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Whatever method is used weight loss workouts generic xenical 60 mg on line, all rely on a period of abstinence and many couples find this difficult weight loss size 0 purchase xenical 120 mg with mastercard. Perfect use of the mucus method is, in fact, associated with a failure rate of only 3. Lactationalamenorrhoeamethod Breast feeding delays the resumption of fertility, and it still has a major impact on fertility rates in developing countries. It has been calculated that breast feeding provides more than 98% protection from pregnancy during the first 6 months post partum if the mother is fully or nearly fully breast feeding and has not yet experienced vaginal bleeding after the 56th day post partum. It is cheap, widely available over the counter and, with the exception of the occasional allergic reaction, is free from side-effects. Spermicides alone are not a very effective method of contraception and are only recommended for use with a condom (most of which are already lubricated with spermicide) or diaphragm. Nonoxynol 9 (N-9) is a spermicidal product sold as a gel, cream, foam, film or pessary for use with diaphragms or caps. The simplest is the calendar or rhythm method, in which the woman calculates the fertile period according to the length of her normal menstrual cycle. Others use symptoms which reflect fluctuating concentrations of circulating oestrogen and progesterone, themselves reflecting follicular development, impending ovulation and completed ovulation. The mucus or Billings method relies on identifying changes in the quantity and quality of cervical and vaginal mucus as a reflection of the steroid environment. As circulating oestrogens increase with follicle growth, the mucus becomes clear and stretchy, allowing the passage of sperm. With ovulation and in the presence of progesterone, mucus becomes opaque, sticky and much less stretchy or disappears altogether. Femalesterilization Female sterilization usually involves the blocking of both fallopian tubes either by laparotomy or minilaparotomy or, more commonly, by laparoscopy. It may also be achieved by bilateral salpingectomy (or by hysterectomy when there is coexistent gynaecological pathology such as hydrosalpinx or fibroids) or by hysteroscopic techniques. Minilaparotomy is most commonly used when sterilization is performed immediately post partum as, at that time, the uterus is large, the pelvis is very vascular and the risks of laparoscopy are increased. It is licensed for use within 72 h of intercourse, but women should be encouraged to present as soon as possible for treatment. If the woman does not wish to continue with the method, it can be removed with the next period or when an alternative method has been established. It has been shown to delay or impair ovulation in some 50% of users, but there is no good evidence that it will inhibit implantation. Neither is there any contraceptive/contragestive effect once implantation is complete. Recent efforts to find a more effective, orally active emergency contraceptive with fewer side-effects have resulted in trials of the antiprogesterone mifepristone (Task Force on Postovulatory Methods of Fertility Regulation 1999). The tubes can be tied with absorbable or nonabsorbable sutures, and the ends can be left free or buried in the broad ligament or uterine cornu. Electrocautery With electrocautery, one or more areas of the tube are cauterized by diathermy. Bipolar diathermy only allows the tissues held between the jaws of the forceps to be cauterized. Falope ring A ring of silicone rubber is placed over a loop of tube with a specially designed applicator. As ischaemia of the loop causes significant postoperative pain, application of topical anaesthesia during sterilization is recommended. They destroy a much smaller length of tube, allowing easier reversal, but special care must be taken to ensure that the whole width of the tube is occluded.

Psychology is also concerned with intelligence weight loss pills at walmart cheap xenical 60mg without a prescription, learning ez 60 weight loss pills effective xenical 60mg, and personality development. There are 2 main approaches: the descriptive, which aims to record symptoms that make up a diagnosis of mental illness; and the psychoanalytic, which is concerned with the unconscious feelings and motives of the individual. Psychosexual disorders include transsexualism, psychosexual dysfunction, and sexual deviation. The main feature of psychotic illnesses is that they cause a person to have a distorted view of life. Symptoms include delusions, hallucinations, thought disorders, loss of affect, mania, and depression. Common examples of conditions that may be psychosomatic are headache, breathlessness, nausea, asthma, irritable bowel syndrome, peptic ulcer, and types of eczema. Prefrontal lobotomy has now been largely replaced by types of stereotaxic surgery. Patients talk to a therapist about their symptoms and problems, with the aim of learning about themselves, developing insights into relationships, and changing behaviour patterns. Pterygium is attributed to prolonged exposure to bright sunlight and is common in tropical areas. The condition may be congenital, occur spontaneously, or be due to injury or disease, such as myasthenia gravis. Ptosis is usually due to a weakness of the levator muscle of the upper eyelid or to interference with the nerve supply to the muscle. Severe congenital ptosis is corrected surgically to avoid the development of amblyopia. On men, the lice may also be found in hair around the anus, 471 on the legs, on the trunk, and even in facial hair. Children can become infested by transmission from parents, and the lice may live on the eyelids. Public health A branch of medicine concerned with prevention of disease through health education, provision of clean water supplies, sewage disposal, safer working conditions, infection control methods, immunizations, and the care of pregnant women and young children. Public health functions are covered by many people and agencies, such as Environmental Health Officers, Medical Officers of Environmental Health, and the Public Health Laboratory Service. A local anaesthetic (see anaesthesia, local) is injected into either side of the vagina near the pudendal nerve. Patients are sometimes described as either pink puffers or blue bloaters, depending on