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The clinical box below includes good practice points based on evidence from randomized controlled trials. It is unclear whether the volume of the cervix removed/destroyed accounts for this difference in risk. It is possible that screening would detect more cases of carcinoma in women with preexisting endometrial lesions or other risk factors for the disease that are on Tamoxifen but there is as yet no evidence that such a strategy would reduce mortality. Common features are:Epithelial cell stratification and atypia: the atypical epithelium is more than four cells in thickness. Urethral pressure profiles If urethral pressure profiles have been performed, these should be analyzed, stating whether they are high, low or normal. A thin latex balloon, 5 cm long, is tied to the probe, enclosing the 4 ring electrodes. Patients present with marked swelling and oedema of the vulval skin with pustules, ulcers, fissures, sinuses, fistulae and induration. Sexual activity must be avoided during treatment and for at least 1 week afterwards. Patients who have failed pneumatic dilation may be referred for a repeat dilation with a larger balloon or myotomy. When compared to the other uterine cancers, sarcomas are more aggressive and carry a far worse prognosis, even when correcting for stage. Initially new drugs are tested in a variety of tumour types in Phase I trials (w30 patients). A trial of pharmacist initiated oral contraception, particularly among women attending for the emergency contraceptive pill, has had high rates of consumer satisfaction. With early identification of illness, clinical assessment and treatment, outcomes are also improved. Consequently, there is earlier hospital discharge and resumption of normal activities. Side effects include nausea, mood changes, breast tenderness and rarely thromboembolic disease (risk increases in smokers, obese and older women). In Scotland, there is a legal requirement to notify the Chief Medical Officer in Scotland of all termination carried out in Scotland. Invasive mole:Invades or perforates uterine wallDefinition: It is defined as a mole that penetrates or even perforates the uterine wall. Endoscopy may also be helpful in determining the degree of esophageal dilatation, whether there is significant esophageal retention of food and fluid, and whether there is coexistent stasis or fungal esophagitis. Conclusion A careful and sensitive approach is needed when evaluating adolescents with gynaecological symptoms. The consensus from most research evidence suggests that hysterectomy improves quality of life and psychological measures. Colonization of the distal urethra and introitus (in the female): By enteric or coliform bacteria from the perineum due to poor hygiene and hormonal effects. Endoscopic injection can be repeated when symptoms return, and extensive use in other conditions has revealed no evidence of longterm harm. The acid perfusion test was originally devised to distinguish between chest pain of cardiac and esophageal origin. Single- and multifactorial fall prevention strategies have been shown to reduce the risk of falls in elderly women living in the community. About one-third of them are performed as primary treatment, one-third are because of resistance to chemotherapy, and another third because of heavy bleeding. Etiology Graves disease (hyperthyroidism) and Hashimoto thyroiditis (hypothyroidism) are considered as two extremes of autoimmune thyroid disorders. Surgery does have some caution and those gynaecologists who are prepared to offer this type of treatment should ideally 1) work closely with vulval service dedicated to the management of women with vulval conditions and 2) offer adequate pre and post treatment support and clinical care for patients. They do not require a resectoscope, but a hysteroscopy should be performed to assess the size, shape of the uterine cavity and rule out suspicious pathology. Keywords ethics; outcomes; professionalism; revalidation Introduction It is fundamental that we as a profession reflect on the findings of the recent Francis report on Mid-Staffordshire and concentrate on the concept of quality of clinical care and improved performance.

