Norwest

Suite 206, 10 Norbrik Drive Bella Vista NSW 2153

WestMead

Suite 29 1A Ashley Lane Westmead NSW 2145

General information

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Gynaecology & Obstetrics

Appointment

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consultation

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observation

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treatment

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Drugs in Pregnancy

the antibiotics that can be used during pregnancy and lactation are: amoxicillin, clavulanic acid, ampicillin, azithromycin, clindamycin, clarithromycin, erythromycin.

Penicillins: Amoxicillin and ampicillin are considered the first choice antibiotics in pregnancy.
Cephalosporins, preferably 1st and 2nd generation, including Cefalexin, Cefaclor and Cefuroxime
Macrolides: Erythromycin (in case of allergy to Penicillins and Cephalosporins)
Clindamycin is used in cases where Penicillins, Cephalosporins and Macrolides cannot be administered.

The drugs used for the treatment of vulvo vaginitis in pregnancy are:
1) Clotrimazole, Miconazole, Econazole, Ketoconazole, Fluconazole, Itraconazole for mycoses
2) Metronidazole, Clindamycin for bacterial vaginosis (Gardnerella vaginalis)
3) Penicillin, Ampicillin
4) Penicillin, Ampicillin, Vancomycin, Clindamycin, Erythromycin for beta hemolytic streptococcus
5) Metronidazole (Trichomonas)

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Vaccination in pregnancy

The vaccination during pregnancy is able to provide protection to certain infections, expressing its action not only on the woman but also on the fetus and the newborn, through the transfer of maternal antibodies via t ransplacentare or through breast-feeding mother .

The vaccines recommended in pregnancy and provided for in the National Vaccine Prevention Plan (PNPV) 2017 – 2019 include:
• diphtheria, tetanus and pertussis (dTpa)
• influenza Ie ( before the start of the flu season in women who will be in the second or third three months during the period)

The vaccines administered King in presenz to factors of risks or are :

• Hepatitis A and B
• Yellow fever
• meningitis

Administration of p vaccines OU be made:
• at local vaccination centers
• at the general practitioner
• at hospitals who have activated this service

Folic acid and iron in pregnancy

A consumption  of folate or multivitamins was therefore recommended before pregnancy and in the first trimester .
Peri-conceptional folate supplementation reduces the incidence of neural tube closure defects, reduces the risk of
gestational hypertension.
It is recommended to take folic acid as early as  three months before conception and must continue throughout the first trimester  of pregnancy.
The main source of folate is: vegetables, legumes, hazelnuts, nuts, eggs, fruit, potatoes and cereals

Iron supplementation  should not be given routinely to all pregnant women. There does not seem to be any benefit in taking, relating to the outcome of pregnancy and fetal health. Before a pregnancy and in the first trimester, a consumption  of folate or multivitamins was therefore recommended .
Peri-conceptional folate supplementation reduces the incidence of neural tube closure defects, reduces the risk of
gestational hypertension.
It is recommended to take folic acid as early as  three months before conception and must continue throughout the first trimester  of pregnancy.
The main source of folate is: vegetables, legumes, hazelnuts, nuts, eggs, fruit, potatoes and cereals

Iron supplementation  should not be given routinely to all pregnant women. There does not seem to be any benefit to the intake, related to the outcome of pregnancy and fetal health

Genetic diseases and pregnancy

Genetic diseases can affect the number or structure of chromosomes, or the structure and function of genes.
Other diseases, defined as multifactorial or complex, are caused by the interaction between genes and the environment.
In the preconception period it is important to:
• identify possible risk factors in the couple and inform the couple about the most frequent risk factors for genetic pathologies in order to implement possible preventive measures ( preconception genetic counseling ).
In abortions, the most frequent anomalies are:
trisomies (27%), polyploidies (10%), X monosome (9%) and structural rearrangements (2%).
Only 6-10% of fetuses with chromosomal alterations reach the term of pregnancy escaping the strong natural selection; this is due to the fact that some pathologies are absolutely incompatible with fetal development and only a minority allow survival.
The first objective of the history of a preconception consultation is the identification of some pathologies that are relevant for the definition of the reproductive risk of the couple, such as:
• consanguinity
• geographical origins and ethnicity
• maternal age
• chronic maternal diseases
• exposure to teratogens
• congenital malformations
• sensory deficits (sight and hearing)
• reproductive history (long-term infertility, repeated abortion, stillbirth or neonatal death)
• recurrent causes of death in the family (eg: early heart attacks)
• people who died in infancy or youth
• growth retardation and mental retardation
• disabling neurological diseases and progressive

Preconception counseling therefore evaluates :
• personal and family
medical history of the two partners • general medical examination • lifestyle
habits (eg smoking)
• pharmacological therapies (eg antiepileptic drugs)
• laboratory tests (eg status immune against infectious diseases, any genetic screening tests: thalassemias)

Hypothyroidism and pregnancy

HYPOTHYROIDISM IN PREGNANCY:

The clinical diagnosis of hypothyroidism in pregnancy is often difficult.
The most common symptoms are:
cold intolerance, coarse hair, difficulty concentrating and asthenia.

The medical history that may cause hypothyroidism in pregnancy is suspected:
• family history of autoimmune thyroid disease, or hypothyroidism
• history of thyroid disease
• antithyroid antibodies relief and / or goiter
• Diabetes Type I diabetes
• other autoimmune diseases
• taking medication

The surveys laboratory useful for diagnosis are:
• FT3, FT4, TSH
• anti-Tg antibodies, antiTPO antibodies, anti-TSH receptor antibodies
• thyroid ultrasound

In case of hypothyroidism during pregnancy, the administration of thyroxine in the mother prevents fetal neurological damage.
The drug of choice for the replacement treatment of hypothyroidism is L-thyroxine , to be taken on an empty stomach 20 min before breakfast.
In the presence of vomiting it should be taken on a full stomach.
After initiation of replacement treatment, serum TSH and free thyroid hormone levels should be checked
after approximately 1 month.
To verify the adequacy of replacement therapy during pregnancy, the TSH and free thyroid hormones should be repeated at the end of the first trimester, at the 5th-6th month, and at the 7th-8th month.

