1) Thromboembolism:

Changes in the clotting factors and venous stasis and thromboembolism (especially after cesarean section).

Thromboembolism may cause death in any of the trimesters of pregnancy.

Thrombolism may also occur after delivery (postpartum).High risk factors for postpartum thrombolism include age over 35 , obesity, post cesarean section.

Mutations in Factor V Leiden and heterozygous factor II can also increase the risk of venous thromboembolism in pregnancy.

The incidence of venous thromboembolism is much higher in women who have both Factor V and factor II mutations.

Increased use of prophylaxis (such as compression stockings in high risk women), can reduce the risk of thromboembolism.

Very high risk pregnant patients (such as patients with a family history and/or personal history of thromboembolism) must be on heparin prophylaxis.

Numerous studies have shown that the use unfractionated heparin (or low molecular weight heparin) with low dose aspirin throughout pregnancy improves fetal outcomes.

2)Haemorrhage:

Postpartum haemorrhage accounts for 50% of the cases of haemorrhage related to pregnancy. The remaining 50% is due to antepartum haemorrhage (This includes placenta praevia and abruptio placentae.) 25% are due to placenta praevia and the remaining 25% is due to abruptio placentae.

Placenta praevia

Placenta praevia is particularly dangerous if it is implanted over a uterine scar. Only a consultant or a senior registrar must carry out the cesarean section for placenta praevia.

Abruptio Placenta

Usually associated with severe pain, but may not have  bleeding per vaginum. Coagulopathy could complicate abruptio placenta.

Postpartum haemorrhage

This topic will be covered in numerous posts .All hospitals must have clear guidelines for the management of postpartum haemorrhage.

3) Hypertensive disorders in pregnancy:

Severe hypertensive disease usually presents around 32 weeks of gestation. Some of the complications of hypertensive disorders in pregnancy include intracranial haemorrhage, acute respiratory distress syndrome,pulmonary edema, cerebral edema etc.

4)Amniotic fluid embolism:

When amniotic fluid finds its way to the maternal circulation, there is a sudden severe reaction in the lungs. This can cause sudden collapse and death, usually during labour.

Proof of the diagnosis is by finding fetal squames in the mothers lungs at autopsy.

5)Puerperal Sepsis:

This is common in developing countries. Prophylactic antibiotics may be given in cesarean section. Prophylactic antibiotics are not recommended in normal vaginal delivery.

6)Deaths during early pregnancy:

This refers to deaths occuring before 24 weeks of gestation.

The common causes of death during this period include ectopic pregnancy, spontaneous abortion and termination of pregnancy.

Ectopic pregnancy presents as abdominal pain with a positive pregnancy test.This can progress to shock and death rapidly if not managed immediately.

7 Deaths due to anaesthesia

This is very rare these days, due to use of modern equipments and anaesthetics.

8)Death due to genital tract trauma

Such as uterine rupture and uterine perforation. This can follow instrumental vaginal delivery.

References:

Pages 175 to 181. Chapter 21. Thrombophilia in Pregnancy by Pankaj Desai and Purvi Patel. Medical Disorders in pregnancy-An Update. Edited by Hiralal Konar and Pralhad Kushtagi. Federation of obstetric and gynaecological societies of India.

Pages 20 to 32.Chapter 3. Maternal and Perinatal Mortality.Obstetrics by Ten Teachers.Seventeenth edition. Edited by Stuart Campbell and Christoph Lees.

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Causes of Maternal Mortality:

1)Severe bleeding- 25%

2)Indirect Causes -20% eg anaemia,malaria and heart disease.

3)Infection- 15%

4)Eclampsia-12%

5)Unsafe abortion-13%

6)Obstructed labour-8%

7)Other direct causes-eg embolism, ectopic pregnancy and anaesthesia related.

The causes of maternal mortality are the same in developed and developing countries.However there is variation in the common causes of maternal mortality, in the developed countries the common causes are thrombosis/thromboembolism,hypertensive disease and cardiac disease, while in the developing countries haemorrhage, sepsis and hypertension tops the list.

