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QUALITY CARE IN REPRODUCTIVE
HEALTH AMONG FAMILY PHYSICIANS IN
KARNATAKA
Reproductive Health
TRAINING MODULE
Indian Medical Association
Karnataka
London School df Hygiene
and
INDIA.
Tropical Medicine
London, U.K.
February 2000
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CONTENTS
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1.
Foreword
2.
Workshop Programme
3.
Role of Private Medical Practitioners in the Provision
of Reproductive Health Services.
4.
Menstrual Disorders in Anaemia
5.
Reproductive Tract Infections
6.
Sexually Transmitted Diseases & HIV
7.
Mental Health & Gynaecological Disorders
8.
Patient Doctor Communnication
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WORKSHOP ON DELIVERY OF QUALITY CARE
IN REPRODUCTIVE HEALTH AMONG PRIVATE
PRACTIONERS / FAMILY PHYSICIANS
IN KARNATAKA
Saturday Sth and Sunday 6th, February 2000
VENUE :
Hotel Gateway,
Residency Road,
Bangalore.
ORGANISED BY
INDIAN MEDICAL ASSOCIATION
(STATE HQ)
IN ASSOCIATION WITH
LONDON SCHOOL OF HYGIENE AND
TROPICAL MEDICINE, LONDON, U.K.
There is no Registration fee.
Last date for registration is 2Olh January 2000
Register early as number of delegates is limited to 40 only
Send your participation form to the undersigned :
Dr.Kishore Murthy
Health Management Consultant
Organising Secretary, QARCH 2000
Adviser Health, A.F.Ferguson & Co.
11, Ashley Park Road, off MG Road
Bangalore - 560001
Tel: 5583871 / 1750 Fax : 5581745
E-mail : affmc ©vsnl.com
ROLE OF PRIVATE MEDICAL PRACTITIONERS IN THE
PROVISION OF REPRODUCTIVE HEALTH SERVICES
PROF. JAGADISH C. BHATIA
CONSULTANT
HEALTH SYSTEMS MANAGEMENT
1
The private health care sector is an important constituent of India's health care
system. It caters to the health and medical care needs of a very large segment of both
urban and rural population. In recent times, with increase in the demand for different
types of health care, there has been tremendous expansion of this sector. The opening of
insurance sector to private enterprises is likely to give further fillip to the development of
private health care systems in India. The available information from health care utilization
studies indicate that there is high dependence of health care seekers on the private sector
and a large proportion of health services are provided by the private institutions and
practitioners as compared to the government facilities (Chatterjee, 1988). Several studies
indicate that in rural area only 10-20 percent of the people uses PHCs medical facilities
(Chuttani et.al. 1976; Johns Hopkins University, Department of International Health 1976;
Khan 1989). A study by Duggal and Amin (1989) indicates that in over three-fourths
(77%) of illness episodes, the patients used private practitioners and hospitals. The
evidence also indicates that private health care services are utilized by all socio-economic
classes. In another study in Bombay slums, it was found that for short term and minor
ailments, patients overwhelmingly used private medical practitioners (Yesudian 1990).
Private spending on health care
Information on household expenditure on health care in India is available from
several small and large studies. This is summarized below:
YEAR
PLACE
1958
All India
0.40 to 7.20
Seal 1961.1962,1963
1968-69
Punjab (Rural)
8.1 1
Parker 1986
1973-74
Punjab (Rural)
16.29
Parker 1986
1973
Tamil Nadu
16.0
Rao 1973.
1973-74
All India
(Urban & Rural)
14.05
NSSO 1982
Karnataka
(Rural)
54.0
Nichter 1980
Karnataka
(Rural)
39.0
Bhatia 1983
Bombay
(Middle Class)
240.0
Duggal 1986
1980
1983
1984
PER CAPITA ANNUAL
HOUSEHOLD EXPENDITURE
ON MEDICAL CARE
(Rupees)
2
SOURCE
1984
1985
1990
Bombay
(Lower Class)
176.0
Duggal 1986
Maharashtra
(Urban & Rural)
183.0
Duggal & Amin 1989
142.60 (Urban) &
151.81 (Rural)
per illness episode
NCAER 1992
All India
(Urban & Rural)
1990-91
M.P (Rural)
24.93
George et.al. 1994
1993
All India
(Urban & Rural)
204.0
NCAER 1995
It could be seen from the above that there are considerable regional variations in
private spending on health care, but it is clearly evident that there has been steady increase
in personal health care expenditures over the years.
The size of private health care sector in India
It has been reported by the Central Bureau of Health Intelligence (CBHI) that in
1988 private organizations and voluntary agencies owned more than half (56%) of
hospitals and approximately one-third (30%) of hospital beds. Here too there are
significant intei-state variations. In Kerala, 92 % of the hospitals are owned by private
and voluntary agencies and this percentage is 70 in Maharashtra. The latest statistics on
the size of private sector are not available, but there has been phenomenal increase in this
sector during the last decade and the proportion will be much higher at present.
Furthermore, since a large number of institutions, especially small hospitals and nursing
homes, in the private sector are not recorded in these health statistics; the official statistics
underestimate the size of private health sector.
Another important indicator of the development of this sector is the number of
physicians practicing privately or engaged in organizations in private sector. According
to the Government of India's estimates based on 1981 census data, out of a total of
2,36,000 qualified allopathic medical practitioners, 69 percent are in the private practice.
In addition 90 percent of an estimated 4,50,000 non-allopathic and unqualified
practitioners work as private practitioners (GOI 1984). Several studies in India have
shown that unqualified or indigenous medicine practitioners practice allopathic system of
medicine (Neumann, Bhatia and Murphy 1967; Bhatia et.al 1975; Chuttani et.al 1973).
Patients from rural areas or small towns are not able to make a distinction between
qualified and unqualified practitioners.
3
Private health care sector and reproductive health of women
One of the dominant themes of the International Conference on Population and
Development held in Cairo in September 1994 was reproductive health. Reproductive
health has been defined by the World Health Organization as a "state of complete
physical, mental and social well being and not merely the absence of disease or infirmity,
in all matters relating to the reproductive system and to its functions and
processes"(United Nations, 1984). Thus the three main dimensions of reproductive health
among adult women are avoidance of unwanted pregnancies, safe motherhood, and
protection against infections and dysfunctions of the reproductive tract, including sexually
transmitted diseases. The first dimension has received considerable attention since the
inception of official family planning programme in India in 1952; the second was
emphasized particularly after the Safe Motherhood Conference at Nairobi in 1986.
However, the third dimension i.e. gynaecological morbidity has been badly neglected.
Gyneacological morbidity can be defined as structural and functional disorders of the
genital tract not related to pregnancy, delivery, or puerpeium. It includes menstrual
disorders, reproductive tract infections, cervical cell changes, genital prolapse, and such
other conditions as syphilis, urinary tract infections, hypertension, anaemia, chronic
energy deficiency (CED), and obesity. The incidence of both obstetric and gynaecological
problems in India is quite high. The results of a study carried out in Karnataka indicates
that two-fifths (40%) of the women reported at least one morbid episode during antenatal,
natal and post-natal period of their most recent delivery (Bhatia & Cleland 1996). A
study conducted in Maharashtra shows that more than nine-tenth of the women included
in the study had at least one gynaecological problem (Bang et-al. 1989). In a Karnataka
study, the laboratory investigations revealed evidence of reproductive tract infections in
more than one-half(56 %) of the cases (Bhatia et.al. 1997).
