Hormone Replacement Therapy - HRT

Q. what is HRT?
Ans. Menopause, which occurs for most women around the age of 50, prompts a decline in hormone production as the ovaries stop producing eggs and menstruation ends. During and after this period, the health risks for certain conditions can increase because as the estrogen level decreases so does its protective function. To help their bodies adjust to this change, some women use hormone replacement therapy (HRT). HRT involves taking synthetic estrogen and progesterone (progestin) hormones.



Q.What are the prerequisites for starting HRT?
Ans. A woman should have complete physical examination for assessment of cardiovascular status, B.P., and respiratory diseases. Breast, abdominal and pelvic examination should be done and Pap smear should be taken to rule out the existnece of cervical malignancy and various blood tests should be done like - hormone and lipid profile, Liver function test, mammoography,etc



Q. What all, the doctor should be told before taking HRT?
Ans. Doctor should be informed about any history of liver disease, previous treatment, past psychological disturbances, past history of thromboembolic phenomenon, family history of ovarian corciroma.



Q. What are the absolute contraindications for HRT?
Ans. Absolute Ccontraindications for HRT are:
(a) Vaginal bleeding of unknown origin
(b) Active severe liver disease
(c) Acute thromboembolic disease / deep vein thrombosis
(d) Recent carcinoma of breast.
(e) Recent carcinoma of uterus (endometrium)
(f) Any congenital lipid metabolism disease.



Q. How frequent the visits to the doctor should be?
Ans. Patient on HRT should have the next visit (after starting the HRT) 6 months later and then yearly. Mammography is done every 3 years. Pap smear every 3 years - Breast and pelvic examination every 12 months.



Q. In what form HRT can be taken and which is the best?
Ans. HRT can be given in Oral preparations, Injections, Transdermal patches, Subcutaneous implants, Vaginal creams and suppositories and as Intrauterine device.
All routes of administration of HRT are beneficial. For most women the oral route will be the simplest, cheapest and most suitable form.



Q. What are the various drugs and preparations and how they should be taken?
Ans.Oral tablets containing low dose of estrogen are given. They are Premarin (0.3, 0.625 mg of conjugated estrogen), Evalon (0.5 mg Estrace (0.5 mg), etc.

Transdermal Patches like Estraderm TTS and Estraderm Mx are available in these doses of 25, 50 and 100 mg / 24 hours. The patch is placed on hairless skin over the buttocks or lower abdomen and fixed by palm pressure for 5-10 seconds. It is waterproof and stays in position for 3-4 days.

Subcutaneous implants like estradiol implant (Organon) contains 17 B-Estradiol in a cholesterol base in silastic rods of 3-6 mm length which can be introduced in subcutaneous fat of lower abdomen or buttock under local anaesthesia and the effect last for 6 months. It is useful in women whom the uterus has been removed.

Intrauterine device contains both estrogens and progesterone.

Transvaginal creams and suppositoryy like Dienesteral cream, Premarin cream, etc.



Q. In what persons transdermal patches are preferable?
Ans. It is useful in women with hypertension, hepatobiliary disorders, Increased triglycerides and venous thrombosis.



Q. How transvaginal creams are useful?
Ans. They help in curing symptoms due to atrophic changes in vagina leading to dyspareunia(pain during intercourse) and dysuria (painful urination).



Q. What are disadvantages of various drugs for HRT?
Ans. Oral tablets lead to nausea, vomiting and poor compliance. It contains higher doses.
Trans dermal patch can lead to local allergic reactions in some women.
Subcutaneous implants can lead to breakthrough bleeding in some patients Intrauterine devices may lead to infections.



Q. What are the risks associated with prolonged HRT treatment and what can be done for it?
Ans. When estrogens alone are taken for long time as HRT, there is a risk of uterine cancer and breast cancer. So progesterone is added for about 10-12 days in each month. But addition of progesterone leads to withdrawal bleeding every month which is not acceptable to most patients. It is given in woman whose uterus has been removed.

The Cesarean Section FAQ

Frequently asked questions regarding Cesarean Section are:
What are the indications that one needs a Cesarean?