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Sperm donors are rigorously screened for sexually transmitted diseases and genetic conditions. Early intervention and multi-disciplinary team involvement is necessary for consideration of re-exploration. If there is a crack in this region, synovial fluid leaks into the marrow space and produces a subchondral bone cyst. However, they do not wish to risk having affected offspring who will undergo the same complex decision making process. Age- and pathology-related bone loss is frequently asymptomatic and often osteoporosis is diagnosed only after a fragility fracture has occurred. If the pregnancy is intrauterine and the device is left in situ, there is an increased chance of second-trimester miscarriage, preterm delivery and infection. Evaluation of ovarian adhesion formation after laparoscopic ovarian drilling by second-look minilaparoscopy. Anti-epileptic medications e there is an increased risk of seizures in the perioperative period in patients with seizure disorders. Other examples of failed operation include failure of surgical termination of pregnancy, the patient presenting afterwards with advanced pregnancy, and incomplete evacuation of products of conception, resulting in sepsis and uterine perforation at a subsequent attempt to evacuate the septic uterus. Inflammatory reaction: Once in bone, the bacteria grow and induce an acute inflammatory reaction with exudates. Distance from the naries is to the left, time is along the x-axis, and pressure is depicted as color, with the association between pressure and color demonstrated by the color bar to the right. This classification includes esophageal motility disorders, and, in practice, patients and doctors often attribute symptoms to "esophageal spasm. The psychological harm from such a pregnancy loss is apparent but more difficult to research and quantify. Mainstay treatment is generally supportive providing symptomatic relief and more directive surgical treatment is reserved for specific secondary causes of dysmenorrhoea or for refractory cases. There are no specific tests to diagnose primary dysmenorrhoea, which is largely made on clinical findings. The significance of normal endometrial cells in cervical cytology in postmenopausal women is less clear. With consistent and correct use the failure may be as low as 5%, but typical use results in a 21% failure rate. Vancaille and Schuessler described a laparoscopic method of colposuspension in 1991. Ureteric damage can be the most serious, especially if not recognized intra-operatively, and advice from a urologist should be sought when managing such injuries. Serum human placental lactogen may be raised and this can be used as a tumour marker. The sympathetic system is mediated by adrenergic receptors that inhibit detrusor activity and increase urethral pressure. All surgeons should be comfortable with how to manage intraand post-operative complications optimally. Rare causes include fatty liver of pregnancy, cardiac disease (myocardial infarction, heart failure), acute graft versus host disease, excess ethanol intake, acute intermittent porphyria, and disorders of fatty acid oxidation. To minimise the risk, a gentle stimulation regimen such as a low dose step up regimen should be used. The nickel titanium outer coil serves as an anchor within the uterotubal junction. In a systematic review, it was demonstrated that venlafaxine is the most efficacious antidepressant for reducing esophageal pain and improving global health assessment. After three weeks the ring is removed to allow for a hormone-free interval of 7 days during which the user experiences a withdrawal bleed. Testosterone is then converted by aromatase enzyme in the granulosa cells to oestradiol.

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The innate immune system, also known as the natural or non-specific immune system is already in place prior to the viral insult. Selection of chemotherapeutic drugs the time for a new drug to come into common use is generally long. Peroral endoscopicmyotomy for the treatment of achalasia: an international prospective multicenter study. Bipolar resectoscopes are now available, and are helpful to avoid problems with water intoxication due to shorter surgical duration. It must always be borne in mind that treatment options may have a significant impact on future general health as well as sexual function and fertility. Recent research has shown that 5-year survival for stage 1 ovarian cancer patients can be increased by 10% by the addition of chemotherapy following surgery. Premature adrenarche is diagnosed when these changes occur before the age of 8 years in girls and 9 years in boys without any other associated features of pubertal development such as breast or penile enlargement. Steep Trendelenberg positioning can be required during complex laparoscopic procedures. Progestogen intolerance Use of continuous oestradiol normally necessitates the addition of cyclical progestogen (10e12 days) to avoid endometrial hyperplasia in women who have a uterus. Relaxation training reduces symptom reports and acid exposure in patients with gastroesophageal reflux disease. Procedures such as adhesiolysis and diathermy to endometriotic deposits should also be discussed with the patient and consent obtained pre-operatively. Criteria for MalignancyNone of the histologic feature can reliably predict clinical behavior. 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. Some will display visual field defects if the there is suprasellar extension leading to compression of optic chiasma. Advanced and recurrent disease Women with advanced or recurrent disease need careful individual consideration in order to define the goals of treatment and balance these against performance status and quality of life. Manifests usually after a latent period of 1 to 4 weeks following primary streptococcal infection. Risk categories will vary depending on risk of premature coronary heart disease and the presence of other risk factors. The relationship of the ureters to the pelvic structures and blood supply is also an essential component of undertaking surgical procedures. Referral to professional guidelines, ethical analysis and the law is therefore even more essential. Ureteral stents are inserted in cases of ureteral obstruction and severe hydronephrosis. Surgical drains There are limited indications for the use of drains in gynaecological surgery. Some of this keratin form epithelial or squamous pearls (inset of A) Morphology Squamous cell carcinoma in situ:Characterized by cells with atypical (enlarged and hyperchromatic) nuclei involving all levels of epidermis. The clinical spectrum of this condition is poorly documented, but patients may frequently have associated developmental disorders outside the genital tract. Fibroids are thought to impede fertility by affecting sperm migration and ovum transport and by causing endometrial vascular disturbances, inflammation and implantation failure. Nearly 90% of women resume sexual activity within three months of childbirth but the sexual morbidity in the first three months is above 80%, which declines to 64% at six months. Children and with hematogenous spread: Metaphysis of long bones (knee, ankle, and hip). Complications of laparoscopic surgery Amy Arnold Jason Abbott Abstract Minimally invasive surgery is widely accepted as the gold standard for many gynaecological surgical procedures. Yet the most impressive change, surprising to both doctor and patient, was her positive stance in the clinic and the revelation that she had finally cut any intimate ties with her ex-partner and had met a new potential partner through a dating agency. The perioperative management of antithrombotic therapy: American college of chest physicians evidence-based clinical practice guidelines (8th edition). Nutritional supplements followed by phytoestrogens and herbal therapies are the most common. Complications include wound dehiscence, infection, lymphocysts and lymphoedema Table 6). Patients should be observed in recovery for at least 42Chapter 3 2 hours with careful assessment for postprocedure pain.