Vaginitis

Bacterial vaginitis : very frequent cause of gynecological examination.
Most often it is caused by Gardnerella vaginalis and Mycoplasma hominis
Fungal vaginitis : C andida Albicans is one of the fungi most frequently associated with vaginitis. It is estimated that 75% of women have contracted candida infection at least once in their life. The risk of contracting Candida vaginitis seems to increase enormously depending on several factors: improper diet, birth control pill, stress, antibiotics and steroid drugs, menopause, HIV, and diabetes.
Parasitic vaginitis : the pathogen involved here is Tricomonas Vaginalis, often sexually transmitted.
Atrophic vaginitis : consequence of the marked reduction of the estrogenic hormonal structure. The inflammation of the vagina is, in this case, caused by chronic vaginal dryness and thinning of the mucosa.

Symptoms: foul-smelling, whitish vaginal discharge, dyspareunia, burning when urinating, vaginal bleeding, itching, vaginal dryness.

Vaginitis

Bacterial vaginitis : very frequent cause of gynecological examination.
Most often it is caused by Gardnerella vaginalis and Mycoplasma hominis
Fungal vaginitis : C andida Albicans is one of the fungi most frequently associated with vaginitis. It is estimated that 75% of women have contracted candida infection at least once in their life. The risk of contracting Candida vaginitis seems to increase enormously depending on several factors: improper diet, birth control pill, stress, antibiotics and steroid drugs, menopause, HIV, and diabetes.
Parasitic vaginitis : the pathogen involved here is Tricomonas Vaginalis, often sexually transmitted.
Atrophic vaginitis : consequence of the marked reduction of the estrogenic hormonal structure. The inflammation of the vagina is, in this case, caused by chronic vaginal dryness and thinning of the mucosa.

Symptoms: foul-smelling, whitish vaginal discharge, dyspareunia, burning when urinating, vaginal bleeding, itching, vaginal dryness.

Hyperandrogenism

Hyperandrogenism is one of the most common endocrine alterations in women. the most frequent clinical manifestations are:

  • hirsutism
  • androgenic alopecia
  • acne, seborrhea
  • menstrual cycle disorders
  • signs of virilization (increased muscle mass, bitemporal baldness, clitoral hypertrophy, breast atrophy, lowered voice)
  • central distribution of adiposity, insulin resistance, alterations in the lipid profile

One of the most frequent causes is polycystic ovary syndrome (PCOS), hypertecosis, ovarian tumors, congenital adrenal hyperplasia, Sd Cushing, adrenal tumors, hypersensitivity to androgens (increased 5 alpha-reductase activity, increased affinity of the receptor for androgens) , SHBG deficiency, hypothyroidism, acromegaly, anabolic steroids, drugs

Laboratory diagnosis: free testosterone assay, SHBG, cortisolemia, 17 OH progesterone, DHEAS, TSH, Prolactin, insulin, glycemia, 

Endometrial receptivity - repeated implantation failures

Diseases of the endometrium are among the main causes of infertility in women. Not all embryos evolve during pregnancy and this may also be due to endometrial receptivity.

  • EGEA ™ (Endometrium Genes Expression Assessment) : molecular test that analyzes tissue taken from an endometrial biopsy, to evaluate the expression of 30 genes in the endometrium during the luteal phase of receptivitỳ. The test allows to evaluate the mRNAs of 30 genes, hormonal response, immune activation, maternal-embryonic interaction, cell proliferation and adhesion, angiogenesis. 

    RNA, or ribonucleic acid, is the nucleic acid that derives from DNA and represents the molecule of passage between the latter and proteins. 
    EGEA ™ can be indicated for all women who have had multiple failures in the implantation of embryos during the various attempts of MAP and represents a support for the gynecologist in choosing the therapeutic option targeted for that woman, in order to increase the chances for the successful outcome of the system. The report consists of: histological evaluation, immunoreactivity with CD 138 for an evaluation of plasma cells to identify any chronic endometritis (consistent / negative – positive), expression profile of some groups of genes related to different aspects of the complex implantation mechanism and maternal-embryonic interaction, any “peaks” (up / down) discordant from the expected one (sample of women who have had pregnancies), thus indicating which variable could most influence the transfer. The purpose of this test is therefore not temporal (indicate a window for the transfer), but to “photograph” and possibly correct the receptivity of that endometrium so that the transfer takes place in the best possible conditions, thus increasing the chances of pregnancy for that woman, regardless of age.

 

  • ERA Test (Endometrial Receptivity Analysis):  is a test that allows you to evaluate the state of endometrial receptivity of a woman, from a molecular point of view; the expression of 238 genes involved in endometrial receptivity is evaluated, in order to identify the best time to transfer the embryo in each case, allowing a real personalization of the treatment.

In the literature we speak of the receptivity of the endometrium as linked to a limited period in time, between the nineteenth and twenty-first day of the standard menstrual cycle, known as the “implantation window”. In a natural cycle, ovulation and endometrial development are synchronized so that the implantation window remains open at the exact moment an embryo is ready for implantation. In assisted reproduction, this window may be moved and it may be necessary to personalize the treatment.

Premature menopause (POI)

Premature ovarian insufficiency (POI) is a clinical syndrome characterized by loss of ovarian activity before age 40.
POI is characterized by menstrual cycle disorders (amenorrhea / oligomenorrhea), increased gonadotropins, decreased estradiol.
diagnostic criteria:

  • oligo / amenorrhea for at least 4 months 
  •  FSH> 25 IU / l 

Causes :

  • genetice (eg. Sd Xfragile)
  • autoimmune (ACA / 21OH antibodies)
  • thyroid disease (Anti TPO)
  • iatrogenic: previous surgery, oncological therapies
  • idiopathic

It is advisable to start hormone replacement therapy (preferably with 17 17β-estradiol) in order to improve cardiovascular, neurological control, genitourinary symptoms, dyspareunia.
It is also advisable to maintain a correct weight and practice regular physical activity.