So far as consultation for reproductive health problems is concerned, available
information in Karnataka indicates that nine out of ten women had at least one antenatal
consultation during their most recent pregnancies. A large number of these consultations
were with private medical practitioners. Furthermore, out of the total number of
deliveries, which took place in hospitals, the majority was in private institutions. Private
nursing or maternity home and hospitals are becoming increasing popular even among the
rural people (Bhatia and Cleland 1995a). Survey data also indicates that majority of
consultations for gynaecological problems are also with private medical practitioners
(Bhatia and Cleland 1995b).
Quality of care in the private sector
The rapid expansion of the private sector has profound implications for the present
character of Indian health care system and its future course. Private institutions and
doctors are patronised even by the rural people because of the poor reputation and
inadequacies in the public health care delivery system. People willingly incur substantial
expenses rather than availing themselves of cheaper services from government facilities.
People appear to prefer private practitioners, perhaps because perceived quality of care is
higher an/or because doctor-patient rapport is presumably better. However, there is no
clear evidence to support this contention. The existence of private health care services
cannot be automatically equated with better quality and efficiency. There is a need to
answer this question through empirical evidence, which is relatively scarce. There is an
4
agent-principal relationship between the doctor and patient, which could result in
inefficiency and poor quality because the doctor has an incentive to perform more than the
needed services to maximize his revenues. Furthermore, the influence of pharmaceutical
companies affects the prescribing patterns and the mix of services or medicines prescribed
is not necessarily the most desirable from the cost-minimization point of view. For
example, available evidence indicates that there is a very high level of use of injections by
the medical practitioners. This is because the patients expect and have faith in injections.
Since the placebo effect of injections is very high, doctors consider it worth giving
injections rather than losing a patient forever (Bhatia and Cleland 1999). Greenhalgh
(1987) in a survey of 2400 patients treated by private and public medical providers,
observed that private doctors prescribe a large number of drugs. The study reports that
combinations/preparations containing 'hidden' classes of drugs are often suggested and
anteinfectives are widely and often inappropriately used. The evidence also indicates that
surgical interventions in delivery are also on the increase and proportion of cases
delivered through episiotomy and caesarian section are significantly higher in private
institutions (Bhatia 1995). In a study conducted in Bombay, it was found that private
medical practitioners have grossly inadequate awareness of treatment regiment for certain
diseases (Uplekar 1989).
In a recent study conducted by the author in Karnataka where private medical
practitioners were interviewed in depth and observed while treating women patients for
their reproductive health problem, it was found that:
•
History taking was inadequate in an overwhelming majority of cases.
•
Male practitioners were not examining the patients at all probably because privacy
was not adequate.
•
Investigations were inadequate and no smears were taken even in a hospital setting,
which had an attached laboratory. No scanning was ordered in gyneacological
problems where it was clearly indicated.
•
Patients were given blind treatment with several drugs.
Partners were not examined or treatment in RTIs and STDs.
•
In reported infertility cases, the practitioners never advised husband to be examined or
ordered smear analysis.
•
In gyneacological problems, in the absence of laboratory investigations, no specific
diagnosis was made and only symptomatic treatment was provided to the patients.
Another phenomenon is self-medication. In a large proportion of illness cases the
patients resort to self medication and patients continue to buy drugs which are prescribed
earlier (Krishnaswamy, Kumar and Radhaiah 1985, Bhatia and Cleland 1999). The
doctors rarely advise the patients about the dangers of self-medication.
5
Need for Continuing Medical Education (CME)
In order to improve the health status of people, particularly the reproductive health
of women, we have to look at the government and private sectors in a more rational
manner. While there is no doubt that government health care facilities need to be
augmented and improved, the promotion of a viable and efficient private sector is also
urgently called for. The improvement in the quality of care is also essential for survival in
current competitive environment. This can be done by updating the knowledge, skills and
treatment patterns of private medical practitioners through Continuing Medical Education
(CME) programmes.
Summary and conclusions
The private sector is an important constituent of India's health care delivery system
and with the opening of health insurance sector to private enterprises, it is likely to
expand further. Available information indicates that more than one-half of total health
institutions, one-thirds of total hospital beds and approximately three-fourths of qualified
allopathic practitioners are in the private sector. Personal expenditures on health care have
also been increasing over the years and form about 5-10 percent of total household
income. The results from several studies indicate that a large proportion of women with
reproductive health problems seek consultation with private medical practitioners.
Although patients perceive that quality of care in the private sector is better, the available
evidence does not support this. There is an urgent need to improve the quality of care
provided by the private medical practitioners to sustain patient's confidence and survive in
the present competitive environment. This objective, to a large extent, can be achieved
through Continuing Medical Education (CME) programmes.
7
REFERENCES
Bang RA, AT Bang, M Batule, ¥ Choudhary, S Sarmukaddam, and O Tale. 1989. "High
Prevalence of gynaecological diseases in rural Indian women". Lancet 8, 629,
1:85-88.
Bhatia JC, Dharamvir, Chuttani CS and Timmappaya A. 1975. Traditional Healers and
Modern Medicine. Social Science and Medicine, 9(1): 15-21.
Bhatia JC. 1995. Levels and determinants of maternal morbidity: results from a
community-based study in south India. International Journal of Gynaecological
& Obstetrics 50 Suppl.2(1995)
Bhatia J. 1983. Assessment of Health Care Needs Care in Rural Karnataka . Indian
Institute of Management, Bangalore, India.
Bhatia JC and Cleland J. 1995a. Self-reported Symptoms of Gynaecological Morbidity
and their Treatment in South India. Studies in the Family Planning,26A:203-2]6.
Bhatia JC and Cleland J. 1995b. Determinations of maternal Care in a Region of South
India. Health Transition Review, 5:127-42.
Bhatia JC and Cleland J. 1996, Obstetric Morbidity in South India. Social Science and
Medicine 43,10:1507-1516.
Bhatia JC, Cleland J, Leela Bhavan and Rao NSN. 1997. Level and Determinants of
Gynaecological Morbidity in a District of South India. Studies in Family
Planning 28,2.
Bhatia JC an Cleland J. 1999. Health Seeking Behaviour of Women and Cost Incurred in
Implementing A Reproductive Health Agenda IN India -The Beginning edited by
Saroj Pachauri, Population Council, South & East Asia-Regional Office, New
Delhi.
Central Bureau of Health Intelligence. 1988. Health Information India - 1988.
Directorate General of Health Services. New Delhi: Ministry of Health and
Family Welfare, Government of India, August.
Chatterjee, Meera. 1988. Implementing Health Policy. New Delhi: Center for Policy
Research.
Chuttani CS, Bhatia JC and Timmappaya A. 1973. A Survey of Indigenous Medical
Practitioners in Rural Areas of Five Different States of India. Indian Journal of
Medical Research, 61 (6):962-967.