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These medications can have serious consequences for pregnancy in the form of feminization of a male fetus and therefore their use needs to be combined with a reliable contraceptive. Since many women have asymptomatic fibroids, it is extremely difficult to determine what proportion will become malignant. A delay in Incidence (%) of most common ovarian masses in pregnancy Type of mass Dermoid (cystic teratoma) Corpus luteul cyst, functional cyst, paraovarian Serous cystadenoma Mucinous cystadenoma Endometrioma Carcinoma Low malignant potential tumour Leiyomyoma % 25 17 14 11 8 2. Repeated treatments are needed but with growing experience in its use, and the development of outpatient treatments, it is an attractive alternative to other second line treatments such as sacral nerve modulation and posterior tibial nerve stimulation. The appearance of the endometrium also varies, depending on the timing of scan in relation to the menstrual cycle and the effect of any drugs. The advantage of digoxin is that it can be used by practitioners who do not have the skills for administering intracardiac foetal injections. The vast majority of hysterectomies are performed via the abdominal route, despite robust research evidence that the vaginal approach is safer and more cost-effective. Clinical FeaturesMostly present as a unilateral painless massLarger tumors may produce local symptoms. Endometriomas are often associated with adhesions and application of pressure with the vaginal probe can cause adnexal tenderness. The results suggested that there was no advantage for routine systematic lymphadenectomy. Usually chemotherapy is not as effective for bowel obstruction if the patient is not chemo-naive. Face to face counselling by staff adequately trained in contraceptive care should be provided using language that is easy to understand and free of jargon. Litigation: life-cycle of a claim Most gynaecologists would at some point in their career have to address a complaint filed by a patient about their care. Lack of the irritating transnasal catheter allows patients to have normal daily activities with sufficient time to monitor esophageal pH. Liver with multiple secondaries from choriocarcinoma Morphology GrossSize: Choriocarcinoma in the uterus range from microscopic foci to huge necrotic and hemorrhagic tumors. Is it when the vault descends half way down the total vaginal length, two thirds of the way down or to the hymen The first step is to decide whether the patient has oropharyngeal dysphagia or esophageal dysphagia based on careful history and physical examination. However, vaginal meshes used in prolapse repair include a larger amount of mesh and tissue response is directly proportional to the surface area of contact (Norris et al). Affected areas may include the labia minora, clitoris, perineal body, perineum, vestibule and perianal area. Most evidence has been gathered from retrospective analysis and hence unproven in reducing or preventing the complications. Twelve per cent of cases also have skeletal anomalies, mostly involving the spine. If the measured lesion is very small it is possible to obtain a wide local excisional biopsy. Norethisterone is the most potent of progestogens and as such provides the best cycle control. Tamoxifen Tamoxifen, used as adjuvant treatment for women with breast cancer, is associated with a significantly increased (2e5 fold) incidence of endometrial pathology including endometrial cancers than in non-users. Few good studies have been published comparing hysteroscopic and laparoscopic sterilization, although existing data suggests that hysteroscopic sterilization has a lower complication and failure rate but that patient satisfaction is equal for both methods. They may not realize that hormonal changes during puberty result in growth of genitals in such a way that the inner labia mostly become longer than the outer labia. The precise volume of fluid replacement can be determined by urinary output measurements. There are no substantial differences in ovulation rates between tamoxifen and clomifene. Early methods tended to be non-surgical: strenuous activity, use of natural abortifacients, fasting, bloodletting, the application of abdominal pressure, pouring hot water on to the pregnant abdomen, lying on a heated coconut shell.

