm, hematuria, frequency of urination, tenesmus, constipation, blood in the stool ‡ Dx: pap smear, biopsy ‡ Mx: radiation, surgery

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Cervical Ca
‡ Preventable Risk Factors: coitus at an early age Multiple sexual partners Sex partner w/ a hx of numerous sexual partners Exposure to STD HPV infections Chemotherapy Contraceptive use>5 yrs Smoking Antenatal exposure to DES History of dysplasia
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Diagnostics: Pap smear Colposcopy Endocervical curettage Management: surgery

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Endometrial Ca
‡ Postmenopausal Risk Factors: Obesity Multiparity DM HPN Use of unopposed estrogen High fat diet Early menarche and late menopause Use of tamoxifen
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Manifestations: ‡ Bleeding in postmenopausal women not treated with HRT Diagnosis: Pap smear Endometrial biopsy USG Management: TAHBSO counseling
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Ovarian Ca
Risk Factors: Increased age (mean age 59 yrs old) Fertility drugs Early menarche or late menopause Asbestos and talc exposure S/sx: abdominal swelling or inc abdominal girth, bloating, pelvic pressure, mild constipation Management: surgery
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Fibrocystic breast disease
Most common benign condition of the breast 20-50 yo D/t imbalance between hormones Rare in postmenopausal women not taking HRT Not risk for Ca except if px has (+) family hx and w/ atypical cellular changes on biopsy S/sx: bilateral cyclic pain, tenderness, nipple discharge Dx: mammography, sonography, FNA Mgmt: restrict Na, mild diuretic, Danazol (hormone inhibitor), Bromocriptine and Tamoxifen to decrease symptoms ‡ ‡ ‡ ‡ ‡

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Fibroadenoma
‡ 2nd most common ‡ Teens, early 30¶s ‡ Not associated w/ breast Ca S/sx: freely movable, solid, well defined, sharply delineated, rounded w/ a rubbery texture Dx: USG, FNA Mgmt: surgery of enlarged
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Intraductal Papilloma
‡ Tumors growing in terminal portionof duct ‡ Potentially malignant S/sx: unilateral mass/solitary nodule, bloody discharge Dx: ductogram followed by mammogram biopsy Mgmt: excision w/ follow up care

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Breast Ca
Risk Factors: Age, female, family hx, HRT > 5 yrs, overweight after menopause, alcohol, bo hx of pregnancy or 1st pregnancy after age 30, never breastfeeding, early menarche, late menopause, radiation, upper socioeconomic areas, geographic location

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Manifestations: painless mass or lumpnipple inversion, change in breast size or shape, erosio, ulceration, axillary lump Dx: mammography, FNA, USG, MRI Mgmt: surgery Simple/Total Mastectomy Modified Radical Mastectomy ± breast + LN Lumpectomy chemotherapy, radiation Tamoxifen (anti-estrogen) Emotional responses
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Infertility ‡ Inability to conceive a child or sustain a pregnancy to childbirth ‡ Pregnancy has not occurred after at least 1 year of engaging in unprotected sexual intercourse ‡ Affects 14% of couples desiring children

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Types of infertility: ‡ Primary infertility - refers to a couple who has never established a pregnancy ‡ Secondary infertility - refers to couple who has conceived previously but are currently unable to establish a subsequent pregnancy

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Male Infertility Factors ‡ Inadequate sperm count ‡ Obstruction or impaired sperm motility ‡ Ejaculation problems

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‡ Male factor: ‡ Obstruction in seminiferous tubules , duct, or vessels preventing movement of spermatozoa ‡ Qualitative or quantitative changes in the seminal fluid preventing sperm mobility (movement of sperm). ‡ Problem in ejaculation or deposition preventing spermatozoa from being placed close enough to the woman¶s cervix to allow ready penetration and fertilization.
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± Causes of inadequate sperm: ‡ Chronic infection ‡ Congenital anomalies ‡ Varicocele ‡ Increase in body temperature ‡ Trauma to the testes ‡ Endocrine imbalances ‡ Drug or excessive alcohol use ‡ Environmental factor

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±Obstruction or impaired sperm motility: ± Mumps or orchitis ± Anomalies of the penis ± Extreme obesity

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Female Infertility Factors ‡ Cervical problems ‡ Vaginal problems ‡ Unexplained infertility

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‡ Ovarian factor: ‡ Anovulation- most common cause of infertility in women 1. genetic abnormality 2.hormonal imbalance 3. ovarian tumor 4. stress 5.decreased body weight

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‡ ‡

Tubal factor: ± Pelvic inflammatory disease Uterine factor: ± Tumor ( fibroma) ± Congenitally deformed uterine cavity ± Endometriosis ± Inadequate endometrium formation

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‡ Cervical factor: ± Characteristic of cervical mucus ± Infection/inflammation of cervix ‡ Coital factor : ± pH of the vagina: alkaline pH is optimum (8) ± Presence of sperm-immobilizing/sperm agglutinating antibodies

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Fertility Assessment ‡ Fertility testing  Semen analysis  Ovulation monitoring  Tubal patency assessment

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Semen Analysis ‡ ‡ ‡ ‡ Number of sperm Appearance of sperm Motility of sperm Sperm penetration