Chuttani CS, Bhatia JC and Timmappaya A. 1976. "Factors responsible for
Underutilisation of primary health centres: A community survey in three state of
India, "NIHAE Bulletin 9(3):229-277.
8
Duggal R. 1986. Health Expenditure in India. Foundation for Research in Community
Health Newspaper, 1,1. Mumbai: Foundation for Research in Community Health.
Duggal R. and Amin S. 1989. A Household Survey in an Indian District. Mumbai:
Foundation for Research in Community Health.
George A, Shah I and Nandraj S. 1994. A study of Household Health. Expenditure in
Madya Pradesh. Mumbai: Foundation for Research in Community Health.
Government of India. 1984. Hand Book of Health Statistics. Central Bureau of Health
Intelligence, Ministry of Health and Family Welfare, New Delhi, India.
Greenhalgh T. 1987. Drug Prescription and Self-medication in India: An Exploratory
Survey. Social Science and Medicine, 253:307-318.
Johns Hopkins University, Department of International Health. 1976. Fundamental
Analysis of Health Needs and Services. New York:Asia Publishing House.
Khan ME. 1989. Access to family planning services in rural Uttar Pradesh,"Journal of
Family Welfare 35(3):3-20.
Krishnaswamy K, Kumar BD and Radhaiah G. 1985. a Drug Survey-Precepts and
Practices. European Journal of Clinical Pharmacology, 29:363-370.
National Council for Applied Economic Research. 1992. Household Survey of Medical
Care. New Delhi: National Council of Applied Economics Research.
National Council for Applied Economic Research. 1995. Household Survey of Health
Care Utilisation and Expenditure. New Delhi: National Council of Applied
Economics Research.
National Sample Survey. 1982. Report of the Third Round 1951-52. National Sample
Survey Organisation, Government of India, New Delhi, India.
Neumann AK, Bhatia JC, Andrews S and Murphy AKS. 1971. Role of Indigenous
Medicine Practitioner in Two Areas of India: Report of a Study. Social Science
and Medicine, 5137-149.
Nichter M. 1980. 'Health Expenditure Report, 'New Delhi: USAID (mimeo).
Parker RL. 1986. Health Care Expenditure in a Rural Indian Community. Social Science
and Medicine, 21,1:23-27.
Rao PSS, Rajamanickam C and James Fernandes SR. 1973. Personal Health Expenses
Among Rural Communities of North Arcot District. Indian Journal of Medical
Research, 61.
Satia J. et.al. 1987. Study of Health Care Financing in India. Ahmedabad: Indian Institute
of Management.
9
Seal SC. 1961, 1962,1963. Reports of the General Survey in Madya Pradesh, Bengal,
Bihar, Rajastan, Assam, Uttar Pradesh, Manipur, Delhi. All India Institute of
Hygiene and Public Health. New Delhi: Directorate General of Health Services.
United Nations. 1994. Report of the International Conference of Population and
Development, Cairo. Document A. Conf. 171/13.
Uplekar, Mukund. 1989. Implications of Prescribing patterns in Private Doctors in the
Treatment of Pulmonary Tuberculosis in Bombay, India, 'Report No.41, Takemi
Program in International Health: Harvard School of Public Health, Pune.
Yesudian CAK. 1990. A Study of Health Service Utilisation and Expenditure.
Department of Health Services Studies, Tata Institute of Social Science. Mumbai,
India.
10
MENSTRUAL DISORDERS AND ANAEMIA
DR. LEELA BHAGWAN
CONSULTANT GYNAECOLOGIST
THE BANGALORE HOSPITAL
BANGALORE
11
Definition
Anaemia is a condition of diminished oxygen-carrying capacity of the blood due to a
reduction in the numbers of red cells or in their content of haemoglobin or both.
Symptoms and Signs of Anaemia
The symptoms and signs due to the diminished oxygen-carrying capacity of the
blood are common to all types of anaemia.
They include
1. general tiredness
2. shortness of breath on exertion
3. giddiness
4. headache
5. pallor
6. palpitations
7. Oedema of the ankles.
Causes of Anaemia
The anaemias maybe classified primarily into two groups
1. Those due to some failure in the quality or quantity of new red cells being produced
in the marrow, and
2. Those due excessive loss of red cells from the circulation either from acute or
chronic haemorrage or from abnormal haemolysis.
There is frequent overlap between these two groups since heamorrage leads to iron
deficiency, which is the commonest form
Classification
Deficient Red Cell Production
1 .Iron deficiency anaemia.
2. Vitamin B12 or folic acid deficiency.
Pernicious anaemia
Macrocytic anaemia of pregnancy
3. Anaemia of myxoedema
4. Anaemia of scurvy
5.Impairment of erythroblastic activity
Aplastic anaemia
Chronic infections, uraemia.
Excessive Loss of Red Cells
1. Heamorrhage.
2. Abnormal heamolysis
Congenital defects in the red cells - sickle cell anaemia
Acquired heamolysis in the blood- incompatible blood transfusion, septicaemias.
12
INVESTIGATION OF ANAEMIA
Heamoglobin
The average Hb content of normal blood is I4.8g per dl. Range 13.5- 18.0g in men
11.5- 16.0g in women.
Red Blood Count - 4-6 million/ cu.mm.
Heamatocrit Value or PCV - 45 ml per cent
Mean Corpuscular Heamoglobin Cone. - MCHC
It is measure of Hb within the red cells and a low value is taken as an indication of
iron deficiency anaemia.
Mean Corpuscular Volume.
Serum Iron
Total Iron Binding Capacity
Serum B12
Serum Folate
IRON DEFICIENCY ANAEMIA
Iron Metabolism
In normal men the amount of iron absorbed daily does not exceed 1 to 1.5mg. Iron
is absorbed from the upper small intestine. The body has no way of excreting iron, the
uptake is controlled so that iron loss is replaced but accumulation does not occur. The
mechanism controlling this delicate balance is not known. The average daily loss of iron
is at least doubled in women during the reproductive period of life by menstruation,
pregnancy, and lactation therefore daily absorption should be 2-3mg instead of l-1.5mg.
Aetiology
1. The most important cause of iron deficiency is HEAMORRAGE, which could
be heamatemesis, malaena or menorrhagia.
2. Dietary deficiency of iron - poverty, ignorance or food fad.
3. Impaired absorption of iron - achlorhydria gastrectomy or malabsorption
syndrome.
Clinical Features
1.
2.
3.
4.
Signs and symptoms of anaemia.
Koilonychia
Dysphagia or Plummer-Vinson syndrome.
Blood count- red cell count is only slightly reduced but the Hb content of
blood is reduced because the cells are smaller and thus contain less Hb
(MCH)
12
Treatment
l.Oral Iron- Ferrous Sulphate is used most commonly and 60mg of elemental
iron is there in 200mg of salt. It is cheapest and as effective as others. But if
gastrointestinal symptoms appear other commonly used is Ferrous Fumirate.
Drug interactions for Iron salts: -
1. Methyl Dopa- iron decreases the efficacy of Methyl Dopa.
2. Calcium- iron absorption is decreased with calcium products.
3. Antacids- iron absorption is again decrease.
Prescribing Oral Iron Therapy
To have optimal absorption oral iron should be taken 30 min before food.