Following are the commonest indications for a cesarian operation:

• Prolapsed cord (where the cord comes down before the baby)
• Placenta abruptio (where the placenta separates before the birth)
• Placenta previa (where the placenta partially or completely covers the cervix)
• Fetal malpresentation (transverse lie, breech )
• Cephalopelvic disproportion (CPD), meaning that the head is too large to fit through the pelvis
• Maternal medical conditions
• foetal distress,
• Repeat cesarean

What type of pain relief is offered before and after a cesarean?
-A regional anesthetic (epidural or spinal)
-A general anaesthetic
-A pre- operative sedative is usually avoided because it can reach the baby and make it difficult for the baby to breath.

-Post operatively pain can be reduced by medication.
What is the procedure for a cesarean?

The basic steps followed are:

• A catheter inserted to collect urine
• An intravenous line inserted
• An antacid for your stomach acids
• Monitoring leads (heart monitor, blood pressure)
• Anesthesia
• Anti-bacterial wash of the abdomen, and partial shaving of the pubic hair
• Skin Incision (vertical or midline(most common))
• Uterine Incision
• Breaking the Bag of Waters
• Disengage the baby from the pelvis
• BIRTH!!!! (Accomplished by hand, forceps, or vacuum extractor)
• Cord Clamping and cutting
• Newborn Evaluation
• Placenta removed and the uterus repaired
• Skin Sutured (Usually the top layers will be stapled and removed within 2 weeks.)
• You will be moved to the Recovery Room (If the baby is able s/he can go with you.)

What is an emergency Cesarean?
Done in the cases of

-placental abruption-prolapsed cord-foetal distress

What will be the recovery like?
Everyone's recovery will be different, depending on your age, body type, and general health.

You may be plagued with gas pains from being opened, incisional pain, uterine contractions (your uterus will take time to get back to it's original shape). Do not lift anything heavier than your baby.

Can I breast feed if I had a cesarean?
Certainly you can. It may take some more effort on your part, but do not hesitate to ask for help. Start breast feeding as soon as possible
If I had one cesarean (or more!), will I have to have another cesarean?
Recent studies have shown that there was an over 80% success rate for Vaginal Birth After Caesarian.

FAQ Menopause

Q. What is Menopause and at what time it occurs?
Ans. Menopause in women is that period of time when permanent cessation of menstruation occurs following the loss of ovarian activity. The average age of menopasue is 50 years, ranging from 45-55 years. Early menopause (<45 years) occurs in smokers, at high altitudes, in women with genetic predisposition i.e. mothers and daughters experience menopause at same age.


Q. What are post menopausal problems?
Ans. Women may experience problems after menopause due to reduction in the level of sex hormones. The main problems are:

• Hot flushes and night sweats.
• Psychological symptoms - anxiety, tension, mood changes and irritability.
• Sleep disturbances and early morning waking.
• Atrophic changes in skin, reproductive organs.
• Other prolonged health problems like osteoporsis / weakness of bones and fracture and heart problems (hypertension, heart attacks and stroke).
• Joint & bone pains.

Q. What are hot flushes and why do they occur?
Ans. Hot flushes occur due to vasomotor instability. There is sudden onset of reddening of the skin over head and neck preceeded by an aura and there is feeling of pressure before flushes. They occur for short duration and there's a sensation of heat for 3-5 minutes followed sometimes by profuse perspiration. It normally lasts for 1 year in 80%of women but may continue forever in 10% women. They are more at night and during stress.



Q. What happens due to atrophic changes in the body?
Ans. Atrophic changes in reproductive tract lead to dyspareunia (pain/burning during coitus), pruritus (Itching / irritation / soreness of vulva and vagina).
Changes in the urinary tract include urgency and frequency of urine, painful urination and infections.
Changes in the skin include dry and loose skin and increased feeling of cold due to decrease in subcutaneous fat.




Q. What can be done to cure these post menopausal problems?
Ans. HRT (Hormone replacement therapy) can be given for the relief of menopausal symptoms by replacing the hormone (estrogen), which decreases at onset of menopause and leads to various symptoms.


Q. Do all women have to take HRT?
Ans. No, all women need not take HRT as many women are asymptomatic, this may be due to production of some hormones but for long terms problems like osteoporosis and heart problems, HRT can be started as a precautionary measure in asymptomatic women.


Q. Does exercise and nutrition have a role in modifying post menopausal problems?
Ans.Yes, maintaining good level of activity and taking a balanced diet is very important. Dietary supplements like Calcium are very important in preventing osteoporosis. Similarly, doing regular exercises helps in preventing bone loss, and special exercises like pelvic floor exercises help in modifying problems like urinary incontinence.