their condition. Pink puffers maintain adequate oxygen in their bloodstream through an increase in their breathing rate, and remain "pink" despite damage to the lungs. Blue bloaters are cyanotic (have a bluish discoloration of the skin and mucous membranes) because of obesity, and sometimes oedema, mainly due to heart failure resulting from the lung damage. If the embolus is large enough to block the main pulmonary artery, or if there are many clots, the condition is life-threatening. Pulmonary embolism is more likely after recent surgery, pregnancy, and immobility. Smaller emboli may cause severe shortness of breath, rapid pulse, dizziness, chest pain made worse by breathing, and coughing up of blood. Tiny emboli may produce no symptoms, but, if recurrent, may eventually lead to pulmonary hypertension. A diagnosis may be made by a chest X-ray, radionuclide scanning, and pulmonary angiography. A small one gradually dissolves and thrombolytic drugs may be given to hasten this process. It may be confined to an area of the lung affected by a condition such as pneumonia or tuberculosis, or it may be widespread through the lungs (see fibrosing alveolitis). Treatment depends on the cause, but in most cases the fibrosis is irreversible and treatment aims to prevent the condition from progressing. The tests include spirometry, measurement of lung volume, assessment of the degree of bronchospasm with a peak-flow meter, and a test of blood gases. Pulmonary hypertension develops in response to increased resistance to 472 blood flow through the lungs.

This fan-shaped sheet is condensed posteriorly to form the uterosacral ligam ents weight loss hypnosis app order xenical 60mg without prescription, and m edially to form the cardinal ligam ent weight loss pills uk order xenical 60mg amex, or the transverse cervical ligam ent. Anteriorly, the fascia sweeps forwards down the anterior wall of the vagina beneath the bladder base. Fundus Peritoneum (serous layer) O viduct Body Cornu Myometrium Endometrium Anatomical internal os Histological internal os Isthmus Supravaginal Cervix Vaginal Arbor vitae uteri Lateral fornix External os Vagina. On the le t the Fallopian tube and ovary are in the position ound in vivo; on the right, dissection has been made. The uterus is supplied by the uterine arteries, which arise from the internal iliac artery. Each gives off a descending branch which anastom oses with the ascending branches of the vaginal artery, and which supplies the lower cervix; and a circular branch to supply the upper cervix. The m ain trunk changes direction and passes upwards, coiled and tortuous, between the layers of the broad ligam ent adjacent to the lateral uterine wall, and supplies branches to the myom etrium at intervals. Each branch supplying the uterus divides in the outer m uscular layer, to send anterior and posterior branches to the myom etrium, and to anastom ose with those from the opposite side. These arteries give off branches at right-angles, which penetrate and supply the myom etrium and, entering the endom etrium, form the basal arteries. The veins of the uterus accom pany the uterine artery and form pam piniform plexuses of great com plexity, particularly in the param etrium, where they com m unicate with the veins of the bladder. The pam piniform plexus drains into the uterine vein and the ovarian vein, and has com m unications with the vertebral plexus of veins. The networks form collecting trunks, which pass from the corpus between the layers of the broad ligam ent along with the ovarian lym phatics. These trunks then pass through the infundibulopelvic fold, and ascend, on the posterior abdom inal wall, to join the nodes of the para-aortic group. The lowest two trunks com m unicate with the collecting trunks from the cervix, which pass through the base of the broad ligam ent to an inconstant node lateral to the param etrial node, to the nodes along the internal iliac arteries (the internal iliac or hypogastric nodes), and to the obturator nodes anteriorly. A few channels pass backwards along the uterosacral ligam ents to the sacral nodes. Uterine activity can continue without interruption in the absence of any nerve connection. They pass through the hypogastric plexuses and the juxtacervical plexus to reach and spread through the entire uterus. The uterus can contract without m otor nerve stim ulation, as occurs in labour in paraplegic wom en. The outer half of each Fallopian tube lies in contact with the ovary, curving over its superior surface to end in the abdom inal ostium. Because the tube is hollow, a direct connection exists between the peritoneal cavity and the uterus. The sensory bres then pass 360 Chapter 4 3 Anatomy of the fem ale genital tract Para-aortic nodes External iliac nodes Internal iliac nodes Sacral nodes Parametrial node Obturator nodes Superficial femoral node. For clarity, the lymphatic channels have been omitted and are indicated by arrows. It includes the trum pet-shaped abdom inal ostium, and lies in close proxim ity to the ovary. The am pulla is the longest segm ent of the oviduct, is norm ally rather tortuous, and has a relatively thin dilatable wall. The isthm us is a straight, narrow, relatively thick-walled segm ent, and the interstitial portion is the short, narrow portion within the uterine wall. The size of the lum en decreases from the infundibular to the interstitial portion, where it is only about 1 m m in diam eter, whereas the com plexity of the folds in the m ucous m em brane increases from the interstitial to the infundibular portions. The m ucous m em brane is lined with epithelial cells, about half of which are m ucus secreting and half ciliated. The m ucus secreted into the lum en is propelled towards the uterus by the action of the cilia and by peristaltic m ovem ents of the m usculature of the tube. The m ucus is rich in protein, and m ay provide nourishm ent for the fertilized ovum during its passage down the Fallopian tube. Each ovary norm ally lies in a shallow peritoneal fossa adjacent to the lateral pelvic wall, with its long axis in a vertical plane, but its position is in uenced by m ovem ents of the uterus and broad ligam ent. The ovaries have an irregular surface, are pinkishgrey in colour, and vary in size in different wom en and at different tim es of the cycle. In the infant, the ovary is a delicate, elongated structure with a sm ooth, glistening surface.