200mg of ascorbic acid enhance the iron absorption by 30%.
Avoid taking Calcium rich substances with iron. Only Ca Carbonate preparations
can be prescribed along with iron.
Tea and coffee should not be taken atleast for one hour after iron tablets as
phytates in them decrease the absorption of iron.
Gastrointestinal upset can be reduced if therapy is started with lower dose like I
tab daily and slowly increased to 2 or 3 tabs per day.
LIQUID IRON THERAPY
Liquid form of iron is supposed to have the advantage of fewer side effects as
compared to oral tabs, however it may lead to staining of teeth. Women who prefer to take
liquid form can take it with straw.
PARENTERAL IRON THERAPY
Indications: 1. Malabsorption syndrome
2. Nontolerance to oral iron.
3. Poor compliance
4. No response to oral iron after 4 weeks and IDA is confirmed.
5. Severe anaemia in last trimester of pregnancy.
Calculation of total dose
250mg deficit of Hb %.
Imferron (iron dextran) can be given both IM and IV.
Jectofer can be given only IM.
ANAEMIAS DUE TO VIT B12 or FOLIC ACID DEFICIENCY
Aetiology
This is primarily a disease of the gastric musoca, which in middle age or beyond fails to
produce hydrochloric acid, pepsin and intrinsic factor. The cause of this failure is not
known probably it is an inherited factor thus there is a significant familial incidence and it
commoner in people with blood group A.
13
MENSTRUAL DISORDERS
In healthy women, menstruation sets in approximately between the ages of 12 and 14 yr.
and persists throughout the reproductive period of life with average rhythm of28 days and
duration of flow between 4 and 6 days. It is not uncommon for departures from this
normal sequence to occur in women who are otherwise healthy, minor departures are
therefore not considered pathological. Geographic conditions, racial factors, nutritional
standard, environmental influences and indulgence in strenuous activity can all affect the
age of menarche.
a) Classification of bleeding patterns :
I. Ovulatory Bleeding:
• Normal
• Menorrhagia
• mid cycle (mittelschemerz)
II Anovulatory Bleeding :
• Polymenorrhoea (<21 days)
• Oligomenorrhoea (40 days)
• Metrorrhagia
• Post-menopausal
• Metropathia haemorrhagica
Ill Amenorrhoea
• Physiological
• pathological
PRECOCIOUS
MENSTRUATION
If menstruation starts before the child reaches the age of 10. the condition is
referred to as precocious menstruation. In precocious puberty (before the age of 8) early
menstruation may occur in addition to development of secondary sex characteristics. In
clinical practice it is first necessary to establish that the haemorrage is true menstruation
and not bleeding caused by injuries, scratching or foreign body.
Diagnosis and treatment
1. Genuine precocious puberty- sympathetic care by the physician.
2. S.C. Inj of longing analogue of GnRH for upto 3 yr. suppresses menstruation.
3. Non- cyclical bleeding suggests oestrogenic ovarian tumour therefore exclude by
examination under anesthesia and ultrasound.
4. Occasional bleeding- exclude foreign body by x- ray or u/s.
18
I
I
i
AMENORRHOEA
i
i
Amenorrhoea is defined as absence of menstruation.
>
CLASSIFICATION
i
i
PhysioIogicakPrepubertal
Pregnancy
Lactation
Post-menopausal
These are all self-explanatory.
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t
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Pathological: Primary
Secondary.
Primary amenorrhoea is defined when menstruation fails to begin by the age of 16. or in
the presence of secondary sex characteristics menses do not start by the age of 14.
Secondary Amenorrhoea is defined as amenorrhoea of 6 months or more in women with
previous normal menstrual function.
Aetiology
Primary Amenorrhoea
1. Delayed puberty, which is constitutional.
2. Congenital obstructive defects in the lower genital tract - commonest being
imperforate hymen.
3. Congenital absence or hypoplasia of the uterus.
4. Congenital aplasia of the ovaries.
5. Intersexualism.
6. Hypothyroidism.
/
Secondary Amenorrhoea
1 /
/
1
Surgical removal of the uterus or hysterectomy.
Tuberculosis.
Destruction of both ovaries- radiation and removal.
Ovarian failure.
Polycystic ovaries.
Diseases affecting the pituitary- Anorexia nervosa, pseudocyesis, Sheehans syndrome,
hyperprolactinemia, oral pills.
7. Hyperthyroidism
8. Diabetes mellitus
1.
2.
3.
4.
5.
6.
Evaluation
•
•
•
•
Psychological factors
Family history of genetic abnormalties
Nutritional status
Sexual activity
1
19
/
/
/
MENORRHAGIA
Anyone who has experienced menorrhagia-heavy prolonged bleeding knows how
unpleasant, disabling and frightening it can be. Sometimes the bleeding is so heavy that
it’s necessary to miss work, school or social activities.
Definition
Menorrhagia is defined as excessively heavy or prolonged bleeding. Menorrhagia
is essentially a symptom and not in itself a disease. It is a cyclical bleeding at normal
intervals which is excessive in amount (80ml) or duration (flow lasting more than 7 days).
Aetiology
1.
2.
3.
4.
Those due to some general disease.
Those due to local cause in the pelvis.
Endocrine disorders.
Hormonal.
General diseases causing menorrhagia-
1. thrombocytopenic purpura
2. Severe anaemia.
3. Psychological disorders.
Local causes-
1. Fibroids.
2. Endometrial polyps
3. PED
4. Chocolate cysts of the ovary
5. IUD
Endocrine disturbances
I .Hypothroidism.
2.Estrogens when prescribed for menopausal symptoms.
Hormonal-Dysfunctional uterine bleeding.
This term should be reserved for those patients in whom not only is the pelvic
examination normal but in whom there is no other demonstrable extra- genital cause for
the bleeding. It is now believed that the aetiology is purely hormonal and that the
hypertrophy and hyperplasia of the endometrium are induced by a high titre of estrogen in
the circulating blood.
Investigations
1.
2.
3.
4.
5.
Complete Blood Count
Coagulation profile
Thyroid function tests
Ultra sound
Diagnostic D & C
6. Diagnostic Laparoscopy
21
Classification of DUB
Anovulatory Ovulatory
Puberty menorrhagia Irregular ripening
Metropathia haemorrhagica Irregular shedding
Premenopausal DUB
IUCD insertion
Following tubectomy
Puberty menorrhagia - is caused by excess or unopposed estrogen and the absence of
progesterone in the Anovulatory cycles.
Menorrhagia may be noticed from the very start of menarche but often the initial
periods are normal. Puberty menorrhagia occurs in the form of excessive bleeding or
normal but continuous bleeding lasting many days. Anaemia may supervene.
Investigations
1. Pelvic or rectal examination preferably under anesthesia.
2. Pelvic ultrasound.
Treatment
1. Progesterone or Oral contraceptives may be given.
Tab. Primolut-N, Tab Deviry. Tab Regesterone, Tab MPA, maybe given in the dose
of 20 to 60 mgm for the first 3 days then reduced to 20 mgm daily for 21 days.