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semen analysis ± count: 20 million / ml or 50 million /ejaculation ± volume: 2.5ml - 6 ml ± Motility: >75% ± Quality of motion: graded 1-4 (poor to excellent) ± Morphology: more than 70% normal

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Ovulation Monitoring ‡ Record basal body temperature ‡ Ovulation by test strip  Assesses upsurge of LH that occurs before ovulation

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Tubal Patency ‡ Sonohysterography  Ultrasound to inspect uterus ‡ Hysterosalpingography  Radiologic exam of fallopian tubes

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Advanced Surgical Procedures ‡ Uterine endometrial biopsy ‡ Hysteroscopy ‡ Laparoscopy

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Infertility evaluation: ‡ Male factor: ‡ Semen analysis ‡ Post-coital test-mucus is examined microscopically between 2- 12hrs after coitus ± Satisfactory test- many motile spermatozoa seen per high power field ± Unsatisfactory result: » No spermatozoa are seen » Majority of spermatozoa are immotile » Very few spermatozoa are present

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‡ Motility is characterized as shaking movement rather than forward movement ‡ Hostile cervical mucus is present ± Sperm antibodies: maybe measured in ± Seminal plasma ± Male serum ± Female reproductive tract fluids ± Female serum

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± Test of fertilizing capacity of spermatozoa: ‡ Measurement of sperm acrosin-enzyme in sperm head that responsible for preliminary changes in the sperm ‡ zona-free hamster ovum penetration test ‡ Human ovum fertilization test ‡ Coital factor: ‡ Taking history of coital frequency, pattern and technique ‡ Anatomic evaluation of the position of the cervix with relationship to the vagina ‡ Post coital testing
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‡ Cervical factor: ± Cervix is the first major barrier encountered by sperm after arrival in the female reproductive tract 1.Abnormalities in the cervix or the cervical mucus ± Abnormal position of the cervix( prolapse or uterine retroversion ± Chronic infection ± Previous cervical surgery ± Presence of sperm antibody in the cervical mucus

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2.mucus quality: - pH -bacteriologic culture for microorganism ‡ Uterine factor: * role of uterus in reproduction: - retention of the zygote after arrival from the fallopian tube - provision of suitable environment for implantation - protection of embryo /fetus from the external environment

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± Hysterography- visualize contour of the uterine cavity ± Hysteroscopy ±visualize uterine cavity to detect anomalous development, polyps or tumors

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‡ Tubal factor: - functions: 1.mechanical function- act to : -conveys recently ovulated ova into fallopian tube -permits spermatozoa to enter the oviduct -effects transfer of the blastocyst into the uterine cavity

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‡ Ovarian factor: -function: serve as repository for oocytes, they release mature oocytes at regular interval throughout reproductive life - secrete steroid hormones that influence the structure and function of tissue in reproductive tract, promoting fertility

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*documentation of ovulation: a. basal body temperature records demonstrate a 14 day elevation of basal temp.( progesterone-thermogenic effect) b. Blood progesterone level c. endometrial biopsy- secretory endometrial pattern

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‡ Treatment : ± Correction of male factor: a. Medical - correction of underlying deficiencies - artificial donor insemination b. surgical - reversal of sterilization - varicocele surgery

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c. assisted reproductive technologies 1. in vitro fertilization and embryo transfer IVF) 2. gamete intrafallopian tube transfer(GIFT) 3. assisted fertilization

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± Correction of ovarian factor: 1. induction of ovulation: - correction of underlying endocrine disorder - clomiphene citrate to correct hypothalamic function - human menopausal gonadotropin - bromocryptine for anovulation due prolactin excess - glucocorticoids for androgen excess

to

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Assisted Reproductive Techniques

‡ ‡ ‡ ‡ ‡

Artificial insemination In vitro fertilization Gamete intrafallopian transfer Zygote intrafallopian transfer Surrogate embryo transfer

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‡ Artificial insemination ± instillation of sperm into the female reproductive tract to aid conception - technique of micromanipulation that thins the zona pellucida and inject sperm into the ovum in an effort to enhance fertilization ‡ In vitro fertilization (IVF)± removing 1 or more mature oocytes from a woman¶s ovary by laparoscopy and then fertilizing them by exposing them to sperm under laboratory conditions outside the woman¶s body (placed on a dish together with the sperm) ‡ Embryo Transfer (ET)± ova transfer; insertion of laboratory grown fertilized ovum into the woman¶s uterus approx. 40 hours after fertilization where 1 or more of them will implant and grow
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ARTIFICIAL INSEMINATION

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IN VITRO FERTILIZATION

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‡ Gamete intrafallopian transfer (GIFT) ±ova and sperm are instilled in the patent fallopian tube within a matter of hours without waiting for the fertilization to occur in the laboratory ‡ Zygote intrafallopian transfer (ZIFT) ± retrieval of oocytes, culture and insemination of oocytes in the laboratory; fertilized eggs are transferred in the patent fallopian tube within 24 hours

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‡ Surrogate embryo transfer ±oocyte from a donor is fertilized by the recipient woman¶s male partner¶s sperm and placed in the recipient¶s uterus by ET or GIFT ‡ Intravaginal culture ‡ Blastomere analysis

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