Breast Feeding

Breast feeding practice is followed everywhere in India, except among higher socio- economic groups, who tend to look for alternatives to breast-feeding. Ignorance of the advantages of breast-feeding and the proper method often leads to discontinuation in most cases.

Basic Facts:

1. The ability of the breasts to produce milk diminishes soon after childbirth, without the stimulation of breast-feeding.
2. The immunity factors in breast milk can help the body fight off infections.
3. Breast milk contains vitamins, minerals and enzymes, which aid the baby’s digestion.
4. Breast and formula feeding can be used together.

Advantages of breast-feeding.

1. It is the simplest way to feed the baby.
2. It increases the period of lactation amenonhoes after childbirth.
3. Breast milk also contains infection-fighting anti-bodies from the mother.
4. Breast feeding in the initial 4- months of the baby’s life reduces the chances of infection and increases the immunity of the baby.
5. The amino acids
   
   in breast milk, the building blocks of proteins, are well balanced for the baby. These proteins best aid the baby’s intestinal tract.
6. The emotional bonding between the baby and mother is strengthened & gives a feeling of satisfaction and achievement to the mother.
7. It is much cheaper than artificial feeding.

The baby should be put to the breast as soon as possible after birth. The initial yellowish and thick fluid (colostrum) is rich in proteins and protective antibodies

. The practice of giving ghutti should be discouraged, because the nourishment of the baby is delayed, increasing chances of infection and delaying the stimulation for milk production.

Some important points:

1. The mother should sit in a comfortable position, hold the baby in her arms and offer the baby her whole breast & not just the nipple.
   
   
2. The baby should be fed from a different breast each time so that both breasts produce the maximum amount of milk.
   
   
3. The baby should be fed, whenever she is hungry. Before offering the second breast to the baby, it should be ensured that the baby sucks the fat rich hind milk from the first breast.
   
   
4. A daily bath is sufficient to keep the breasts clean.
   
   
5. Frequent cleaning with soap removes the natural oils from the breasts, predisposing the nipples to develop fissures.
   
   
6. Burping the baby after every feed by holding her against the shoulder is advisable.
   
   
7. A mother who is feeding her baby should eat healthy foods to keep up her strength & feed the baby letter.
   
   
8. At times the breasts may feel hot, heavy and hard, due to accumulation of milk.
   
   
9. The mother should be encouraged to let the baby continue to suck for as long as possible.
   
   
10. If still enough milk is not removed, the milk should be squeezed out in a clear (preferably) boiled cup using the thumb and the finger.
    
    
11. A warm compress on the breast or a warm bath is also helpful.
    
    
12. It the baby is fed frequently both during the day and night this condition (engoryememt of breast) is uncommon.
    
    
13. If nipples are cracked and painful, the mother is advised to leave a drop of hind milk on, the nipple after feeding as this helps in healing. Malai can also be can applied.

Premenstrual Syndrome

DEFINITION
PMS consists of various physical and/or emotional symptoms that occur in the second half of the menstrual cycle, after ovulation. It is characterized by premenstrual discomfort in the lower abdomen and back, and in the breasts. All these features precede the period by a week or ten days. Fortunately, a woman obtains relief when her menstrual period begins. Another feature of PMS is a symptom-free time for several days every month, in the first half of the menstrual cycle.



Features: these include physical features like acne, backache, bloating, sore breasts, and headache. Emotional symptoms might include changes in sexual desire, difficulty concentrating, irritability.

Women may gain upto a kg. of weight or more in the latter part of the menstrual cycle due to water retention in the body. Emotional stress often contributes to the symptoms.

The only saving grace in this problem is that few women experience all these symptoms! Most have a few that recur each month.

The symptoms of certain medical conditions

can resemble PMS. These conditions include allergies, depression, diabetes, dysmenorrhea (painful periods), endometriosis, fibrocystic breast disease, and thyroid problems.



CAUSES
There's still some disagreement about what causes PMS, but it definitely seems to be linked to hormones. A relative lack of the hormone progesterone is suspected along with increase in a water retaining substance called anti diuretic hormone.