Oral contraceptives like Tab Novelon or Femilon may be used for atleast 6 months
Premenopausal Menorrhagia
Here again the cycles are Anovulatory and there is progesterone deficiency.
Investigations
1. Pelvic Ultrasound.
2. Blood pressure and blood sugars.
Treatment
1. Styptics like Tab Styptovit, Tab Dicynene, Tab Ethamsyl, or Cap Gynaec-CVP can
be tried in doses of 1 tds for 3 to 5 days.
2. D D & C and send the currettings for histopathology.
3. Tab Regesterone, Tab Deviry, Tab Meprate, given in the dose of 20 to 60 mgm (lor
2 tabs tid )
4. Hysterectomy preferably vaginal.
5. NSAIDS like Tab Ponstan 500mgm BD or tid can also be given.
Metropathia haemorrhagica
This is a special form of DUB where one can come to an accurate diagnosis, as its
characters are well defined.
22
Signs and symptoms
1.
2.
3.
4.
5.
Most prevalent in women over the age of 40.
Irregular and prolonged bleeding in women who have a delayed menopause.
Painless bleeding as it is Anovulatory.
On PV the uterus maybe symmetrically enlarged with cystic ovaries.
On DD&C plenty of polypoidal endometrium is obtained - HPR will show cystic
glandular hyperplasia
Treatment
1. DD&C in itself may cure the condition.
2. Tab Progesterone may be given in doses of 10-mgm tid from the I5lh to 25th day of
the cycle.
3. Oral contraceptive in younger age group.
Irregular ripening
It is an Ovulatory bleeding in which, due to deficient corpus luteal function,
endometrium receives inadequate support and break through bleeding occurs before the
actual menstruation begins. This bleeding occurs in the form of spotting or brownish
discharge. The endometrium reveals incomplete secretary changes.
Treatment is to administer Progesterone in the premenstrual phase or the last
10 days.
Irregular shedding
This is rare and is a self-limiting process and is due to persistent corpus luteum.
The menstruation comes on time, but is prolonged and not heavy. Endometrial curettage
at the end of menstruation shows persistence of secretary changes along with proliferative
endometrium. The treatment is difficult but fortunately it is self-limiting.
ORGANIC CAUSES OF ABNORMAL UTERINE BLEEDING.
1.
Cervical polyps and other lesions
Bleeding due to cervical polyps is characteristically slight and intermenstrual and
is provoked by defecation or by coitus. Many polyps cause no bleeding at all and
are discovered accidentally.
Treatment- Eversion of the polyp.
2.
Cervical cancer
Cx cancer may present with intermenstrual bleeding or spotting particularly after
coitus. Examination should include a speculum examination under good light, a
Pap smear Colposcopy and direct biopsy.
23
3.
Endometrial polyp
Because of their protected position within the uterine cavity they are less likely to
bleed. Small polyps cause no symptoms but large polyps may bleed excessively.
Uterine cramps are common.
Treatment - Removal with the help of Hysteroscope.
4.
Chronic Endometritis and infections
Endometritis is not a common cause of uterine bleeding. Inflammatory disease of
the tubes and ovary may cause irregular uterine bleeding.
Treatment - a course of antibiotics preferably with metronidazole.
5.
Uterine cancer
Endometrial hyperplasia and adenocarcinoma of the uterine body are usually
present with postmenopausal bleeding. Any bleeding after menopause shc-nld be
investigated.
Diagnosis is by DD&C.
Fibroid uterus
6.
Submucous fibroids are likely to cause bleeding and the endometrium overlying
the surface is necrotic.
Diagnosis is by ultrasound and Hysterscopy.
POLYCYSTIC OVARIAN SYNDROME
This is an important cause of secondary amenorrhoea in young women and is now
regarded as a systemic disorder as there is hyperinsulinism and there is gross dismrbance
of lipid and carbohydrate metabolism. Basically the pathology is in the ovaries with
hyperactivity of theca stromal cells under the influence of LH.
Signs and symptoms
1.
2.
3.
4.
Irregularly irregular cycles.
Obesity.
Hirsutism.
Infertility.
Investigations-
1.
2.
3.
4.
Ultrasound of the pelvis.
Laparoscopy- ovaries may enlarged to 3 to 4 times its normal size.
Elevated LH levels.
Oral GTT shows abnormal glucose levels.
Treatment
1. Oral contraceptives may be given in those not intending to start a family.
2. Ovulation induction regimes with Clomiphene Citrate tabs like Tab. Fertyl given as
50mgm 1 daily at night for 5 days from the 5lh day if the cycle for 5 days. "Dus can
be given for 5 months.
3. Surgical treatment- Wedge resection of the ovaries.
4. Latest protocol is to give oral anti diabetic drug like Tab Metformin 500mgm tds or
BD for a period of 6 months.
24
ADOLOSCENT - DYSFUNCTIONAL UTERINE BLEEDING
This is due to hypothalamic - pituitary - ovarian axis dysfunction and gets corrected
spontaneously in one to tow years.
Symptoms
Patterns of bleeding:
•
•
•
Polymenorhoea
Metropathia Haemorrhagica
Profuse painless bleeding
Physical examination :
•
•
If hymen is perforated PV to be done
If hymen is intact - no PV - do PR
Diff. Diagnosis
a) Pregnancy
b) Organic causes of genital bleeding e.g. TB endometritis
c) Endocrinal causes like - Polystic ovarian disease
Hyperprolactinemeia
Hypothyroidism
d) Other causes
• Idiopathic thromocytopenic purpura
• Leukemia
Investigations
•
Haemogram
• t3, t4 tsh
•
•
Coagulation profile
Abdominal ultrasound
Management
Mild to Moderate DUB
•
•
•
•
Maintain menstrual calendar
Reassurance
Vitamin and iron supplement
Progestine therapy 3-6 months if moderate bleeding
Severe DUB
•
•
•
•
In addition to above management
Blood transfusion if low HB%
D & C when hormonal therapy fails
D & C material to be sent for histopathological study and AFB culture
25
DYSFUNCTIONAL UTERINE BLEEDING
Strategy of management of dysfunctional uterine bleeding.
Age
Dilatation and
curettage
20 and under Only if bleeding
persists or is severe
Hormone and antifibrinolotic therapy
Hysterectomy
whenever indicated,
e.g. excessive bleeding
never (or almost
never)
20-40
Always, but may be
deferred (up to 3
months) if bleeding
moderate, regular,
and there is no
suspicion of organic
disease
First resort after
dilatation and
curettage
seldom, only if
bleeding is persistent
or severe after
dilatation and
curettage and
hormone therapy
40 and over
Mandatory in all
cases
Only after dilatation
and curettage, in
absence of organic
disease
First resort if bleeding
is persistent after
dilatation and
curettage and
hormone therapy
26
PATIENT WITH EXCESSIVE MENSTRUAL FLOW - MENNORRHAGIA
Obtain detailed medical and gynaecological
history, drug ingestion, prior bleeding conditions
or manifestations, exercise, stress, weight
change, possible pregnancy.
>
Undertake thorough physical examination.
Look for evidence of bleeding disorder, thyroid,
ovarian or adrenal dysfunction, as well as
pregnancy and pregnancy-related complications.