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The purpose is to achieve the optimal preoperative condition for each patient by anticipating potential problems, thereby improving the outcome. The combinations of biological, psychological and interpersonal factors can play a part in the development of dyspareunia. The degree of pain induced correlated to the amplitude and duration of esophageal contractions in these studies. Chain of evidence this is term describing the process by which the validity of samples is ensured for the court. This led to the implementation of the test of cure in England and Scotland in early 2012. Not infrequently vulvodynia can lead to secondary psychosexual problems such as avoidance, phobia of touch, loss of libido and vaginismus (see below). Heymann nephritis: It is experimental model for in situ antibodies against planted antigens. It is only through this work that clinicians will be able to practice in a truly evidencebased way to effectively treat this condition. Increased awareness and education about strategies to reduce the level of risk, combined with optimizing surgical training opportunities, remain fundamental to improving outcomes. This review summarizes the information available on these techniques and also provides suggestions for further reading. This is likely to be at least in part due to lack of technical expertise and/ or confidence in performing the procedure. Medications that reduce visceral sensitivity such as trazodone may be helpful in other cases, although they do not reduce dysmotility. It has been used for advanced maternal age, recurrent miscarriage and male infertility with the aim of improving pregnancy rates Table 4). Data are extracted in April from the previous calendar year, and the results are republished in May. Many attempts were made to change the test from a qualitative to a quantitative tool. A thorough history and examination is required to determine the most likely cause of anovulation. This recommendation relates to a woman self administering the Misoprostol at home. Cervical priming immediately before uterine evacuation does not increase the need of subsequent chemotherapy. Conversely, those with predominant chest pain tend to have higher distal contractile pressure than those with dysphagia (amplitude 202 vs 118 mm Hg; P < 0. There is an increased prevalence of dysmenorrhoea in women with a history of sexual abuse but there is little research into this compared to other chronic pelvic pain syndromes. The ipsilateral ureter should always be identified prior to and following dissection, as well as ensuring the dissection plane does not extend towards the rectosigmoid or bladder junctions. It is thought that unopposed oestrogen has a carcino-mutagenic effect on stromal and glandular cells of the endometrium leading to hyperplastic lesions. Patients with sexual pain should have an adequate sexual history taken asking specifically about the presence of vaginal lubrication, vaginismus and sexual avoidance. The initiative involved active learning and skills development, and was compared with a randomised control group of 12 schools (2125 participants analysed), matched for socio-demographic characteristics. This "conformal" radiotherapy is possible due to the introduction of the multi-leaf collimator. Nausea and vomiting Nausea and vomiting affects 50e70% of patients with advanced cancer. Screening Although many endometrial cancers develop by way of a precursor lesion. However, adjuvant pelvic radiotherapy leads to improved local control but no overall survival advantage in women with low-risk endometrial cancer. High sodium and/or caffeine intake promotes urinary calcium excretion and should be avoided. They returned to follow-up clinic three months later to discuss the prognoses further. Those who fail to ovulate with clomifene have the option of surgical management with laparoscopic ovarian drilling or further medical management with gonadotropins or metformin. The complications will be divided into: cardiovascular system and preparation of surgical instrumentation including suction, vascular clips and sutures.

