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Pure choriocarcinomas of ovary are extremely rare and most coexist with other germ cell syncytiotrophoblast without any villi prostate health foods purchase genuine rogaine 5 on line. Other Germ Cell TumorsEmbryonal carcinoma: Highly malignant tumor of primitive embryonal elements androgen hormone jacksonville discount rogaine 5 60ml otc, similar to that of testes. The corresponding tumors may be either feminizing Produce estrogen or (granulosa-theca cell tumors) or masculinizing (Leydig cell tumors). Granulosa-Theca Cell TumorsGranulosa cell tumor of the ovary is associated with estrogen secretion. Clinical Features the presenting clinical features may be due to secretion of hormones mainly estrogen and occasionally androgen. Photomicrograph composed of tumor cells are arranged in sheets punctuated by small follicle-like structures (Call-Exner bodies). Behavior: All granulosa cell tumors are considered as potentially malignant because it may spread locally as well as metastasize. Biochemical markers: Inhibin is secreted by granulosa cells and elevated tissue and serum Granulosa cell tumor: Marker is inhibin. Clinical FeaturesUsually present as a pelvic mass sometimes accompanied by pain. Source of Primary TumorFrom genital tumors: Most common metastatic tumors are derived from tumors of the uterus, fallopian tube, and contralateral ovary. Metastatic tumors of ovary: Most common source of metastatic from genital tumors originate from uterus, fallopian tube, and contralateral ovary. Krukenberg tumor:Metastatic tumor of ovaryMost common primary is from stomach. Morphology Krukenberg tumor: Microscopy shows nests of mucin-producing, signetring cancer cells within a cellular stroma of the ovary. Gestational trophoblastic disease:Tumors and tumor-like lesionsProliferation of placental tissue (villous or trophoblastic). Hydatidiform Mole Definition: Hydatidiform mole is benign gestational trophoblastic disease characterized histologically by cystic swelling of the chorionic villi, accompanied by variable trophoblastic proliferation. Significance: Hydatidiform mole is associated with an increased risk of invasive mole or choriocarcinoma. Age: Mostly present in the fourth or fifth month of pregnancy with vaginal bleeding. Currently, due to routine ultrasound examination during early pregnancy, moles are detected at earlier gestational ages. Complete mole: the genetic material/ chromosomes of the sperm (23,X not 23,Y) undergoes duplication a phenomenon called androgenesis. Partial mole:TriploidTwo sets of paternal chromosomesFetal tissue present. More commonly complete moles develop from fertilization of an empty ovum by a single sperm that undergoes duplication of its chromosomes; B. Less commonly, complete moles may arise from fertilization of an empty ovum by two sperms (dispermy); C. Partial moles develop from fertilization of single ovum by two sperm and forms partial mole with triploid karyotype Risk FactorsMaternal age: It has two peaks. Write short note on differences Depending on cytogenetic and histological features, benign, noninvasive moles are divided between complete and partial mole. Thus, the characteristic feature is complete absence of maternal chromosomes (empty ovum) and the genetic material is completely paternally derived (from sperm). The genetic material/chromosomes of the sperm (23,X not 23,Y) undergoes duplication a phenomenon called androgenesis. Complete hydatidiform mole: Whole placenta is neoplastic without any fetal parts and are diploid. Partial mole: Part of placenta neoplastic, fetal parts present and triploid (karyotyping shows 69 chromosomes). Complete hydatidiform mole: Hydropic avascular villi with trophoblastic proliferation.