Feeding time

Breast milk is the only natural food that contains all the nutrients in the right proportions and is easily digested. It contains a number of factors that protect against infections (thanks to colostrum) and help prevent certain diseases (gastroenteritis) and allergies, improves vision and psychomotor development.

The most important world health organizations consider human milk the ideal food for babies up to 6 months of life, therefore they recommend weaning after the 6th month: at six months the baby is able to swallow semi-liquid meals, opens spoonful or turn his face to reject it, grab objects with his hands to bring them to his mouth and manage to sit on the high chair.
Breastfeeding, during weaning, can safely continue on request as long as the mother and baby both agree to continue it. Obviously the number of feedings will be reduced according to the complementary meals taken by the child. It is essential that 50% of the total nutritional intake continues to be covered by breast milk or formula milk until the age of one.

Male Infertility

Male infertility corresponds to a reduced reproductive capacity of the man, due to an insufficient production of spermatozoa or to anomalies in the quality of the spermatozoa produced. It is a common cause of couple infertility and is often not associated with specific symptoms.

Genetic causes

About 15% of cases of severe male infertility can be traced to chromosomal abnormalities or single gene mutations.

Cryptorchidism

It is a cause of congenital testicular infertility, due to the failure of the testicles to descend into the scrotum within the first year of life. The condition is surgically corrected in the first few years of life

Varicocele

It is a dilation of the testicular veins, which take on the appearance of varices. It occurs mostly on the left testicle. The mechanism by which varicocele reduces fertility is the increase in the temperature of the testicle, which, over the years, can progressively damage sperm production.

Orchites

This is how inflammations and infections of the testicles are defined; among the best known is that caused by the virus of the Epidemic Mumps (“mumps”). Among the most common bacterial infections we remember gonorrhea and chlamydia, while among the viral ones the mumps in post-pubertal age, can also have permanent effects on spermatogenesis.

Obstructive post testicular causes

Due to an obstacle to the passage of spermatozoa along the various tracts of the male reproductive system, resulting in obstructive azospermia (lack of spermatozoa in the ejaculate).

The obstructions may be due to malformations already present at birth, and therefore congenital, or developed over time, for example due to inflammation.

Retrograde ejaculation

Rare disorder that prevents the ejaculate from being properly expelled to the outside ( antegrade ejaculation ). The ejaculate, in these subjects, is conveyed into the bladder and is expelled with the urine.

Antisperm antibodies

Their presence reduces the fertilizing capacity of spermatozoa and can hinder their transit in the female genital tracts.

Erectile dysfunction

Erection-related dysfunctions are linked to 5% of infertility cases.

Medicines

Cancer drugs, those for the treatment of hypertension or high cholesterol (dyslipidemia) are a risk factor.

Surgery

Surgical treatments of the genitourinary system, inguinal hernias or demolition treatments following neoplasms can modify, even irreversibly, the male reproductive capacity.

Trauma

Trauma and testicular torsions can affect their functionality.

Lifestyles

Tobacco or cannabis smoke damages the DNA integrity of spermatozoa and reduces their number and motility. Other risk factors are a sedentary lifestyle, overweight, obesity, poor diet, alcohol and drug intake.

Environmental risks

Pesticides, solvents, plastics, paints, electromagnetic radiation can reduce fertility

Endometritis

Chronic endometritis is a persistent inflammatory and infectious processes of the endometrium , usually insidious, asymptomatic or nonspecific symptoms such as abnormal uterine bleeding, pelvic pain, or foul-smelling stream.

In the field of Reproductive Medicine it is important to diagnose it, because it could cause polyabortivity or repeated failures of embryonic implantation (understood as the transfer of at least 3 good quality blastocysts in women of maximum 37 years or of 3 euploid blastocysts in women over 37 years of age, without get pregnant, in the absence of obvious causes of implantation failure).

In the past it was thought that the uterus was a sterile cavity, but today we know that the endometrial cavity has a microenvironment. In most cases, chronic endometritis is asymptomatic. Diagnosis is based on histopathological findings, although there are no universal criteria.

The best method to diagnose it is the hysteroscopic examination with endometrial biopsy, the definitive diagnosis is in fact histological and is based on the presence of plasma cell infiltrate in the context of the endometrial stroma (CD138 +). Furthermore, most of the causative agents are common bacteria and mycoplasma, although there are about 32% of bacteria that we cannot grow, hindering diagnosis and targeted treatment. Antibiotic treatment is carried out according to the antibiogram. In more recent studies, new diagnostic techniques such as PCR or NGS are proposed to identify cultivable and non-cultivable germs.

Endometritis

Chronic endometritis is a persistent inflammatory and infectious processes of the endometrium , usually insidious, asymptomatic or nonspecific symptoms such as abnormal uterine bleeding, pelvic pain, or foul-smelling stream.

In the field of Reproductive Medicine it is important to diagnose it, because it could cause polyabortivity or repeated failures of embryonic implantation (understood as the transfer of at least 3 good quality blastocysts in women of maximum 37 years or of 3 euploid blastocysts in women over 37 years of age, without get pregnant, in the absence of obvious causes of implantation failure).

In the past it was thought that the uterus was a sterile cavity, but today we know that the endometrial cavity has a microenvironment. In most cases, chronic endometritis is asymptomatic. Diagnosis is based on histopathological findings, although there are no universal criteria.