Causes of maternal mortality in developed countries:

Direct deaths (In descending order of incidence)

Thrombosis and thromboembolism

Hypertensive disease

Amniotic fluid embolism

Early pregnancy deaths due to ectopic pregnancy, spontaneous miscarriage and legal termnation

Sepsis

Haemorrhage

Genital tract trauma

Other direct causes

Indirect deaths (In descending order of incidence)

Cardiac disease

Psychiatric disorder

Other indirect causes

Direct causes account for about 80% of maternal deaths, the remaining 20% are due to indirect causes.

Social factors that influence maternal mortality:

i)Women’s age: The optimal child bearing age is from 20 to 30 years. There is a gradual increase in the risk of maternal mortality <20 years and >30 years.

ii)Parity: Parity means the number of children. The higher the parity, the higher will be the maternal mortality.

iii)Birth interval: There is an increase risk of maternal mortality with short birth intervals.

iv) Poor socioeconomic status.

v) Bad cultural practices and beliefs.

vi) Nutritional status-eg malnutrition

vii) Environmental factors-eg poor environmental sanitation.

vii)Literacy

viii)Lack of maternity services

ix) Shortage of manpower in the health sector

x) Poor communications and transport facilities.

Important measures to reduce maternal mortality:

i)Early registration of pregnancy.

ii)A minimum of three antenatal check-ups.

iii) Correction of anaemia and dietary supplementation.

iv) Prevention of haemorrhage and infection during the puerperium.

v) Prophylaxis against malaria and tetanus.

vi) Delivery in a very clean environment.

vii)Treatment of medical conditions such as diabetes, tuberculosis and hypertension.

viii)Institutional delivery for women with bad obstetric history and high risk factors.

ix) Training of traditional birth attendants and female health care workers.

x) Promotion of family planning.

xi) Prevention of complications such as eclampsia, malpresentations and ruptured uterus.

xii) Searching for the cause of every maternal death.

References:

Maternal mortality ,pages 20 to 27. Chapter 3.Obstetrics by Ten Teachers. 17th Edition. Edited by Stuart Campbell and Christoph Lees.

Pages 387 to 389. Maternal Mortality Rate.Chapter 9.Preventive Medicine in Obstetrics,Paediatrics and Geriatrics.Park’s Textbook of Preventive and Social Medicine by K. Park. 17th Edition.

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Clear definitions of maternal mortality must be made so that we can compare these rates from different communities/countries. By allowing us to focus on the causes of mortality (especially the common causes), we will be able to reduce the maternal mortality rate.

Important definitions in maternal mortality:

Maternal Mortality rate:

This is the risk of women dying from “puerperal causes”.

= The total no. of female deaths due to complications of pregnancy, childbirth or within 42 days of delivery from “puerperal causes” in an area during a given year/ The total no. of live births in the same area and year

X 1000

The denominator should include all deliveries and abortions.

Ideally the maternal mortality rate should be expressed as a rate per 1000 live births. But lately the multiplying factor of 100000 is used .This is because of the recent decline in the maternal mortality rate in developed countries. This helps avoids fractions.

Definition of  Maternal Death by W.H.O

A maternal death is defined as the death of a woman while pregnant or within 42 days of termination of pregnancy,irrespective of the duration and site of pregnancy,from any cause related to or aggravated by the pregnancy or its management but not from accidental or incidental causes.

Direct and indirect obstetric deaths:

The ICD (International classification of diseases) has recommended that maternal deaths should be classified into direct and indirect deaths.

i) Direct obstetric deaths:

These are deaths resulting from obstetric complications of the pregnant state (pregnancy,labour and puerperium), from interventions,omissions, incorrect treatment, or from a chain of events resulting from any of the above.

ii) Indirect obstetric deaths:

These are deaths resulting from previous existing disease or disease that developed during pregnancy and which was not due to direct obstetric causes, but which was aggravated by physiologic effects of pregnancy.

Late maternal death:

A late maternal death is death of a woman from direct or indirect obstetric causes more than 42 days but less than one year after termination of pregnancy.

Fortuitous death:

Deaths from unrelated causes that may happen in pregnancy or puerperium.