TREATMENT

The assessment of the emotional and work related stress is very important. Many women find that a balanced diet and healthy snacks are helpful, as are avoiding caffeine and reducing salt intake. Simple reassurance often does wonders, but often it is necessary to treat the symptoms with various drugs
Diuretics ("water pills") can reduce bloating
Analgesics like ibuprofen, aspirin ease headache or cramps
Combined oral contraceptives also called the birth control pill may be useful for some women.
Evening primrose oil (gamma linolenic acid) is also used widely these days.

HIV / AIDS

What are HIV and AIDS?
Over the last fifteen years a new disease spread by a family of viruses, HIV, has spread globally. HIV stands for Human lmmuno-deficiency Virus. HIV has been given this name because its long-term effect is to attack the immune system of the body, making it weak and deficient. We live virtually in a sea of microorganisms and at every moment an enormous number of them are entering our body. It is the immune system that normally fights off these microorganisms and keeps us healthy. Any compromise with the working of the immune system has profound effect on our body.

After about 5 to 10 years of contracting the HIV infection, the virus has weakened the immune system of the patients so much that they develop a number of different illnesses such as tuberculosis, pneumonia, persistent diarrhea, fever and skin infections. This condition is called AIDS Acquired Immune Deficiency Syndrome.



Why do you need to know about it?
At the moment it is estimated that 13 million people in the world may have HIV. Every day there are thousands of new cases of HIV infections in the world and these occur in every country. People who have HIV may have no symptoms for many years, and infected people may not even be aware that they have the virus. They look and feel well, but can infect other people during this time.

The most difficult aspect of HIV/AIDS is that though there are medicines, which can help them, cope with these illnesses, there is no vaccine, and no cure for the HIV, so almost all the infected people become more and more ill and eventually die. It is important that we all know and understand about this infection, so we can protect ourselves and our families.

We have responsibility not only towards ourselves but also towards our children who are growing up in a very different world from that of our childhood. They will have many new opportunities, but also may sometimes be faced with new relationships, standards of behavior and new risks. It is up to us to explain the truth of the situation to them in an honest and informed way, so they may have the knowledge to take the necessary steps to protect their health.

We have to understand that presently prevention is the only cure of HIV/AIDS and that can come about only if we are adequately informed about it. Following are some frequently asked questions about HIV/AIDS:



How does HIV affect the body? Is it the same as AIDS?
When HIV gets into a persons blood it attaches itself to a special type of white blood cells called as helper T-Lymphocytes. These Helper T- cells are crucial in defending the body against many infections. during all this the persons have no symptoms at all. They look and feel well. They may not know they now have the virus, but could pass it on to someone else through having sex, or by sharing needles or syringes.


Being HIV Positive is not the same as having AIDS. The HIV actually goes inside the white blood cells and lies their quietly. After about 5 to 10 years the HIV virus tricks the cell to start making the viral proteins, this results in the formation of a huge number of viral particles inside the white cells and eventually the cells burst releasing thousands of new viruses in the blood. The released viruses infecting new white cells This cycle goes on and on, and eventually the immune system of the body is overwhelmed and is no longer capable of fighting the infections.

Eventually the infected person may lose weight and become ill with diseases like persistent severe diarrhea, fever, or pneumonia, or skin cancer. He or she has now developed AIDS. People with AIDS can be helped with medicines for the different infections. At the moment though, in spite of much research, there is no cure for HIV or for AIDS and so, sadly, it is almost certain that people diagnosed with AIDS will die.

FAQ for Females

The first time a woman has sex, it may or may not be painful.There may be psychological and physical reasons for it. If you are not sure about your partner or if you are not entirely convinced about the timing and place, then you may feel more pain than you should. If you and your partner truly care for one another and he is gentle and understanding and will go slowly, then there may be less discomfort. Physically, often, the first time a woman has sex there will be some bleeding as the hymen is torn. Using large amounts of a water-based lubricant may help. If you have been using tampons, that may have helped to stretch your hymen.



Does sex hurt the first time? What are the precautions for having sex the first time ?
First time intercourse may or may not be painful for a woman. It is entirely a personal experience and can't really be generalized. It is basically breaking of the hymen that causes the pain. It is believed that if a woman is properly aroused at the time of penetration it lessens thew pain to a great extent. Those who feel pain, have psychological and physical reasons for it. Any kind of apprehension or doubt regarding the partner, place or timing of lovemaking, can make it hurt more than it normally does. Using a water-based lubricant will help in reducing the pain.