The best method to diagnose it is the hysteroscopic examination with endometrial biopsy, the definitive diagnosis is in fact histological and is based on the presence of plasma cell infiltrate in the context of the endometrial stroma (CD138 +). Furthermore, most of the causative agents are common bacteria and mycoplasma, although there are about 32% of bacteria that we cannot grow, hindering diagnosis and targeted treatment. Antibiotic treatment is carried out according to the antibiogram. In more recent studies, new diagnostic techniques such as PCR or NGS are proposed to identify cultivable and non-cultivable germs.

Contraception

Contraception protects against unwanted pregnancy and, some methods, even sexually transmitted diseases.
The combined contraceptive pill inhibits the secretion of FSH and LH by blocking ovulation.
The combined contraceptive pill is taken every day at the same time for 21 consecutive days followed by a 7-day break, during which pseudomenstruation occurs.

The most used pills can be:

  1. The monophasic combined pill . It is the most used subtype. Those who resort to this solution take a product that has the same amounts of estrogen and progesterone for 21 days;
  2. The biphasic combined pill . Those who resort to this solution take: in the first 7 days or so, a product with a higher estrogen content; in the next 14 days or so, a product with a higher progesterone content.

Oral contraceptives containing Dienogest and Drospirenone  are most effective in women with acne or hirsutism, due to the compound’s anti-androgenic properties. 

Oral contraceptives containing Gestodene are useful for women who have had breakthrough spotting or breakthrough bleeding with other preparations, and also result in more effective cycle control than desogestrel.  

Levonorgestrel- containing oral contraceptives have been in use for many years and are slightly less expensive than the newer oral contraceptives. Determine the best cycle control. One of the  ailments  

 more frequently reported by women who take the latest generation, low-dose contraceptive pills, is “spotting”, that is, small irregular bleeding: before giving up taking a low-dose pill, it is advisable to continue taking it for at least three four months. Only if the ailment persists or is really annoying can you think about changing the product, knowing that spotting is nothing more than a nuisance. It does not represent a health problem or a sign of a reduction in the effectiveness of the contraceptive pill.
other disorders may be: breast tension, headache, nausea, weight gain, very low flow, decreased sexual desire, vaginal dryness, depression, irritability.

For women with acne: Most girls with acne get a satisfactory result when a combination pill is used. And several studies now show that almost all estrogen-progestogen combinations achieve the same result over a twelve-month period.

In terms of antiandrogenic potency and therefore of rapidity and efficacy of action, dienogest and drospirenone come immediately after cyproterone acetate.

For women over the age of 35 who are non-smokers, they can safely use a low-dose oral contraceptive, which can be prescribed until menopause.
On the other hand, smoking represents a real contraindication, depending on the quantity of cigarettes smoked, to the use of estrogen-progestin preparations after the age of 35.

For perimenopausal women, the pill is also an opportunity to improve perimenopausal vasomotor (caldane) symptoms before adopting hormone replacement therapy.

 

Vaginal ring and patch:

there are products similar to the combined contraceptive pill that can be administered by the vaginal or cutaneous route respectively; they release hormones constantly and therefore appear to have fewer side effects than oral preparations.

Morning-after pill (emergency contraception):

It is a progestogen-only pill (levonorgestrel) to be taken within 72 hours of unprotected intercourse.

Contraindications:  The CDC (Centers for Disease Control) in 2016 modified the WHO tables for the eligibility criteria for contraception. On this basis, some of the  conditions that make the  health risk of taking estrogen progestins unacceptable include 

  • Age ≥35 years and smoker of ≥15 cigarettes per day
  • Multiple risk factors for cardiovascular diseases (old age, smoking, diabetes, hypertension)
  • Systolic hypertension ≥160 mmHg OR diastolic ≥100 mmHg
  • Venous thromboembolism
  • Known thrombogenic mutations
  • Known myocardial ischemia
  • History of stroke
  • Heart valve disorders, pulmonary hypertension, high risk of atrial fibrillation, history of bacterial endocarditis (including subacute)
  • LES
  • Migraine with aura (any age)
  • Breast cancer
  • Cirrhosis
  • Hepatocellular adenoma or malignant hepatoma

Disorders in pregnancy

NAUSEA AND VOMIT

They are symptoms frequently not associated with adverse events in pregnancy and which resolve spontaneously within 16-20 weeks of gestation.

  • Among the pharmacological treatments available aimed at reducing nausea and vomiting, antihistamines (doxylamine, dimenhydrinate, diphenhydramine, hydroxyzine, cyclizine) are effective;
  • Ginger is among the effective non-drug treatments for reducing nausea and vomiting, but its safety in pregnancy has not been established. 

HEMORRHOIDS:

They are ectasias of the hemorrhoidal plexus. They can be associated with itching, pain, and intermittent bleeding of the anus. 
The need for treatment is proportional to the severity of symptoms (Changes in diet, local creams, oral therapies)

CONSTIPATION:

The increase in progesterone also slows down intestinal transit, thus worsening pre-existing constipation or causing a previously non-existent problem to appear.
In addition to the slowing effect of progesterone, there is compression on the terminal tract of the intestine due to the pregnant uterus; during pregnancy, it is necessary to maintain adequate lifestyles, with particular attention to having a weight gain of no more than 12 kilos (for women who begin pregnancy with a normal weight), a diet rich in fiber and liquids, and to exercise daily. The laxative should be used when these measures remain inadequate or in any case insufficient.

BACK PAIN (LUMBALGIA):

It occurs in the lumbar region or at the level of the pelvis, sometimes with irradiation to the legs. The more the volume and weight of the belly and breasts increase, the more your body will try to counterbalance the weight to allow you to remain upright, causing a shift in the physiological center of gravity.

MELASMA:

The spots of melasma (skin hyperpigmentation) have irregular outlines and inhomogeneous shapes; they are distributed on the cheekbones, nose, forehead, chin and upper lip. It is caused by excessive hormonal stimulation, which can increase the production of melatonin. Chloasma (pregnancy mask) can occur in pregnancy due to the appearance of hyperpigmented patches on the face.
Sun exposure, thyroid disease, and certain medications can also accentuate hyperpigmentation. Melasma is more prevalent in people with dark skin and with relatives who have suffered from the problem.