Assess objectively by laboratory studies
Beta-subunit hCG
Bleeding time and coagulation profile
CBC, serial hematocrit and hemoglobin levels
-
4”
Positive beta-subunit hCG
Negative beta
submit hCG
41
Ascertain status of uterus
and adnexa
Papanicolaou smear
Evaluate for Ectopic pregnancy,
Incomplete abortion
I
—I
T”
Mass is detected
Findings are normal
Obtain pelvic
ultrasonography
or computer tomography
Hysterography
V
V
Uterine leiomyoma
confirmed
Adnexal mass
detected
Unclear pathology
DILATATION AND
CURETTAGE
Evaluate and
treat
I
V
V
Diagnose
Leiomyoma
Adenomyosis
Endometrial
polyps
Adenocarcinoma
Diagnose dysfunctional
uterine bleeding
Follow-up in 3 months
I
V
V
Bleeding recurs
Bleeding abates
v
Supplement with progestin or
oral contraceptives
I
V
Unresponsive bleeding
Bleeding abates
V
REPEAT DILATATION
AND CURETTAGE
I
V
V
Bleeding persists
Symptoms resolve
V
Weigh future fertility needs
____ i____
Follow-up in 3 months
[Consider option of HYSTERECTOMY]
27
PATIENT WITH INTERMENSTRUAL BLEEDING
Probe detailed medical, gynecological,
contraceptive and obstetrical history.
Determine possibility of pregnancy, bleeding
tendency.
Assess for obesity, hypertension, diabetes.
>
Undertake thorough physical examination
Obtain laboratory studies, including complete blood
count, urinalysis, coagulation profile,
Papanicolaou cytology, endometrial sampling,
pregnancy test, and pelvic ultrasonography.
Determine source of bleeding by observation
Look for local lesion, trauma, foreign body
V
V
Bleeding is extrauterine
Bleeding source is uterine
Inspect vulva carefully
Exclude pregnancy by beta-subunit
human chrionic gonadotropin (hCG)
4s
I
V
V
No lesion is seen
Lesion is found
i
V
;
Undertake vaginal
exploration
Diagnose and treat
V
Lesion identified
No lesion is seen
Diagnose and treat
Inspect cervix
V
V
Ulceration disclosed
No lesion is seen
Diagnose and treat
Examine
catheterized
urine specimen
Determine
contraceptive
practice
Evalute for ectopic
pregnancy,
threatened or
incomplete abortion
I
V
V
Negative hCG
Positive hCG
Intrauterine
device
Oral
contraceptive
Consider removal
Break through
bleeding
~l
V
Obtain pelvic
ultrasonography
Undertake evaluation
V
Abnormal findings
I
None
DILATATION AND
CURETTAGE
I
V
""I
Benign condition
found
V
V
Negative
examination
I
Diagnose and treat
as needed
Resolved
$
V
Determine cervica
or uterine cancer
V
Recurrent bleeding
J
HYSTEROSCOPY
Follow-up care
Consider REPEAT
CURETTAGE
28
PREMENSTRUAL SYNDROME
PMS consists of various physical and/ or emotional symptoms that occur in the
second half of the menstrual cycle after ovulation. The symptoms begin about midcycle
and are generally the most intense during the last 7 days before mensturation.
Causes
There’s still some disagreement about what causes PMS but it is definitely linked
to hormones. PMS symptoms begin in the second half of the menstrual cycle, at this time
production of the female hormone progesterone increases. Then about 7 days before the
menstrual period production of both progesterone and estrogen decreases dramatically.
Many women find that PMS worsens as they get older-this also suggests a hormonal role.
Hormonal imbalances are more likely the closer a woman is to menopause.
Pre-menstrual syndrome is not just a single clinical entity but probably constitutes
a number of different syndromes. Etiology is as yet unclear and management to date has
been largely empirical. The syndrome is clearly related to and perhaps a variant of
otherwise normal physiologic overian function. This is evidenced by the effective
reversal of its manifestations by gonadotropic in releasing hormone against, which
suppresses ovarian function.
Diagnosis
Timing of Symptom : a week or more prier to the onset of menstruction.
• Cyclicity with ovulatory cycles
• Repetitive nature of the symptoms
• Prompt disappearance of symptoms after the onset of menstrual bleeding.
Symptoms:
Breast engorgement, sensitivity and discomfort, fluid retention, weight gain,
abdominal pain or bloating, odema of lower extremities, headaches, dizziness,
pallpitations, acne, mood changes and irritability, depression.
A complete history and thorough physical examination has to be done.
Laboratory examinations
•
•
Routine blood & urine examination.
Serum Prolactin
Psychoogical assessment
Therapy is elusive. Balanced Diet, exercise and vitamins (Vitamin B6, magnesium)
evening primrose oil should be tried before embarking on a programme of hormonal
therapy. Dietary7 modification to reduce sodium intake (salt intake) in the second half of the
cycle. Diuretics, analgesics, or oral contraaceptives may be used judiciously.
Avoid stimulants such as tea, coffee, chocolate and caffeine containing soft drinks.
Relief breast discomfort with supportive brassieres.
Mild Symptoms
•
•
Trial with oral contraceptive pills.
Progesterone administration in the luteal phase
29
DYSMENORRHEA
There are probably few women who can truthfully claim they never had dysmenorrhea;
majority of woman is thought to experience some degree of dysmenorrhea. Literally
means painful menstruation and can be of sufficient magnitude so as to incapitate day to
day activities. There are 2 types:
1. Primary (spasmodic)
2. Secondary.
Primary dysmenorrhea
No disease or other medical cause can be found for the pain and other symptoms,
which may include backache, diarrhea, dizziness, headache, nausea, vomiting, and a feeling
of tenseness. Primary dysmenorrhea frequently affects women in their teens and early 20s
who have never had a baby (adolescent girls). Appears within 2 years of menareh. Mother or
sister may be dysmenorrhic Psychosomatic factors due to tension and anxiety during
adolescece. Almost always confirmed to ovulatory cycles, pain is cured fl lowing pregnancy
and vaginal delivery. The pain is related to dysrhythmic uterine contraction and hypoxia.
The symptoms are caused by prostaglandin, a natural hormone produced by the cells in the
endometrium. The level of prostaglandin increases in the second half of the menstrual cycly
and when the period begins the endometrial cells release the prostaglandin as they are shed.
Women with severe dysmenorrhea have significantly higher prostaglandin level in their
menstrual fluid. These symptoms last only for two or three days. Abdominal or pelvic
examination does not several any abnormal findings.
Secondary Dysmenorrhea
This is caused by a physical condition and women who suffer tend to be older.
Some of the causes are.
1. Adenomyosis.
2. Endometrial polyps
3. Endometriosis.
4. Gobroids
5. PED
6. UseoflUCD
Investigations
1. Pelvic examination
2. Ultrasound of the pelvis
Treatment
.
General measures include improvement of general health and simple
psychotherapy in terms of explanation and assurance. Usual activities including sports
and exercises are to be continued.