Calcitonin administered as nasal spray at 200 units a day has been shown to reduce the risk of vertebral fractures by 33% over 5 years in a placebo-controlled study man health georgia erectile dysfunction gallery buy 60ml rogaine 5. However no effect women at high risk of hip fracture there was a 36% reduction of the relative risk of hip fractures seen after 3 years of treatment prostate in women best rogaine 5 60ml. It has to be administered after and followed by a 2 h fast, thus it is given last thing at night. Strontium ranelate is generally well tolerated and the most common side effects include nausea and diarrhoea, which usually subside with continuous treatment. New developments the use of combination therapy in treatment of postmenopausal osteoporosis has been addressed by several studies. Further research in this area is necessary to establish efficacy and safety of different regimens. Recent advances in the understanding of bone pathophysiology at a cellular and molecular level have allowed for development of novel treatments for osteoporosis such as denosumab, described above and already in clinical use. A number of other novel antiresorptive compounds including cathepsin K inhibitors are being investigated in postmenopausal osteoporosis. A phase 3 trial of over 16,000 postmenopausal women with osteoporosis is expected to be completed by July 2012. As inhibition of cathepsin K does not affect osteoclast viability, theoretically osteoclasteosteoblast communication should be preserved allowing for uninterrupted new bone formation. It remains to be seen whether this concept translates into an advantageous clinical effect over the classic antiresorptives. There was a 65% and 54% fracture risk reduction seen in vertebral and non-vertebral sites as well. The number of hip fractures was lower, however a significant fracture risk reduction was not seen possibly due to small numbers. Teriparatide has been also shown in clinical trials to be of particular value in steroid-induced osteoporosis, which is characterized by suppressed bone turnover, in which state the anabolic action of teriparatide is of particular benefit. Teriparatide has also been shown to reduce pain associated with osteoporotic vertebral fractures. Teriparatide should be given to patients who are vitamin D replete and is licenced to be used for 24 months, Conclusions In the ageing population osteoporosis is a growing health problem and an increasing economic burden. Efforts to attain and maintain peak bone mass for as long as possible seem a logical approach and include a healthy lifestyle, nutritious and balanced diet with optimal calcium and vitamin D intake and physical exercise with skeletal mechanical loading. In addition a plethora of pharmacological treatments is available for women with or at risk of osteoporosis or fragility fractures and can be targeted to the individual. Bisphosphonates are recommended as first-line therapy, however there have been concerns with regard to long-term safety and their use is generally not recommended for longer than 10 years. For older patients intolerant of bisphosphonates, strontium ranelate is a good choice. Denosumab is a safe option in patients intolerant of, or with contraindications to bisphosphonates and improves compliance. There is a need for more research in order to understand the underlying mechanisms of bone loss leading to osteoporosis, so that novel treatments can be developed with an emphasis not only on suppression of bone resorption, which may lead to unwanted consequences long term, but on bone preservation and improvement of bone quality. Evaluation, treatment, and prevention of vitamin D deficiency: an Endocrine Society clinical practice guideline. Recent education and enhanced contraception services are initiatives which have met with variable success. In this summary, we discuss these, and the welcome recognition of other contributing factors, such as poverty; unless such contributing factors are addressed, any prevention initiatives are threatened. The gynaecologist should be constantly prepared to consider the issue in any young woman. Keywords adolescent; prevention; strategies; teen; teenage pregnancy Introduction Eleven percent of births worldwide are to mothers aged between 15 and 19 years. The rates are significantly lower in developed countries but still felt to be unacceptably high. This is despite a termination rate of 50% in England Wales in pregnancies occurring in under-18s. Our societal view of teenage mothers is negative e associated with the benefit culture, lack of social mobility, poor educational attainment and suboptimal life chances for the children. The aim of this being to support teenage parents, and to reduce the conception rate in this age group. This ambitious goal was not met, the actual decrease in teenage pregnancy between 1998 and 2010 being 13.

When first described mens health 2012 purchase rogaine 5 amex, it was called globus hystericus because it was thought to be a psychological problem of women androgen hormone yakiniku buy rogaine 5 60 ml without a prescription. Pathophysiology While the pathogenesis of globus is not known, a number of possibilities have been proposed. They include cricopharyngeal spasm, motor dysfunction of the pharynx or esophagus, gastroesophageal reflux, esophageal hypersensitivity, or psychological problems. The most widely accepted, but by no means proven, etiology for globus is gastroesophageal reflux. The odds ratio for someone with globus having reflux symptoms (regurgitation and/or heartburn) is reported to be 11. They range from showing no difference in acid exposure between globus sufferers and controls44 to the incidence of globus increasing with the amount of acid exposure. In a small, randomized, sham-controlled trial, symptom improvement was better in those who had the inlet patch ablated than in the sham group. Patients with globus are more sensitive to electrical stimulation or balloon dilation of the esophagus, and they almost universally sense the stimulus at or near the suprasternal notch rather than substernally. Still, there is some evidence that life stress might participate in the genesis of globus and exacerbate the symptom. There is essentially no good evidence supporting the hypothesis that globus arises from pharyngeal or esophageal motor dysfunction. The upshot of all these studies is that we really do not know what causes globus and that the pathogenesis is likely to be multifactorial. All patients with globus should have a careful exam of the neck and nasolaryngoscopy to rule out the unlikely presence of a pharyngeal neoplasm. Epidemiology Globus is exceedingly frequent, being reported in up to 46% of seemingly normal people. It is just as prevalent in men as women in the community,53 but women are more likely to seek medical attention for globus. Treatment Our poor understanding of its pathogenesis and our lack of efficacious treatments make the management of globus difficult. The patient should be counseled that globus is a benign condition that might persist for years. Studies suggesting that globus might arise from hypersensitive esophageal sensory afferents imply that drugs that modulate sensory pathways might be of some benefit. The incidence, co-occurrence, and predictors of dysphagia, dysarthria, and aphasia after first-ever acute stroke. Functional lesions in dysphagia due to acute stroke: discordance between abnormal findings of bedside swallowing assessment and aspiration on videofluorography. Savary dilation is a safe and effective long-term means of treatment of symptomatic cricopharyngeal bar: a single center experience. Manofluorographic and functional outcomes after endoscopic laser cricopharyngeal myotomy for cricopharyngeal bar. Dilatation therapy for dysphagia in patients with upper esophageal sphincter dysfunction-manometric and symptomatic response. Long-lasting effect of a single botulinum toxin injection in the treatment of oropharyngeal dysphagia secondary to upper esophageal sphincter dysfunction: a pilot study. Prevalence and clinical spectrum of gastroesophageal reflux: a population-based study in Olmsted County, Minnesota. A double-blind controlled study of the efficacy of cimetidine in the treatment of the cervical symptoms of gastroesophageal reflux. Lansoprazole in globus pharyngeus: double-blind, randomized, placebo-controlled trial. Argon plasma coagulation of cervical heterotopic gastric mucosa as an alternative treatment for globus sensations. Evidence for oesophageal visceral hypersensitivity and aberrant symptom referral in patients with globus.