Feeding in pregnancy

Calorie Requirements in Pregnancy
The daily calories needed during pregnancy range from 2,550 to 2,700 for almost all women. These values ​​must be commensurate, case by case, with the body mass index before pregnancy, the speed of weight gain, maternal age, physical activity.
Conversely, pregnant women who eat more than 3,350 calories a day, compared to those with less than 2,000 calories, have a greater risk of pre-eclampsia.

3-4 portions of dairy products, 2-3 portions of meat, fish or eggs, 3 portions of fruit, 4-5 portions of vegetables or vegetables, 7-8 portions of cereals and legumes are recommended.

It is recommended to consume daily:
foods rich in iron, calcium and proteins (meat, eggs, fresh legumes, fresh cheeses, sea fish) to be distributed throughout the day in five small and frequent meals, at regular intervals. Excessive consumption of sugar, sweets, chocolate, fruit

must be avoided ;

• You should never skip a meal, even in the absence of appetite; Prolonged fasting should be avoided
• Weekly self-monitoring of weight gain
is recommended • Moderate physical activity is recommended.
• Obese women before pregnancy need to check blood pressure, blood sugar, fetal growth and amniotic fluid volume more often; they also have to gain little weight

In pregnancy, to reduce the risk of listeriosis, salmonellosis and toxoplasmosis, it is recommended:

  • drink only pasteurized or UHT milk;
  • avoid eating meat or other products prepared for gastronomy without these being re-heated to high temperatures;
  • avoid contaminating the food being prepared with raw foods and / or from the counters of supermarkets, delicatessens and rotisseries; do not eat soft cheeses if you are not sure that they are made with pasteurized milk;
  • do not eat fresh, non-canned meat pates;
  • do not eat smoked fish;
  • wash fruits and vegetables before consumption;
  • wash your hands before, during and after food preparation;
  • refrigerate food prepared in small containers, to ensure rapid reduction of the temperature;
  • cook all animal-derived foods, especially poultry, pork and eggs;
  • avoid (or at least reduce) the consumption of raw or undercooked eggs (for example, with a bull’s eye), homemade ice cream and eggnog, or other foods prepared with dirty or broken eggs;
  • protect prepared foods from contamination by insects and rodents;
  • prevent people with diarrhea from preparing food.

To decrease the risk of toxoplasmosis it is recommended to:

  • washing fruits and vegetables (including prepared salads) before handling and consumption;
  • wash your hands before, during and after food preparation;
  • cook meat well and also ready-made frozen dishes;
  • avoid raw preserved meats, such as ham and sausages;
  • avoid contact with mucous membranes after handling raw meat;
  • avoid contact with soil potentially contaminated by cat feces (if necessary, wear gloves and then wash your hands well);
  • avoid contact with cat feces (possibly wear gloves when changing the litter box and then wash your hands well).

The foods to include in the diet during pregnancy are:

  • copious amounts of fruits and vegetables;
  • starchy foods such as bread, pasta, rice, potatoes;
  • proteins derived from fish, meat, legumes;
  • abundance of fiber derived from wholemeal bread, fruit and vegetables;
  • dairy products such as milk, cheese, yogurt.

Hazardous foods in pregnancy:

  • soft cheeses derived from raw milk and molds, such as Camembert, Brie and cheeses with blue veins;
  • pates, including those of vegetables;
  • liver and derived products;
  • ready-to-eat raw or semi-raw foods;
  • raw or preserved meat, such as ham and salami;
  • raw seafood, such as mussels and oysters;
  • fish that may contain a high concentration of methyl-mercury, such as tuna (consumption should be limited to no more than two medium-sized cans or tuna steak per week), swordfish;
  • unpasteurized raw milk.

In pregnancy, the consumption of caffeine (present in coffee, tea, cola and chocolate) should be limited to no more than 300 mg / day.

Menopause

Menopause is a physiological period in the life of every woman which in fact coincides with the end of menstruation and reproductive capacity.

Symptoms:

Menopause, in fact, does not arise abruptly, but occurs gradually over a rather long period of time and on average between five and ten years (climacteric).
During the climacteric, the cycles can be interrupted for several months and then return, as are frequent variations in the duration and intensity of the flow. The purpose of hormone therapy is to improve the quality of life and reduce the symptoms of menopause.

Menopausal symptoms:

  • menstrual cycle irregularities;
  • weight gain;
  • fatigue;
  • hot flashes;
  • night sweats;
  • arthralgia;
  • muscle aches;
  • headache;
  • irritability;
  • anxiety;
  • mood drop;
  • depression;
  • vaginal dryness;
  • pain during sexual intercourse;
  • decreased libido;
  • memory deficit;
  • palpitations;
  • osteoporosis;
  • dryness of skin and hair.

Although according to statistics, the average age at which a woman enters menopause is 51, it is not uncommon for the onset of at least some of the menopausal symptoms to occur before or after (EARLY MENOPAUSE OR POF) .

Different systemic treatments currently available for (post) menopausal women:

  • Hormone Replacement Therapy (Tibolone)
  • ET estrogen-only hormone therapy in women without a uterus
  • SERMs (selective estrogen receptor modulators (tamoxifen, raloxifene, bazedoxifene, ospemifene)
  • TSEC (BZA / CE)

It is recommended to start therapy with a low dose, and then possibly increase it if the therapy is not effective after the first 3 months.



Contraindications to hormone therapy : undiagnosed abnormal uterine bleeding, thromboembolism risk, uncontrolled hypertension, myocardial infarction, stroke, coronary heart disease, liver disease, liver failure, estrogen related tumors.
 

Menopause

An ovarian cyst is a sac filled with liquid, or more rarely solid, material inside or outside an ovary.