During periods, bowel should be kept empty; mild analgesics and antispasmodics
may be prescribed. Habit forming drugs such as pethidine or morphine must not be
prescribed. With these simple measures, the pain is relived in majority.
30
Drugs
The drugs used are:
• Prostaglandin synthetase inhibitors
• Oral contaceptives (combined oestrogen and progestogen)
Prostaglandin Synthetase Inhibitors (PSI)
These not only reduce the prostaglandin synthesis but also have a direct analgesic
effect, any of the preparations listed in the table can be used orally for 2-3 days starting
with the onset of period. The drug should be continued for 3-6 cycles.
(i)
(ii)
(iii)
Fenabate group - Mefanamic acid 250-500 mg 8 hourly or Flufenamic acid 100200 mg 8 hourly
Propionic acid derivatives Ibuprofen 400 mg 8 hourly or Naproxen 250 mg
6 hourly
Indomethacin 25 mg 8 hourly
The suitable cases are - comparatively young age and having contraindications to
‘pill’. The contraindications of its use include allergy to aspirin, gastric ulceration and
history of asthma.
Oral Contraceptive Pills
The suitable candidates are patients - (I) wanting contraceptive precaution, (ii)
with heavy periods and (iii) unresponsive or contraindications to anti-prostaglandin drugs.
The pill should be used for 3-6 cycles.
Secondary (Congestive)
Secondary dysmenorrhoea is normally considered to be menstruation - associated
pain occurring in the presence of pelvic pathology.
Cause of Pain
The pain may be related to increasing tension in the pelvic tissues due to
premenstrual pelvic congestion or increased vascularity in the pelvic organs.
Common offending lesions are - Chronic pelvic infection, pelvic endometriosis,
adenomyosis, uterine fibroid, endometrial polyp, IUCD in-utero etc.
Patient profile
The patients are usually in thirties; more often parous and unrelated to any
social status.
31
Clinical features
The pain is dull, situated the back and in front without any radiation. It usually
appears 3-5 days prior to the period and relieves with the start of bleeding. The onset and
duration of pain depends on the pathology producing the pain. There is no systemic
discomfort unlike primary dysmenorrhoea. The patients may have got some discomfort
even in between periods. There are symptoms of associated pelvic pathology.
Abdominal and vaginal examinations usually reveal the offending lesion,
times, the lesion is revealed by laparotomy or laparoscopy.
At
Treatment
The treatment aims at the cause rather than the symptom. The type of treatment
depends ont he severity, age and parity of the patient.
Membranous Dysmenorrhoea
This is one variety of primary dsymenorrhoea but is rare. There is shedding of big
endometrial casts during period. It is probably due to the deficiency of the tryptic ferment
normally secreted in the endometrium. The treatment is the same as that for primary
dysmenorrhoea. But the success rate is very low. It is not relieved even following pregnancy.
Ovarian Dysmenorrhoea
The clinical entity was first described by O’Donnel Browne. The pain usually appears
2-3 days before menstruation. The pain is continuous and dull and is distributed to either one
or both quadrants innervated by Tio to LI segments. The pain is ascribed to ovarian nerve
degeneration of sclerocystic condition of the ovary. In obstinate cases, division of the
infundibulopelvic ligament carrying ovarian sympathetic nerves is prescribed.
Right ovarian vein syndrome
Right ovarian vein crosses the ureter at right angle. During premenstrual period,
due to pelvic congestion or increase blood flow, there may be marked engorgement in the
vein>pressure on ureter>stasis>infection>pyelonephritis>pain.
Causes of unilateral pain during period
(Dysmenorrhoea)__________________
• Ovarian dysmenorrhoea
*
• Bicomuate uterus
• Unilateral location of pelvic
endometriosis
• Small fibroid polyp near one
cornu
• Right ovarian vein syndrome
• Colonic or caecal spasm
32
Mittelschmerz’s Syndrome (Ovular pain)
Ovular pain is not an infrequent complaint. It appears in the midmenstrual period.
The pain usually situated in the hypogastrium or to one side and does not change from
side to side according to which ovary is ovulating. Nausea or vomiting is conspicuously
absent. It rarely lasts more than 12 hours. It may be associated with slight vaginal
bleeding or excessive mucoid vaginal discharge.
The exact cause is not known. The probable factors are - (i) increased tension of
the Grafian follicle just prior to rupture, (ii) peritoneal irritation by the follicular fluid
following ovulation and (iii) contraction of the tubes and uterus.
Treatment is effective with assurance and analgesics. In obstinate cases, the cure
is absolute by making the cycle anovular with contraceptive pills.
Pelvic Congestion Syndrome
There is disturbance in the autonomic nervous system which may lead to gross
vascular congestion with pelvic varicosties. The patient has a congestive type of
dysmenorrhoea without any demonstrable pelvic pathology.
The patient complains of vague disorders with backache and pelvic pain at times
with dyspareunia. There may be menorrhagia or empimenorrhoea. The uterus may feel
bulky and boggy.
The treatment in unsatisfactory and the protocol may be the same as that of
premenstrual syndrome. In parous women with advancing age, hysterectomy may relieve
the symptoms.
33
PATIENT WITH MENSTRUAL PAIN
Probe history of pain pattern, relation to
menarche, periods, quality, cyclicity,
progression, radiation and other associated
symptoms.
Degree of incapacitation y pain and effect of
pain medications, if any.
Prior pelvic inflammatory disease, intrauterine
device use, other gynaecological or medical
conditions.
Psychosocial assessment.
>
Ascertain temporal relationship to menses
I
Contemporaneous, comenstrual
Unrelated to periods
Perform detailed physical
examination
Evaluate abdominal pain as
presenting symptom
I
V
—4
Abnormal findings disclosed
No pelvic abnormality
Undertake diagnostic evaluation
for secondary dysmenorrhea,
including ultrasonography,
hysterosalpingography, and
laparoscopy, if indicated.
Manage for primary dysmenorrhea
T
I
Diagnose and treat
endometriosis, adenomyosis,
uterine anomaly, uterine
leiomyomas, salpingitis or
adnexal disorder.
I
V
V
Symptoms persist
despite correction
Symptoms are relieved
by correcting condition
found
Determine contraceptive needs
4
I
Follow-up care
V
No need^at present
Need exists
Provide therapeutic sequential
trials of prostaglandin inhibitor,
analgesic drug, and
hypnotherapy. Offer support
and counselling.
Evaluate and counsel
about contraception
4-
|
V
Symptoms persist or
become incapacitating
Relief is achieved
4’
Follow as needed
34
>
Consider:
CERVICAL DILATATION,
PRESACRAL NEURECTOMY
or HYSTERECTOMY
MANAGEMENT PROTOCOL OF PRIMARY DYSMENORRHOEA
• Assurance
• Analgesic and antipasmodic drugs
• To empty the bowel
• Encourage normal activities
Fails
I
• No contraindication of ‘Pils’
• Wanting contraception
• No contraindication A.P. Drugs (PSI)
• Presence of contraindication of ‘Pil’
• Patient wanting pregnancy
• Presence of contraindication of P S I
V
> Oral contraceptive pills
(3-6 cycles)
Anti-prostaglandin drugs
(PSI)
No contraindication of either
I
I
Fails
Laparoscopy
To exclude pelvic pathology
(endometriosis)
I
Dilatation of the cervix
!