The death certificate must include questions regarding current pregnancy and pregnancy within one year preceding death. This will help improve the quality of data on maternal mortality. This recommendation was made by the 43rd World Assembly in 1990.

The incidence of maternal mortality in different countries:

In the whole world there were 536,000 maternal deaths in 2005. That is an average Maternal Mortality Rate (MMR) of 400 per 100,000.

In the developing countries , the average MMR is as high as 960 per 100,000, an exception being Sri Lanka with a MMR of 58 per 100,000.

Comparism of Maternal Mortality in 1990 and 2005 by regions

Maternal mortality rates are highest in Africa. In some parts of rural Africa it may be higher than 1000 per 100,000 live births.

In developed countries the maternal mortality rate is around 9 per 100,000.

Most maternal deaths are preventable (See my article on causes and prevention of maternal mortality).

References:

WHO- Maternal Mortality in 2005

Maternal mortality ,pages 20 to 27. Chapter 3.Obstetrics by Ten Teachers. 17th Edition. Edited by Stuart Campbell and Christoph Lees.

Pages 387 to 389. Maternal Mortality Rate.Chapter 9.Preventive Medicine in Obstetrics,Paediatrics and Geriatrics.Park’s Textbook of Preventive and Social Medicine by K. Park. 17th Edition.

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i) There should be no delay in the examination:

Valuable time should not be lost when a woman complains of rape. She should be brought immediately for medical examination.

The police should bring the alleged rape victim as soon as possible. Detail statements may be taken by the police after the medical examination.

Medical evidence is very important in cases of rape,as there should be “independent corroboration” of the victims story by other evidence.

ii)Being Sensitive:

One should be very sensitive while examining a rape victim. The examiner should realize the gravity of the situation. The woman may even need psychological/psychiatric care later in life.

iii)Must be examined only if referred properly:

Any medico legal examination should be undertaken only when there is proper referral (such as MLEF issued by the police or court/magistrate in Sri Lanka).

It is not necessary for the doctor to examine a rape victim brought by her husband or relative without reporting it to the police.

Alternatively the emergency unit of the nearest police station can be called to the hospital/clinic if she presents there first (done in some countries).All these measures are to reduce the delay in examining the patient.

iv) Presence of a female chaperone during examination:

It is unethical for a male doctor to examine a female patient in the absence of a female chaperone. In the absence of a hospital nurse a female relative or a female friend of the woman should be present. However it is not suitable to have a female police officer as admissibility of evidence obtained may be challenged.

v)Obtain written consent:

Written consent should be obtained. The examnation the doctor is going to conduct should be explained in detail to the victim. She should also be informed that the reports will be issued to the police/courts and she also has a right to refuse examination.

Her consent should not be influenced by others.The victim must be mentally capable (incapable persons/mentally retarted/psychiatric individuals cannot give valid consent). In such cases the consent of the parents or guardian is essential. For girls below 18 years of age ,consent of the parents/guardian is essential.

vi) History:

History should be obtained separately from the victim, witnesses, police,parents etc.

It should include the full name ,age address, national id card no. The correct age is very important, to determine if she is a minor.

A quick assessment of her mental state should be done, so that one can decide if she is of sound mind to give a reliable history.

Important aspects of the history include the history of the act (eg how many assailants ,is the assailant known to her,was he under alcohol,were any weapons used, was a condom used,was she forced to do oral sex,any anal intercourse etc), menstrual and sexual history.

The time of the incident should be noted ,as it is important as the signs expected on examination may vary as time passes.

To be continued in the final part :Rape Management Part 3

References:

Pages 758 to 759. Chapter 17. Rape.Gynaecology. CMDT 2006. Current Medical Diagnosis and Treatment 2006.45 th Edition. Edited by Lawrence M. Tierney,Jr. Stephen J McPhee, Maxine A. Papadakis.

Pages 122 to 134.Chapter 19 .Sexual offences. Forensic Medicine and Medical Law. Notes on Forensic Medicine and Medical Law.Dr Hemamal Jayawardena .2nd edition. Former lecturer in charge.Department of Forensic Medicine.University of Kelaniya.Sri Lanka.