Interestingly prostate test psa discount rogaine 5 60ml fast delivery, the serious complication rate was higher in patients treated by surgery or surgery plus radiotherapy rather than radiotherapy alone prostate cancer odds order rogaine 5 master card. Up to 1999 radical radiotherapy alone was the treatment of choice for stages 2b-4a carcinoma of the cervix. More recently studies have shown that radiotherapy given concurrently with platinum based chemotherapy can increase disease-free survival and overall survival in these patients and this has been adopted as the standard treatment in patients suitable for concurrent therapy. This is expressed as progressive fibrosis and arteritis leading to necrosis, fistulae or stricture. The serious complication rate for patients treated for carcinoma of the cervix by radical radiotherapy is about 5%. The therapeutic ratio the therapeutic ratio has been defined as the relationship between the desired and unwanted effects of therapy. One method to reduce the risk of normal tissue injury and increase the therapeutic ratio is to fractionate treatment. The total dose of radiation to be delivered is divided into 20e30 separate treatments and given daily over 4e6 weeks. An alternative approach is to administer continuous radiation directly into or adjacent to the tumour. Radiotherapy machines Modern radiotherapy departments use linear accelerators, which are used to produce X-rays of energies of 6e20 million electron volts (MeV). Such X-rays have major clinical advantages over low energy X-rays generated by older kilovoltage machines. It is fairly easy to treat deep-seated tumours with a homogeneous radiation beam and the radiation dose to bone no higher than surrounding tissues. Older kilovoltage apparatus generates X-rays of 100,000e300,000 electron volts (KeV). These machines produce X-rays only 2e3 times more energetic than those used to take diagnostic radiographs. The maximum energy of the kilovoltage X-rays is deposited on the skin surface, this meant their usefulness is limited in treating deeper tumours. At present these machines are used for low dose palliative treatments or for the treatment of skin/superficial tumours. Brachytherapy Brachytherapy involves implantation or insertion of radioactive seeds or sources directly into or adjacent to the tumour (or tumour bed). It allows a high radiation dose to the tumour with low doses to surrounding tissue to reduce toxicity. It is an essential part of the radiation therapy for carcinoma of the cervix and may also be used in the treatment of endometrial carcinoma. The patient has hollow tubes placed into the uterus (usually under general anaesthetic) or vagina. The current practice is to use an afterloading device which is able to move the radioactive sources remotely from a machine into the intra-uterine or vaginal applicators and back out again at a prescribed time to deliver the appropriate radiation dose. The patient is kept in isolation during the treatment but the sources can be moved back into the machines at the touch of a button in the case of emergency. Current developments in radiotherapy the vast improvement in diagnostic imaging has been immensely helpful in radiation treatment planning. With the use of reconstructed matched computed tomograms and magnetic resonance images the accuracy of treatment planning can be improved and this reduces the possibility of a "geographical miss". Moreover, the dose distribution to the target volume can be shaped to conform tightly to the shape of the tumour, reducing the volume of normal tissue irradiated by up to 50%. The risk of late damage (side effects developing months or years following radiotherapy treatment) can therefore be reduced and the dose given to the tumour can be increased with a greater probability of tumour control. This "conformal" radiotherapy is possible due to the introduction of the multi-leaf collimator. This is an apparatus in the head of the linear accelerator made up of pairs of tungsten bars (5e10 mm width). Prospective dose escalation studies in prostate cancer showed that higher doses could be given using this technique with better tumour outcomes and no increase in late toxicity. The main interest is in improving radiation treatment for cervical carcinoma by reducing bowel and urinary toxicity whilst looking at the possibility of increasing dose to the primary and areas at risk. It involves careful delineation of areas at risk by the clinician and very precise radiotherapy beam arrangements.