Clinical aspe cts With the widespread use of ultrasound a com m on presen tation is at the tim e of a routine ultrasound exam ination when a fetal heart is not detected extreme weight loss purchase 60mg xenical visa. Alternatively the wom an m ay report that she has had a sm all am ount of vaginal bleeding and this m ay be accom panied by the disappear ance of early pregnancy sym ptom s weight loss 600 calories per day order generic xenical on line. It has been estim ated that after one m iscarriage the risk of another is 20%; after two m iscarriages it is 25% and after four 40%. A wom an who has three or m ore successive m iscarriages is term ed a recur rent m iscarrier. T atme nt re There is no m edical need to treat m issed m iscarriage urgently as m ost cases end in a spontaneous m iscarriage. Inform ation and support m ust be given to the parents once they becom e aware that the fetus has died in utero, as this can be a very traum atic experience. A vaginal exam ination m ay show uterine broid or cervical incom petence, and the diagnosis can be clari ed if a transvaginal 109 Fundam entals of Obstetrics and Gynaecology ultrasound im age is obtained. Subm ucous broids or uterine septa m ay be rem oved by abdom inal surgery or under hysteroscopic vision. If endom etrial infection is considered a causative factor (as is the case with som e specialists), endom etrial tissue cultures m ay be m ade. However, it is doubtful whether toxoplasm osis, cytom egalovirus, herpesvirus, rubella or listeria are causes of recurrent m iscarriage. Other endocrine disorders, such as thyroid disease and diabetes, are not causes of recurrent m iscarriage unless they are poorly controlled. Although it is usual to investigate both parents for chro m osom al abnorm alities, such aberrations account for only 5% of recurrent m iscarriages at the m ost, and no treatm ent is available apart from donor gam etes. These include cytokines, either pro or anti in am m atory, and hum an leucocyte incom patibil ity between the two parents. Antiphospholipid syndrom e (lupus anticoagulant, anticardiolipin antibodies and anti B2 glycoprotein 1 antibodies) is associated with adverse pregnancy outcom es including recurrent m iscarriages and preterm birth due to placental disease. These antibodies have been found in 15% of wom en with recurrent m iscar riage com pared with <2% of healthy controls. Treatm ent with aspirin and unfractionated heparin increases the live birth rate, but they still have higher rates of pre eclam psia, fetal growth restriction and preterm birth, so close surveil lance throughout their pregnancy is needed. If there is clear evidence of cervical incom petence, treat m ent entails placing a soft nonabsorbable suture (such as Mersilk 4) around the cervix at the level of the internal cervical os. The patient m ay return hom e the sam e night or stay in hospital for a day, depending on the circum stances. There is no place postoperatively for the use of progesterone, uterine relaxants or narcotics. If there is doubt about the diagnosis, then surveillance with ultrasound is undertaken, cerclage being perform ed if there are signs of cervical shortening and/or beaking of the m em branes through the internal os. Following cervical cerclage 10% of wom en abort, 10% give birth prem aturely, and the rem ainder give birth after the 36th week of pregnancy. If m iscar riage or prem ature rupture of the m em branes occurs or prem ature delivery becom es inevitable following cerclage, the suture m ust be cut. In all other cases the suture is left until about 7 days prior to term, at which tim e it is cut, and the wom an m ay then be expected to give birth vaginally. Wom en need counselling on these m atters and need to have an opportunity to express their feelings. They should be advised to stop sm oking, to avoid sexual intercourse and not to travel. The results from this regim en are as good as those following the use of m ultivitam ins, horm ones (including hum an chorionic gonadotrophin), m etallic chem icals, thyroid extract and acupuncture, all of which are advocated from tim e to tim. Ce rvical inco mpe the nce About 20% of wom en who have recurrent m iscarriages in the second quarter of pregnancy will be found to have cervical incom petence. The doctor should provide answers sensitively and sym pa thetically even if the questions are not asked. This will reduce the period of grief and distress that usually follows a spontaneous m iscarriage.