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Drugs to be given to rape victims:

i) Analgesics or sedatives should be administered if indicated.

ii) Tetanus toxoid should be given if deep lacerations are present.

iii)Antibiotic -Ceftriaxone, 125mg intramuscularly to prevent gonorrhea.

-Give metronidazole 2 g (single dose) and azithromycin 1g orally (or doxycycline 100mg twice daily-for 7 days) to prevent chlamydial infection.

Syphilis: The above antibiotics will probably eliminate incubating syphilis. However the VDRL test should be repeated 6 weeks after the assault.

iv)Vaccinate against hepatitis B

v)Consider HIV prophylaxis (covered under a different post).

vi)Pregnancy can be prevented by using any of the methods discussed under emergency contraception (covered in another post).

Medico-legal aspects of investigating a victim of sexual violence

The aim of the examination is to gather evidence regarding:

i)Penetration/ejaculation

ii)Force/lack of consent

iii)Identification of the assailant

iv)Question of age.

v)Other corroborating evidence-This will help establish links among the victim, assailant ,scene etc.( Lochard’s Principal)

References:

Pages 758 to 759. Chapter 17. Rape.Gynaecology. CMDT 2006. Current Medical Diagnosis and Treatment 2006.45 th Edition. Edited by Lawrence M. Tierney,Jr. Stephen J McPhee, Maxine A. Papadakis.

Pages 122 to 134.Chapter 19 .Sexual offences. Forensic Medicine and Medical Law. Notes on Forensic Medicine and Medical Law.Dr Hemamal Jayawardena .2nd edition. Former lecturer in charge.Department of Forensic Medicine.University of Kelaniya.Sri Lanka.

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Because of the gravity of the situation, the emergency staff/ clinician who first sees a rape victim must be empathetic.

1)Written consent must be obtained for the gynaecological examination.

Photographs may also be taken if they are to be used as evidence. The written consent may be obtained either from the patient or guardian/next of kin.

The police should also be notified as soon as possible.

2)History should be obtained from the patient. Ideally it must be recorded in her own words. Important aspects of the history include the time, place, circumstances ,last menstrual period (LMP). It is also important to ask if she is pregnant and the time of the most recent coitus prior to the sexual assault.

Other details should include, which of the orifices were penetrated, use of foreign objects, number of assailiants.

Did the victim come directly to the hospital or did she bathe and change her clothing.

3)What is the general appearance of the victim? do you think drugs or alcohol may be involved? Is the victim calm, agitated or confused?

The patient should disrobe while standing on a white sheet. Any hair,dirt, underclothing must be kept as evidence. Torn and stained clothing should also be kept as evidence. The pubic hair should be combed for evidence. Material should also be scraped from beneath the finger nails. All evidence must be placed in separate bags/envelopes and labeled carefully.

The patient should be examined ,and traumatized areas should be photographed.

The body and genitals should be examined with wood’s light to identify semen. Positive areas will fluoresce .These areas should be swabbed with a moisened swab and air-dried in order to identify acid phosphatase.

Colposcopy may be used to identify small areas of trauma eg in the posterior fourchette.

4)A pelvic examination should be performed after explaining the procedure and obtaining the patients consent.

Only a narrow speculum should be used. In rape victims one should only use water as a lubricant.Sterile cotton swabs should be used to collect material from the cervix and upper vagina. These should be air dried on two glass slides after smearing.

Wet and dry swabs should also be collected and refrigerated for subsequent DNA and acid phosphatase evaluation.

If appropriate the mouth and the anus must be swabbed (eg in anal rape).

Secretions from the vagina,mouth,anus may be collected by a swab and placed on a slide. A drop of saline should be added and covered with a coverslip. This should be examined for motile and non motile sperms. The finding must be recorded. The percentage of motile forms must be noted.

5)Laboratory tests should be done to identify sexual transmitted diseases. Swabs may be taken from the vagina, anus or mouth and cultured for N Gonorrhoea and chlamydia. A wet mount for trichomonas vainalis and a papanicolaou smear should be done. A VDRL test (for syphilis) and a pregnancy test should be done.