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In addition, results can be confounded if fermentation of bacteria in food retained in the esophagus leads to lactic acid production. Dysgerminoma:Sheets of tumor cells separated by scanty fibrous stromaTumor cells are monotonousStroma infiltrated by mature lymphocytes. Diagrammatic; Ewing sarcoma composed of sheets of closely packed uniform small round cells with scanty cytoplasm. Lower oestrogen doses are associated with more breakthrough bleeding, therefore increasing the ethinylestradiol dose can help, once other causes have been excluded. The direct and indirect costs are considerable for well-resourced societies even if the absolute prevalences are lower than in the developing world. Oral morphine however, remains the primary choice for initial management, given in 4 hourly doses and titrated up to the optimal dose that alleviates pain without causing unacceptable side effects such as day time drowsiness. Absolute risk of endometrial carcinoma during 20 year follow up among women with endometrial hyperplasia. Poorly differentiated tumor: May require immunohistochemical stains for keratins to confirm the diagnosis. Consequently, these products are poor long-term treatment options and should be reserved for patients who are judged to be poor candidates for myotomy or pneumatic dilation. If the leak is localized to the pelvic area, vaginal or rectal examination can assess for masses, tenderness or cervical excitation. The prognosis is better when there is no significant discrepancy in diameters of the two ends of the tube at the site of anastomosis. Regional anaesthesia may be an excellent option for post-operative pain control in obese patients. The size and topography of the lesion should be ascertained, especially if there is any extension of the lesion into the cervical canal or onto the vagina. Of those with poor response, 3 proceeded to full-length myotomy, 2 of whom had relief of symptoms. Vulval cellulitis: presents with aching pain, tenderness and a beefy-red swelling of the labia. Medical and surgical management of chronic pelvic pain Amy Robb Tahir Mahmood with pregnancy. Sentinel node detection should only be performed by appropriately trained gynaecological oncologist within a skilled multidisciplinary team. This technique is particularly useful in cases of suspected invasion and glandular disease; the lack of diathermy minimises the thermal artefact and allows accurate assessment of the excision margins. Establish a current menstrual history, including bleeding irregularities that may interfere with sex. The concept, Introduction All forms of surgery, whether elective or therapeutic, involve a degree of risk and recognized complication rates exist for each procedure. In such circumstances you can offer to review the patient in a couple of months it gives them a chance to think about things (cooling off period) and the patient may come back with a different view to things. Microscopic examination of a vaginal smear may also detect trichomonal infections and bacterial vaginosis (with Gram staining). Teratoma contains mature or immature cells or tissues representative of more than one germ cell layer (at least two) and sometimes all three embryonic layers. Where the patient consents disclosure is permissible and where there are statutory requirements disclosure is mandatory. In women with prolapse, this could further add to the strain on the area and worsen the condition. The late proteins that form the viral capsid induce the strongest and most consistent antibody response. They impair sperm motility, reduce sperm penetration in the cervical mucous and affect the capacitation and acrosomal reaction interfering with sperm oocyte interaction. As malignancy and dysplasia are rare, conservative management in asymptomatic women may be appropriate. Operative laparoscopy, however, requires a high degree of technical skill and training.

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Recognition of fluid overload is vital and requires careful monitoring of intra-operative fluid deficits. Bowel injury by the Veress needle is usually insignificant and closes spontaneously, but unrecognized injury with a trocar can lead to faecal peritonitis and potential death. A systematic review of transvaginal ultrasonography, sonohysterography and hysteroscopy for the investigation of abnormal uterine bleeding in premenopausal women. This includes the training costs of gynaecologist as well as the cost of the procedure and treatment of injuries. Recurrent stress urinary incontinence There is no consensus on the correct procedure for the management of recurrent stress urinary incontinence. Other mechanisms occurring at the molecular level contribute to an increase in hypertension at the time of menopause: oxidative stress, endothelin levels, sympathetic nervous system activity and plasma renin. Simple monopolar diathermy has an inherent risk of complications at the point of use due to relatively wide thermal spread as the tissues surrounding the application site are in circuit. The diagnosis is mainly a clinical one based on a history of second-trimester miscarriage preceded by spontaneous rupture of membranes or painless cervical dilatation. As already mentioned, many units now allow women to go home to pass the pregnancy in terminations below 9 weeks gestation, following the administration of the Misoprostol in a licenced unit. 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. Patients must adopt the belief that psychological factors cause chest pain and attribute the chest pain to panic attacks, anxiety, and/or other psychological factors. Abdominal hysterectomy e abdominal hysterectomy is indicated in women with a uterine size greater than 12 weeks of pregnancy, endometriosis or a history of pelvic inflammatory disease, previous c/section, or a long vagina and a narrow sub pubic arch, making the vaginal approach technically difficult. Pneumatic dilation requires concomitant endoscopy and fluoroscopy to place and visualize the guidewire and to verify appropriate balloon position. Bilateral partial obstruction may manifest as polyuria and nocturia due to inability to concentrate the urine (tubular dysfunction). Some authors have considered fitting successful if a pessary was perceived comfortable by a patient when retained during Valsalva and voiding at the initial visit, while others considered it successful if a patient continued to use the pessary until the following visit to the doctor. Regional anaesthetic techniques and nerve blocks have been recommended over the use of long-acting opiates. Most of the epithelial tumors of the bladder are composed of urothelial (transitional) cell type and are known as urothelial or transitional tumors. These procedures have few complications and are relatively easy to perform, however they have a relatively high recurrence rate, with the risk of having to have repeat surgery reported to be as high as 29%. Recent evidence suggests that the origin of epithelial ovarian cancer may be the distal fallopian tube so removal of the tubes at sterilization may be preferable. Since 2011 gonorrhoea now requires at least two agents including a higher dose injectable cephalosporin for treatment. A magnetic resonance imaging scan may add more information, particularly in cases where there may be an associated rudimentary uterine cavity, leading to cyclical pain that will need surgical excision. The role of the generalist clinician is to diagnose and treat uncomplicated conditions, whilst also determining the likelihood of malignancy and referring for further investigations appropriately. Interestingly, the addition of paclitaxel to carboplatin reduces the degree of thrombocytopenia. Analgesia Most patients complain of pain and will benefit from simple analgesia such as paracetamol and codeine. Acid and non-acid reflux in patients with persistent symptoms despite acid suppressive therapy: a multicentre study using combined ambulatory impedance-pH monitoring. Partial mole: Part of placenta neoplastic, fetal parts present and triploid (karyotyping shows 69 chromosomes). There are insufficient data to recommend the routine use of progestogens or natural progesterone.