The fluid shift within the body compartments also leads to a prothrombotic state secondary to both haemoconcentration and hyperoestrogenic state with increased levels of clotting factors resulting in thromboembolic sequelae such as pulmonary embolism and cerebrovascular thrombotic strokes mens health xtreme nitro cheap rogaine 5 60 ml line. This acts by binding vasoactive substances and preventing fluid shift into the third space by increasing intravascular oncotic pressure mens health xmas gift guide discount rogaine 5 60 ml line. The optimal dose and timing of albumin administration are not clear and there are concerns about febrile and allergic reactions, and potential risk of virus/prion transmission. An alternative to albumin is hydroxyl ethyl starch which is a plasma substitute and may be safer, cheaper and effective. In vitro maturation of oocytes by aspirating all follicles at mid-follicular phase after a short period of ovarian stimulation. It is also associated with an increased risk of maternal morbidity (preeclampsia, thromboembolic disease, ante partum and postpartum haemorrhage and caesarean section). It is envisaged that by better embryo culture and selection methods and wider use of single blastocyst transfer that this would be a realistic target. Bleeding during oocyte retrieval either from the vagina or internally from the ovaries or more rarely from pelvic blood vessels. Torsion of the ovaries can occur as a rare complication of ovarian enlargement and hyper stimulation and is reported in 0. Women should be counselled regarding the uncertainty of the current evidence and that there may be increased risk of borderline ovarian tumours. Textbook of Assisted reproductive techniques: laboratory and clinical perspectives. Specific pre-treatment infertility work-up include assessment of pelvic anatomy by Transvaginal ultrasound and/or hysteroscopy, assessment of ovarian reserve, interventions such as salpingectomies for hydrosalpinx, discussion and decision about welfare of the child and the use of gametes/ embryos. Single embryo transfer (particularly at blastocyst stage) is advisable to reduce the risk of multiple pregnancies. Patients with severe hyperstimulation (severe symptoms of bloatedness, nausea, abdominal discomfort, enlarged ovaries and evidence of third spacing manifested as ascites or pleural effusion) needs admission to hospital for close monitoring, supportive therapy, thromboprophylaxis and possible albumin infusion. Menstrual dysfunction Gail Busby Abstract Menstrual dysfunction is common, with approximately 9e30% of reproductive-aged women presenting with menstrual irregularities requiring medical evaluation. This article reviews the most common causes of menstrual dysfunction using case histories for illustration. The conditions covered in this review include menstrual dysfunction around the time of menarche, ovulatory and anovulatory dysfunctional uterine bleeding, polycystic ovarian syndrome, uterine fibroids and dysfunctional bleeding around the perimenopause. Ovulatory cycles are predictable and patients often have an imbalance of prostaglandin levels and increased fibrinolytic activity. In all cases of dysfunctional uterine bleeding, pregnancy, and the complications thereof should be ruled out as a cause. This review gives five scenarios which are common presentations of menstrual dysfunction. Case 1: abnormal uterine bleeding around the menarche A 15-year-old presents with a history of heavy, irregular periods. Her periods started nine months before and although initially average in flow, they increasingly became heavier and more frequent. Anovulation looms large in the pathogenesis of heavy, irregular bleeding around menarche. The result of this is prolonged stimulation of the endometrium by oestrogen until the thickened endometrium is unable to be supported and sheds. The adolescent with irregular and heavy periods should be investigated for clotting abnormalities as the reported prevalence of bleeding disorders in adolescents with menorrhagia varies between 10. Pregnancy should not be forgotten as a possible cause of irregular bleeding in this age group. If flow remains a problem, the addition of Tranexamic acid and/or Mefenamic acid during withdrawal bleeds is frequently adequate. This treatment can be continued indefinitely, or stopped after 1 year or so to determine if ovulatory cycles have commenced, which should result in regular cycles of normal flow. Keywords abnormal uterine bleeding; dysfunctional uterine bleeding; endometrial hyperplasia; menstrual dysfunction; perimenopausal bleeding; polycystic ovarian syndrome; uterine fibroids Introduction the majority of menstrual cycles are between 24 and 32 days and a normal cycle is considered to be 28 days.