A HIV antibody test should be done and repeated  after 2 to 4 months later, if the initial test was negative.The  pregnancy test must be repeated if the next menses is missed. Ideally the VDRL should be repeated in six weeks time.

Blood(without anticoagulant) and urine specimen should be obtained if there is a history of forced ingestion or injection of drugs .

6) Laboratory specimens should be transferred to the responsible clinical pathologist/technician in the presence of witnesses and never via a messenger, so that evidence is not breached.

Treatment /drugs administered to rape victims will be addressed in a subsequent post.

References:

Pages 758 to 759. Chapter 17. Rape.Gynaecology. CMDT 2006. Current Medical Diagnosis and Treatment 2006.45 th Edition. Edited by Lawrence M. Tierney,Jr. Stephen J McPhee, Maxine A. Papadakis.

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Rape has many definitions ,depending on various jurisdictions. It is important for emergency staff and clinicians who deal with rape victims to be familiar with the laws pertaining to rape (sexual assault )in their own country and state (laws vary in different us states).

About 95% of rape victims are women. It is also essential to note that people involved in the management of rape victims understand and recognize the violent nature of the crime.

Penetration of which orifice constitute rape?

It is important to note that the penetration may be vaginal,anal or oral.

The penetration may be by the hand,penis or by a foreign object.

It is also important to note that the absence of genital injury does not mean that the individual has given consent.

The rapist (assailant) may be a stranger or more frequently an acquaintance or even the spouse.

What is statutory rape?

Statutory or “unlawful sexual intercourse” is intercourse with a female before she reaches the age of majority, even with her consent.

Who are rapists?

Rapists are usually hostile men that terrorize and humiliate women by raping them. It is important to note that women do not want to be raped or even enjoy being raped under any circumstances.

What are the physical and psychological consequences of rape?

In 5 to 10% of cases rape involves severe physical injury. Women are terrified for their lives.

It is also important to note that all victims suffer some psychological aftermath.

Some rape victims may acquire sexually transmitted diseases (such as AIDS) or become pregnant.

What is the rape trauma syndrome?

Each person deals with rape differently, because it is a personal crisis.

There are two principal phases in the rape trauma syndrome:

1)Immediate or acute phase: Here there is sobbing, shaking and restless activity. This phase may last from a few days to a few weeks. The patient may experience anger,guilt or shame.The victims personality and circumstances of the attack may determine the reaction by the victim.

2)Late or chronic: This may change the work pattern and lifestyle of the individual. This develops several weeks or months later.Victims may develop phobias or sleep disorders. Rare cases of suicide have been reported during the chronic phase.

What are rape crisis centers?

These are centers created to provide information for clinical and emergency department personnel. They can also provide ongoing support and counseling for rape victims.

References:

Pages 758 to 759. Chapter 17. Rape.Gynaecology. CMDT 2006. Current Medical Diagnosis and Treatment 2006.45 th Edition. Edited by Lawrence M. Tierney,Jr. Stephen J McPhee, Maxine A. Papadakis.

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History of Menstruation

These are questions that will be asked by your doctor. It is very important in gynaecological disorders.

i)How old were you when the monthly periods (menstrual periods) began. This is the age of menarche.

ii) What is the date of your last period?Can you remember it. What the the period before the last one?

iii)How often do you have your menstrual periods?This is the average date between the periods. It is about 28 days on average.

iv)How regular are your periods?Are the regular or irregular?

v)How long does the menstrual periods last?How many days does it last?

vi)How heavy is the menstrual flow?How many pads or tampons do you use daily?Do you use more than one at a time?

vii)Do you have any bleeding between periods?

viii)Do you bleed after sexual intercourse?

ix)Do you have any pain or discomfort during your periods?If so what is it like? How long does it last?

x) In middle-aged and older women you may ask if she has stopped menstruating.

xi) In adolescent girls you may ask questions like, do you know about monthly periods?, How did you first learn about monthly periods? Have you been bothered sometimes that you periods got delayed?