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For all patients a detailed inspection of the vulva is needed, gently parting the labiae, checking for normal anatomy, oestrogenisation, dermatoses, candidiasis, cysts, warts, trauma, episiotomies, state of the hymenal ring, prolapse and size of the introitus. Premature adrenarche the pubertal awakening of the adrenal gland is called adrenarche. This view is supported by the finding of increased numbers of choline acetyltransferase-positive neurons in the myenteric plexus of affected patients. Consent to examination: a child under the age of 13 cannot consent to examination or any treatment or operation. Anti-fungal therapy is with oral fluconazole (not in pregnancy) or with clotrimazole (topical cream and vaginal pessaries). Furthermore the presence of a skilled assistant familiar with the procedure can often help to avoid inadvertent errors as well as allowing efficient management when complications occur. Theophylline, a xanthine derivative, has been shown to inhibit adenosine-induced anginalike chest pain and adenosine-induced pain in other regions of the body. The modified FerrimaneGallwey score is the most common method for grading the extent of hirsutism. It is important to remember that superadded infection can complicate and exacerbate a pre-existing inflammatory dermatosis, making treatment of the underlying condition more difficult. Management of reflux symptoms with over-the-counter proton pump inhibitors: issues and proposed guidelines. Surgery should be carefully planned and may require collaboration with a urologist or colorectal surgeon. Prognosis Children: Prognosis is good in children and more than 95% totally recover. A normal cycle is between 25 and 35 days in duration, with bleeding lasting from 5 to 7 days. Thus, the detection of achalasia requires vigilance and an understanding of the varied esophageal pressure topography phenotypes to confirm the diagnosis. The disease and its treatment can have a huge physical and psychological impact on women. Urinary infections are more common in females, because of: Shorter urethra Absence of prostatic fluid, which has antibacterial properties Normal urine in the bladder is sterile. If untreated, complications such as acute pyelonephritis, septic shock, kidney injury and even death. The couple were informed that his sperm count might fully recover, but this may take longer than 6 months after stopping self-medication. However, hysteroscopic resection of polyps is associated with significant symptomatic improvement of intermenstrual bleeding but may be less effective at reducing heavy menstrual bleeding. A number of alternative laparoscopic techniques to perform all or some of the hysterectomy have therefore been introduced to simplify the procedure, but retain the major advantages of the approach, i. If she misses a pill, she should take the dose as soon as possible and continue her usual pill-taking schedule. Immediate repair has a better prognosis than delayed repair and early specialist involvement is ideal for effective management of the injury. Alopecia: temporary hair loss is thought to occur due to direct toxic insult on rapidly dividing hair follicle cells. If Tamoxifen is to be continued a hysterectomy should be considered for these women. Chemoradiation e there is now consensus that the use of concurrent cisplatin-based chemotherapy with radiotherapy is superior to radiation alone for the treatment of cervical cancer. Weight loss in obese anovulatory women should be the main focus of treatment and can lead to spontaneous ovulation. Palpation of abdominal organs can only be performed with laparoscopic instruments, which reduces the information derived. They have an important role in picking up ova and transporting ova, sperms, and the embryos. Similarly these factors may have debilitating effect on spermatogenesis in the young male.