What is the G-spot and where is it?
G-spot refers to the most erotic zone of the female body. The highly sensitive part is located within the vaginal opening and plays an important role in bringing a woman closer to a climax. G-spot stimulation can also lead a rare ejaculation in women. The significance of the G-spot is that in about half the women it is a highly sensitive area that under the right conditions can be very pleasurable if stimulated. For some it is a primary source of stimulation leading to orgasm during intercourse.



What is the clitoris and where is it?
A small organ consisting mainly of highly sensitive nerves is located near the opening of the vagina, is responsible for sexual excitement in women. It's a small part that plays an important role in achieving an orgasm. A clitoral orgasm can be achieved with or without penetration.

Persistent pain in all the positions should prompt a visit to your gynaecologist for a thorough checkup.



What is oral sex?Can oral sex lead to pregnancy?
Oral sex refers to stimulation of the genitalia using lips and tongue. It often includes kissing, sucking and licking. It does not include penetrative sex and therefore does not lead to pregnancy but can surely be infectious. Always use a condom to save yourself from catching STDs and sexual infections. Flavored condoms are a good choice for oral sex. Also do not indulge in oral sex if you have any cut or wounds in your mouth, on your tongues or lips.



Is it okay to have sex during periods?
Sex during periods is absolutely normal. People in general avoid sex during periods because its messy. It is a proven fact that women experience a higher sex drive when they are menstruating . Also sex during periods is more enjoyable as the vagina is soft and moist.



Is it normal to feel pain during sex or What could be the reason?
Pain during sex may be experienced due to a number of reasons. Pain on initial penetration is often due to infection, spasm of the vaginal muscles or inadequate lubrication whereas pain on deeper thrusting is often caused by endometriosis, adhesions (scar tissue), a retroverted (backward-tilting) uterus or fibroids. If it hurts in a specific position simply avoid it. On the other hand if almost all positions hurt, or even many of them, see gynecologist for a complete and detailed check up.



What is the safe time to have sex in order to avoid pregnancy?
There is no such thing as safe period for having unprotected sex and avoiding pregnancy. But there are some days when you are less likely to get pregnant. 8th to 21st day of your cycle, counting from the first day of menstrual period is the fertile period. Make sure not have unsafe sex during the fertile period. Usually 4 to 7 days before and after your menstrual cycles is considered to be safe. The best way is to maintain a diary of your cycles and keep a track of when you are ovulating. Usually after your ovulation period unprotected sex will not lead to pregnancy.



What do i do if i miss my periods?
What could be the reason for a missed period depends on your lifestyle. If you are in a sexual relationship, first thing to do when you miss your periods is to check for pregnancy. Get a home kit, its easy to use. If you have just started or stopped taking a pill, your body might be just reacting to a foreign entrants, or the absence of a familiar body respectively. For a virgin, missing a period might imply hormonal imbalance, sudden change in lifestyle, some undiagnosed disease or infection. See a gynecologist.



What are the chances of pregnancy if my guy uses a condom?
Condoms are largely successful at preventing pregnancy. But there is always a probability of a condom getting torn while sex. In such a case, nothing can be guaranteed and its advised to go for an emergency contraceptive.



What are common STD's and how can I be save myself from them?
STDs are sexually transmitted diseases that may be acquired by sexual contact with a person already suffering from them. The most common sexual and sexually transmitted diseases are Chlamydia, Scabies. Pubic Lice, Gonorrhea, HIV, Herpes, Molluscum Contagiosum or Water Warts, Thrush or Candida, Trichomoniasis, Hepatitis, Bacterial Viagnosis, Chancroid, Syphilis, Mycoplasma Genitalium and Genital Warts. While most of them are curable but watch out for the ones that are not. All of these diseases have different symptoms and can be easily identified or diagnosed. Abstinence from sex is the only way to ensure 100% prevention against STDs. For those who wish to indulge in sexual pleasures should practice some basic precautionary measures to save themselves from acquiring sexual as well as sexually transmitted diseases. It is very important to be faithful to your partner. This reduces your risk for catching sexually transmitted diseases to a great extent. Get yourself and your partner checked for STDs before indulging in any sexual activity. Always, always use a condom for sex. Though it is not 100% safe, but is a great help.