In the United States girls begin to menstruate between the ages of 9 and 16. It often takes 1 year or more before it settles into a regular pattern.

The average interval between periods ranges from 24 to 32 days. The flow lasts from 3 to 7 days.

History of Menopause

Menopause is a retrospective diagnosis. It is the absence of menses for 12 consecutive months (usually between the ages of 48 and 55 years).

Ask for the history of associated symptoms.

Associated symptoms include hot flashes, flushing, sleep disturbances and flushing.

Have you stopped having your regular periods?

Have your periods stopped completely?

How do you feel about not having your periods anymore? Has this affected your life in any way?

Postmenopausal bleeding

Postmenopausal bleeding is defined as bleeding that occurs six months without periods. It warrants further investigations (because of the high risk of endometrial cancer).

Amenorrhoea

This is absence of periods. There are two types primary amenorrhoea and secondary amenorrhoea.

Primary amenorrhoea refers to a condition where the girl/woman has never had her periods (failure to initiate periods).

Secondary amenorrhoea refers to cessation of periods after it has been established.

However secondary amenorrhoea may also have normal (physiologic forms) such as in pregnancy,lactation and menopause.

Oligomenorrhoea

This refers to infrequent periods which may also be irregular.It occurs for about two years after menarche and also before menopause.

Dysmenorrhoea

This is pain during menstruation.

It is a bearing down, aching or cramping sensation in the lower abdomen/pelvis.

Premenstrual syndrome (PMS)

This refers to a complex of symptoms which usually occur about 4 to 10 days prior to the onset on menses. Symptoms include irritability, depression,mood swings,weight gain, edema, bloating,tenderness of the breast ,headache,nervousness and tension. These symptoms are usually mild.

Sometimes women may present with severe and disabling PMS symptoms.

Polymenorrhoea

This refers to abnormally frequent periods.

Metrorrhagia

This is bleeding in between periods. It is also known as intermenstrual bleeding.

Postcoital bleeding

This is bleeding after sexual intercourse or other forms of vaginal contact such as douching etc.

References:

Pages 432 to 435. Health History. The female genitalia. Chapter 12. Bates guide to physical examination and  history taking.9th edition. Lynn. S. Bickley.

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The patients should be educated about the start-up symptoms of HRT.

These inclede:

-Breast tenderness

-Nipple sensitivity

-Rise in appetite

-Weight gain

-Cramps in the calf

Patients should be informed that during starting the HRT symptoms similar to early pregnancy will be common.These symptoms usually remit at about 12 to 14 weeks of gestation.

Patients receiving HRT should ideally be reviewed Annually

Blood pressure:

Blood pressure should be checked.

Breast:

Patients should be taught how to self examine her breast. Should should also have regular mammography.

Pelvic examination:

This is especially very useful for unscheduled bleeding, especially if it is prolonged,heavy or recurrent. In cases of bleeding that is unscheduled a specialist consultation with a view to hysteroscopy and biopsy if indicated.

Ultrasound examination either transabdominally or vaginal (preferable) is also very useful as fibroids and endometrial polyps may be identified.

Use of local estrogens:

Symptoms originating in the lower genital tract (Bladder and urethra) may be treated with locally-applied estrogens.

Locally applied estrogens may be in the form of cream, pessary or vaginal tablet.It should be inserted/applied to the upper vagina where it will disperse to nearby local estrogen receptors.

Even patients who have had a past history of breast cancer can receive local vaginal estrogens for genitourinary symptoms.

References:

Pages 2209 to 2212.Chapter 327. The menopause transition and postmenopausal hormone therapy.Harrisons Principles of Internal Medicine. Volume II.16th edition. Kasper,Braunwald,Fauci,Hauser,Longo and Jameson.

Pages 227 to 229. Chapter 19. Menopause. Gynaecology by ten teachers. Seventeenth edition. Edited by Stuart Campbell and Ash Monga.

Pages 760 to 762. Chapter 17. Menopausal syndrome.Gynaecology. CMDT 2006. Current Medical Diagnosis and Treatment 2006.45 th Edition. Edited by Lawrence M. Tierney,Jr. Stephen J McPhee, Maxine A. Papadakis.