Causes

Most are physiological and dependent on the menstrual cycle. In a minority of cases, they are instead the effect of a tumor process or other pathological conditions. In light of this, ovarian cysts are divided into two categories:

  • Functional cysts . They are the most common version of ovarian cysts. They are due to a physiological process.
  • Pathological (or non-functional) cysts . This category includes cysts that arise from a tumor, benign or malignant, or from endometriosis or polycystic ovary syndrome.

PATHOLOGICAL (OR NON-FUNCTIONAL) CYSTS:

  • The dermoid cysts . Dermoid cysts develop from the cells that produce the oocyte during embryonic life. For this reason, within them it is possible to trace portions of human tissues that resemble hair, bones, fat, teeth or blood. Dermoid cysts can take on important dimensions and even reach 15 centimeters in diameter; Dermoid cysts are benign tumors which very rarely become malignant;
  • The cystadenomas . They are benign tumors that grow on the outer surface of the ovaries and which may contain (as a cyst) water or mucus. If they contain water, we speak of serous cystadenomas, while if they contain mucus we speak of mucinous cystadenomas.
    Serous cystadenomas do not usually reach large sizes and do not cause particular disorders; mucinous cystadenomas, on the other hand, can grow considerably and even reach 30 centimeters in diameter;
  • Endometriotic cysts (or endometriomas) . Endometriosis is a disease characterized by the presence of endometrial tissue outside its natural location, which is the uterus. In some women, however, it can also be characterized by the appearance of ovarian cysts filled with blood;
  • Cysts due to polycystic ovary syndrome . Polycystic ovary syndrome (or ovarian polycystosis) is a morbid condition characterized by enlarged ovaries covered with many small cysts.

Symptoms 

In most cases, ovarian cysts are asymptomatic; however, when it happens that:

  • They reach large sizes and / or;
  • They break, releasing their content and / or;
  • They block the flow of blood to the ovaries (known as ovarian torsion or ovarian torsion).

the following signs and symptoms may appear:

  • Pelvic pain
  • Pelvic pain during sexual intercourse
  • Difficulty completely emptying the intestines
  • Need to urinate often
  • Changes in the normal menstrual cycle;
  • Sense of heaviness and swelling in the abdominal area;
  • Dizziness, vomiting and a feeling of emptiness in the head.

Premenstrual syndrome

Premenstrual syndrome of biological and psychological alterations extremely variable from one case to another, but always with a very precise temporal localization with respect to the menstrual cycle.

About 80% of women may complain of more or less unpleasant symptoms near the menstrual flow (premenstrual syndrome), which can affect their work and lifestyle.

Symptoms

They usually appear 7 to 10 days before the start of the flow, are extremely variable and difficult to assess in their extent; the most common symptoms are:

  • breast tenderness;
  • headache;
  • abdominal bloating;
  • swelling in the legs;
  • irritability and / or behavioral instability.

Causes

  • hormonal, consisting of an altered estrogen-progesterone ratio due to a progesterone deficiency in the luteal phase (the second half of the cycle);
  • alteration of hydro-saline exchange (water-salts) caused by the excess or defect of various hormones that have an action on the hydroelectrolytic balance: estrogen and progesterone, antidiuretic hormone ADH or vasopressin), prolactin, aldosterone;
  • thyroid disease (hypothyroidism): in these patients the administration of thyroid hormones determines an improvement of the premenstrual syndrome;
  • deficiency of vitamin B6;
  • hypoglycemia;
  • That of prostaglandin deficiency, which are substances involved in the perception of pain;
  • The psychosomatic one, which is based on psychological, behavioral and social considerations, and on the finding of an association, even if not frequent, of the premenstrual syndrome with real psychiatric pathologies.

Hemorrhagic corpus luteum

The haemorrhagic corpus luteum is formed at the ovarian level due to an alteration of the follicle luteolysis process: in fact, if after ovulation the fertilization of the oocyte does not occur, sometimes the corpus luteum does not undergo physiological luteolysis, therefore it remains at ovarian forming cyst containing serous liquid material or blood ( corpus luteum cyst or luteal cyst ).

Most common symptoms and signs:

  • Changes in the menstrual cycle;
  • Abdominal, ovarian, pelvic pain;
  • Fever;
  • Backache;
  • Nausea;
  • Painful ovulation
  • Peritonism;
  • Vaginal bleeding
  • Tachycardia;
  • He retched.

Endometriosis

Disease characterized by the presence of the endometrium in locations other than the uterus (ectopic endometrium) : therefore it behaves exactly like the endometrial tissue that physiologically covers the inner wall of the uterus. However, unlike what happens with menstrual blood (which comes out of the vagina), the blood coming from the lesions on the ectopic endometrium does not have the possibility to exit; therefore, it tends to accumulate, inflaming the surrounding areas and sometimes resulting in characteristic cysts, known as endometriotic cysts or endometriomas

In 20-25% of clinical cases, endometriosis is asymptomatic and is randomly diagnosed during surgery performed for other purposes.
the most common symptoms are:

  • Chronic pelvic pain
  • Dysmenorrhea, which is very painful menstruation;
  • Dyspareunia, i.e. pain in the pelvis and inside the vagina during sexual intercourse;
  • Infertility
  • Pain when defecating or passing urine
  • Changes in the menstrual cycle, with heavy bleeding during menstruation (menorrhagia) or with bleeding during the menstrual period (menometrorrhagia)

Sexually transmitted diseases

The group of sexually transmitted diseases (STDs) are most frequently due to sexually transmitted microorganisms (viruses, bacteria, fungi and parasites) such as:

  • Neisseria gonorrhea: bacterium responsible for gonorrhea (also called discharge or blenorrhagia);
  • Treponema pallidum: bacterium responsible for syphilis;
  • Chlamydia trachomatis: bacterium responsible for urethritis, cervicitis and pelvic inflammatory disease;
  • Trichomonas vaginalis: flagellate protozoan (unicellular organism) responsible for trichomoniasis;
  • HPV (Human PapillomaVirus): some types (16, 18, 31, 33, 45, 52 and 58) can cause cervical cancer, while other strains are responsible for condyloma acuminata;
  • HSV (Herpes Simplex Virus): some types (one and in particular the two) are responsible for genital herpes.