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Weather to take postmenopausal hormonal therapy or not is one of the most complex health care decisions facing women. It is also a complex decision for doctors to determine which of their patients will benefit from postmenopausal hormonal replacement therapy.

In the United States about 30% of postmenopausal women use hormonal replacement therapy.

Please do not forget to read my post on the benefits and risks of postmenopausal hormone therapy.

History and Examination prior to commencing hormonal therapy

A thorough history should be taken .Symptoms that are due to estrogen deficiency should be noted. The impact of these symptoms in the patients life should also be noted.

It is also important to ask tactfully about difficulties in sex life such as dyspareunia and loss of libido.

The history should include cardiovascular disease (such as angina pectoris, stroke and myocardial infarction) and skeletal system (history of fracture of the wrist,hip etc). History of osteoporosis in relatives is also important.

History of the gastrointestinal tract and liver disease is important because it might interfere with the pharmacodynamics of estrogen therapy.

A thorough gynaecological history should include medical and surgical interventions, history of irregular bleeding, history of previous biopsy etc. One should also ask specifically for history of breast disease.

All patients being considered for hormone replacement therapy (HRT) must have a physical examination by an experienced physician.This will help to identify potentially estrogen sensitive tumours in the pelvis and breast. A thorough breast and pelvic examination should be done. On pelvic examination one should look for masses suggestive of fibroids, endometriosis (past and present) and adnexial masses suggestive of ovarian tumours.

Contraindications to Hormonal Replacement Therapy:

Absolute

-Present or suspected pregnancy

-Suspected breast cancer

-Suspected endometrial cancer.

-Active acute liver isease

-Diagnosed venous thromboembolism

-Uncontrolled hypertension

Relative

-Migraine

-Uterine fibromyomata

-Past history of benign breast disease

-Chronic liver disease

-undiagnosed but suspected venous thromboembolism

Methods of administering hormonal replacement therapy

i) Oral:

The oral route is the most common route in the United Kingdom.

estrogen should be given daily,mimicking the perimenopausal daily release by the ovary.

The commonly used oral estrogen’s are:

-Oestradiol valerate 1mg or 2mg.

-Oestrone 1.25mg

-Conjugated equine estrogen 0.625 mg or 1.25mg.

The oral route cannot mimic the normal physiological ratio of oestradiol:oestrone, which should be 2:1 but it is exactly the opposite ie 1:2.

ii)Transdermal estrogen:

Patches are available in varying strengths of 28 micro gram to 100 microgram of oestradiol per day. Patches for one week are now available.

The estrogen being lipid soluble passes across the epidermis into the systemic circulation avoiding the first pass metabolism by the liver.

This route maintains the normal physiological ratio of oestrodiol:oestrone of 2:1.

Percutaneous gel with a similar mechanism of action of transdermal estrogen is also available.

iii)Subcutaneous implantation:

This is usually restricted to those who have undergone hysterectomy with or without oophorectomy. A pellet is placed in the subcutaneous tissue of the lower abdomen with local anesthetic under sterile conditions. Implants are available at strengths of 25,50 and 100 mg and reviewed at intervals of six months.

iv)Gonadomimetic therapy:

Tibilone, a synthetic steroid which exhibits progestogenic, estrogenic and androgenic activity. It is given in a dose of 2.5mg per day to women for a least one year. It supresss the symptoms and prevents bone loss

References:

Pages 2209 to 2212.Chapter 327. The menopause transition and postmenopausal hormone therapy.Harrisons Principles of Internal Medicine. Volume II.16th edition. Kasper,Braunwald,Fauci,Hauser,Longo and Jameson.

Pages 227 to 229. Chapter 19. Menopause. Gynaecology by ten teachers. Seventeenth edition. Edited by Stuart Campbell and Ash Monga.

Pages 760 to 762. Chapter 17. Menopausal syndrome.Gynaecology. CMDT 2006. Current Medical Diagnosis and Treatment 2006.45 th Edition. Edited by Lawrence M. Tierney,Jr. Stephen J McPhee, Maxine A. Papadakis.

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