Abnormal Vaginal Secretions:

  • yellowish and creamy discharge (gonoccal infection);
  • foamy, foul-smelling and green-yellow vaginal discharge associated with itching and irritation (Trichomonas);
  • white, greyish, foamy discharge with a fetid odor especially after sexual intercourse or intimate hygiene (bacterial vaginosis, Gardnerella vaginalis);
  • modest vaginal discharge well adhering to the walls, associated with intense itching and burning, white and of a cheesy consistency, similar to a (Candidiasis);
  • muco-purulent vaginal discharge associated with pains during sexual intercourse (Clamydia, Ureaplasma urealyticum).

Infection:

It occurs during sexual intercourse of various kinds (genital, oro-penile, oro-vaginal, anal) with direct contact of infected fluids, such as sperm, vaginal secretions and blood lost from small lesions. AIDS and the hepatitis B virus, can also be contracted for the exchange of syringes in drug addicts, these venereal diseases can also be transmitted through the mixed use of razors or not well sterilized cutting objects (for example for surgery or tattoos ). Other microorganisms (hepatitis A, shigella, salmonella, Giadia lamblia) can be transmitted through the orofecal route (ingestion of contaminated food), but also during oral-anal and genito-anal sex (including the sharing of sex toys that are not properly sterilized or protected by a condom).

Symptoms:

They are sometimes asymptomatic because the immune system is able to confine the pathogen; in other cases (HPV and HIV) they take a long time to produce the first symptoms. Other diseases, on the other hand, have shorter incubation times which facilitate timely recognition.

In general, the symptoms can be: vaginal discharge and unusual bleeding outside of menstruation, pain or burning when urinating, pain or discomfort during sexual intercourse, itching, irritation, redness and burning of the genital organs, blisters, ulcers or blisters more or less pain in the genital, oral or rectal area, enlargement of the inguinal lymph nodes, fever, genital and / or pelvic pain, infertility, inguinal abscesses.

Prevention:

General rules for the prevention of venereal diseases

  • Constantly use condoms during each sexual intercourse regardless of whether or not other forms of contraception (pill, spiral) are used.
  • Limit the number of sexual partners.
  • Go promptly to the specialist as soon as even subtle symptoms appear or there is even the slightest suspicion of infection after risky sexual intercourse.
  • It is essential to avoid unprotected sexual intercourse during therapy
  • Screen for sexually transmitted diseases at least once a year

Uterine prolapse

Uerine prolapse: descent of the uterus downwards or beyond the vaginal intake.

Causes:

  • the weakening or damage of the supporting tissues of the perineum. For this reason, the disorder most commonly affects women of advanced age or who have had one or more children vaginally; 
  • reduced congenital resistance of connective tissue (e.g. Marfan syndrome);
  • pelvic organ surgery;
  • obesity, chronic cough, constipation, lifting weights and repeated exertion.

Uerine prolapses can be of:

  • 1st degree (the uterus is contained in the upper portion of the vaginal canal);
  • 2nd degree (reaches the vulvar rim, but does not exceed it);
  • 3rd degree (protrudes outside the vagina).

The symptoms : feeling of pressure or foreign body in the genitals, pain during sexual intercourse, vaginitis, bleeding, urinary disorders (urinary incontinence, cystitis)

Irregular menstrual cycles

When metrorrhagia appears during the menstrual cycle it is called menorrhagia (the result is profuse blood loss); if instead the flow, in addition to being abundant, also continues in the intermenstrual phase, one speaks more correctly of    menometrorrhagia .

Causes of bleeding during puberty :

EARLY PUBERTY: the girl becomes a woman early and this determines premature sexual development (breast growth, development of the genital organs, growth of pubic and axillary hair, the appearance of menstruation and expansion of the uterus in terms of volume):

Causes Metrorrhagia in adult women:

  • Uterine causes: UTERINE MYOMAS, ENDOMETRIAL POLYPS, ENDOMETRITIS, TUMORS;
  • Sometimes, abundant genital blood loss is a sign of SPONTANEOUS ABORTION;
  • HORMONAL CAUSES: metrorrhagia can in fact be the “simple” result of transient hormonal alterations;
  • GENERAL CAUSES: modification of blood clotting, heart disease, infections.

Metrorrhagia in menopause:

  • menopause, a period in which the woman is no longer fertile. In the event that the woman experiences metrorrhagia in the phase preceding the menopause, the aforementioned condition can be considered pseudo-physiological. If it also occurs during menopause, it is ALWAYS CONSIDERED PATHOLOGICAL and can be caused by tumors of the female genital system.

Poly-abortion and endometrial receptivity test

Abortion , the most common complication of pregnancy, is defined as the’ spontaneous abortion within 24 weeks of gestation.
From a clinical point of view, three types of abortion are distinguished: occasional, repeated and recurrent.
Recurrent abortion is defined as the presence of three or more consecutive episodes of miscarriage. Currently, we speak generically of poliabortivity and a screening in this sense is carried out starting from the second consecutive episode of abortion.

Causes of recurrent abortion

In most cases of poly-abortion it is not possible to find a certain cause, however, the main causes known as predisposing factors for recurrent abortion are chromosomal abnormalities (5%), uterine malformations (15 to 27%) and maternal pathologies (from 20 to 50%), such as infections of the genital tract, exposure to drugs and toxins, endocrine alterations, congenital and acquired thrombophilias, immunologicals.
It is possible to carry out an in-depth study of polyabortivity as well as a specific therapeutic treatment based on the causes: 
– maternal and paternal serological diagnostic tests
– endometrial microbiome study and presence of bacteria related to embryo implantation failure – EMMA TEST
– study of chronic endometritis through the presence of endometrial pathogens correlated with uterine infections and repeated abortions, ALICE TEST
– embryological factors: PGT-A

Physiological Pregnancy

The number of visits offered to pregnant women must not be less than four.
The first visit should take place within the 10th week at the latest.

The objectives of the first visit during pregnancy are:

  • evaluate the RISK of pregnancy through an accurate medical history (family, social, proximate, remote and obstetric pathology, lifestyle, work activity, diet, smoking, drugs) in order to personalize the care profile.

Smoking in pregnancy carries risks to fetus-neonatal health (such as the greater likelihood of delivering a low birth weight baby and the greater likelihood of preterm delivery)

  • offer information on services available for assistance and support to women, including birth attendance courses;
  • identify women who may need intensive care and plan their path;
  • measure the body mass index, detect blood pressure and search for any proteinuria;
  • offer screening for hemoglobinopathies, Rh (D) status, anemia, anti erythrocyte antibodies, HIV, rubella, syphilis, toxoplasmosis;
  • offer screening for Chlamydia trachomatis, HCV, gonorrhea in the presence of risk factors;
  • offer screening for asymptomatic bacteriuria;
  • offer information on the possibilities of screening and prenatal diagnosis of Down syndrome;
  • offer the ultrasound survey for the determination of the gestational period;
  • diagnostic pathway for chromosomal pathology screening, through:
    – combined serum tests with nuchal translucency from 11 + 0 weeks to 13 + 6 weeks;
  • offer the ultrasound investigation for structural fetal anomalies, possibly to be carried out between 19 + 0 and 21 + 0 weeks of gestational age;
  • haematological tests to be performed before 10 weeks (blood group, Rh (D) status, hemoglobinopathies screening, anemia, antibodies to erythrocytes, HIV, rubella, syphilis, toxoplasmosis) and other tests limited to risk groups;
  • urinalysis (proteinuria and urine culture for asymptomatic bacteriuria);
    – moderate physical activity in pregnancy is not associated with adverse events.
    – having sexual intercourse during pregnancy is not associated with adverse events.

The second trimester (13 + 0 weeks to 27 + 6 weeks)

The objectives are:

  • identify women who need assistance other than that appropriate for physiological pregnancy and check hemoglobin levels;
  • detect blood pressure;
  • offer women who are at risk for gestational diabetes a glucose load test (OGTT) at 16-18 weeks of gestational age, and an additional OGTT at 28 weeks of gestational age;
  • offer women with one of the identified risk factors an OGTT (75 g) at 24-28 weeks of gestational age for seronegative women, retest for toxoplasmosis and rubella;
  • if it has not already been discussed in the first trimester, offer information on the ultrasound examination for the diagnosis of fetal structural anomalies (MORPHOLOGICAL ULTRASOUND) 19 + 0 and 21 + 0 weeks;
  • evaluate any placental insertion problems.

The third quarter (from 28 + 0 weeks to the end)

Visits during this period are aimed at:

  • examine and discuss with the woman the results of the tests performed;
  • identify women who need assistance other than that appropriate for physiological pregnancy;
  • check hemoglobin levels;
  • offer routine anti-D prophylaxis to Rh (D) negative women at 28 weeks;
  • detect blood pressure;
  • offer screening for HBV, HIV, toxoplasmosis, syphilis, beta hemolytic streptococcus;
  • offer information and opportunities for discussion of topics deemed relevant by the woman.

The woman must be informed of the offer of accompanying birth courses in the area.
Women in whom a previous examination has revealed a placenta covering all or part of the internal uterine orifice should be offered an ultrasound at 32 weeks.

At 34 weeks, the professional should offer the woman information and the opportunity to discuss preparation for labor and birth, including information on delivery planning, how to recognize labor and how to cope with pain. 

At 36 weeks the presentation of the fetus should be verified.

This is also the time when information on breastfeeding, infant care, newborn screening tests should be offered.

At 40 weeks, the practitioner should offer the woman information on managing the pregnancy up to 41 weeks and beyond.

Gynecological endocrinology

The alterations of the hormone production in the woman represent the field of investigation of the gynecological endocrinology

Gynecological endocrinology is the science that studies women’s hormones.

AMENORREA : the irregularity of the menstrual cycle is one of the most frequent causes of gynecological consultation.
We speak of Amenorrhea when there is the complete absence of menstruation or oligomenorrhea when the cycles are present even if late.
Amenorrhea may be primary , when the woman has never had menstruation at the age of sixteen years of age or five years after breast development ( you must consult a gynecologist to check for chromosomal disorders) or  s econdaria in case of interruption of menstruation for at least six consecutive months in a woman with regular  menstrual cycles  . 

CAUSES:

  • anatomical (congenital anomalies of the vagina, imperforate hymen, vaginal septa, cervical stenosis intrauterine synechiae, absence or abnormal development of the uterus or vagina);
  • ovarian failure (POF) ;
  • chronic anovulation: polycystic ovary syndrome (PCOS);

Genetics

  • androgen insensitivity syndrome
  • Turner syndrome

Other endocrine dysfunctions

  • Cushing’s syndrome
  • hyperprolactinemia
  • hypopituitarism

These forms of menstrual irregularities require the utmost attention from the specialist since at the base of the symptom there may be possible malformations of the reproductive system, genetic anomalies, disendocrinopathies, dysmetabolisms, etc. Pathologies such as hyperprolactinemia or Polycystic Ovary Syndrome, very often present with nuanced symptoms, such as menstrual irregularity or hyperandrogenism, but can have much more relevant consequences for the woman’s health.

The measurement of AMH, for the evaluation of the ovarian reserve, and in case of amenorrhea, allows to recognize the forms associated with ovarian insufficiency (POF).

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