Recur
;
Repeat dilatation
I
I
Fails
Pre-sacral neurectomy
35
PATIENT PRESENTING WITH PELVIC PAIN
Obtain detailed history
Concentrate on past abdominal and
gynaecological illnesses.
Determine evolution and events
relating to current pain episode.
>
Probe pain pattern
Acute, intermittent, progressive, or chronic
Degree of associated incapacitation,
Characterize nature and determine radiation
Assess for factors that enhance or relieve pain.
Determine relation to menstruation, position change
Plain produces acute distress.
Progressive in nature, Associated
with signs of peritonitis, bleeding,
sepsis, or shock.
Pain is chronic
Recurrently episodic
Nonprogressive course
Stable general condition
Pain intermittent
I
1
▼
Relieved by change
in position
Unrelieved by
position change
4
Assess for radiation
Undertake thorough physical
examination and laboratory
investigations CBC, urinalysis,
pregnancy test.
Consider:
Urinary tract
infection
Gastroenteritis
Sickle cell crisis
Other non surgical
abdominal
disorders
I
3
V
Localized
to pelvis
Radiates
to flank
__ I
4’
Diagnose acute
abdominal
emergency
V
Conduct physical examination and
appropriate laboratory studies, as
indicated.
Pelvic mass palpated
Note size, shape,
consistency, mobility,
tenderness.
Ultrasonography
Radiographic studies
I
Differentiate
Adnexal accident
Tubo-ovarian abscess
Ectopic pregnancy
Salpingitis
Uterine myoma
Endometriosis
V
Assess need, urgency, timing for
undertaking surgical procedure.
36
Clinical and
laboratory studies
are unrevealing
Rule out
Dysmenorrhea
Dyspareunia
Psychosomatic pain
Malingering
Gastrointestinal
urinary, orthopedic,
or neurologic
condition
I
Consider
urolithiasis
Excretory
urography
REPRODUCTIVE TRACT INFECTIONS
(NON SEXUALLY TRANSMITTED)
DR.PUSHPA SRINIVAS
PROF.HEAD DEPT OF OBSTETRICS & GYNAECOLOGY
DR.B.R.AMBEDKAR MEDICAL COLLEGE
BANGALORE
37
INTRODUCTION
Reproductive tract infections (RTI ) are infections of lower tract (vulva, vagina, cervix),
upper tract (uterus, fallopian tubes, ovaries) - caused by a variety of bacterial, viral and
protozoa infections.
Reproductive tract infections (RTI) is one of the common causes of gynaecological
morbidity. Most but not all RTI are sexually transmitted(STI). Similarly some STI like
HIV, Hepataitis B infections are more systemic disorders than RTI. RTI including
sexually transmitted infections (STI) are responsible for a large amount of female, male
and infant morbidity and mortality causing enormous public health burden in India.
Reproductive Tract Infections
Lower genital tract
Upper genital tract
Vulva
Vagina
Cervix
Uterus
Fallopian tubes
Ovary
At the International conference on population and development held at Cairo, Egypt in
September 94 a programme was adopted to make reproductive health services universally
available. Reproductive health services has three main dimensions.
a)
Avoiding of unwanted pregnancies.
b)
Safe motherhood.
C)
Protection against infection and dysfunction of the reproductive tract including
sexually transmitted disorders. This particular aspect is badly neglected and needs
proper attention.
The reproduction and child health programme in India, was officially launched on 15th
October '97 in which services for the prevention and treatment of RTI are an integral part
of the programme.
Magnitude of the Problem
75% of the women with RTI are below the age of 25 years and 40% of gynaecological
OPD attendenqe is because of RTI. Pelvic inflammatory diseases (PID) constitutes 15%
of gynaec admission.
Community based prevalence studies of gynaec morbidity have shown marked variation
in their results e.g. excessive discharge as a symptoms varied from 13 to 75% and
symptoms indicative of RTI or related morbidity (PID) ranged from 55-84%. The three
commonly used modes of assessing RTI in community based studies are - self reported
symptom, clinical diagnosis and laboratory examination.
38
Prevalence of Clinically Diagnosed RTI
Vaginitis
Cervitis
Cervical erosion
PID
4 - 62 %
8 - 48 %
2 - 46 %
1 - 24 %
In two villages in Maharastra the prevalence of clinically diagnosed RTI was 64% and in
other studies it ranged from 19% to 71%. In a study from rural Karnataka 36% of women
had clinical and 56% lab evidence of RTI.
The self reports yeilded a lower estimation suggesting that many infections are
asymptomatic - in one study it is as high as 82%.
The annual incidence of STI in India is estimated as 5% which means approximately 40
million new infections every year.
It is important to note that several community based studies have shown that RTIs are not
limited to high risk population but also is prevalent among others, particularly with poor
health facilities.
Sequelae of RTI
RTIs leads to several problems notable among them is the high incidence of infertility
which is a major psycho social problem in our community. About 15-25% of women who
developed PID become permanently infertile as a result of tubal blockage.50-80% of
female infertility in Africa is thought to be due to RTI.
It should be emphasised that RTI increases the risk of transmission of HIV infection.
Infact the awareness of RTI has improved of late because of the wide spread educative
information regarding HIV infections.
Sequelae of RTI
Gynaecological
Obstetrics
Infertility
Chronic pelvic pain
Irregular menstruation
Tubal pregnancy
Abortion, preterm delivery
PROM, still birth
Congenital infection
39
Lower Genital Tract Infections
VAGINA
VULVA
CERVIX
Natural Defence Mechanism (Lower Genital Tract)
VULVA
• Inherent - resistance to infection,
• Apocrine gland is rich in undecyclinic acid which is fungicidal.
• Closure of introitus by apposition of labia minora.
VAGINA
• Apposition of anterior and posterior vaginal wall
• Tough epithelium, no glands no crypts no multiplication
• Acidic PH because of doderliens bacilli, glycogen, lacticacid & oestrogen hormone.
CERVIX
• Mucus plug which is bactericidal
Vaginal defences are lost due to change in PH from acidic to alkaline during prepubertal
period, menstruation, after delivery, during menopause.
Natural Defence Mechanisms (Upper Genital Tract)
UTERUS
• Periodic shedding of endometrial lining during menstruation .
• Closure of uterine osteum of the falliopian tube even with minimum inflammation.
• Harbouring of non pathogenic micro-organisms which acts as scavengers
FALLOPIAN TUBES
• Peristalisis of tubes and movements of cila towards uterus.
TYPES AND CAUSES OF RTI
• RTI can affect lower and upper tracts.
The causes of RTI are :
Endogenous - Infections caused by over growth of organisms normally found in genital
tract. These are seen particularly in individuals who have inadequate personal, sexual and
menstrual hygenic practices.
Sexually Transmitted - The second route of infection is sexually transmitted diseases
mainly through unsafe sexual contact.
Iatrogenic - This is due to unhygenic procedures adopted during abortion, deliveries and
IUD insertions.
40
Reproductive Tract Infections.
SEXUALLY TRANSMITTED
INFECTIONS
NON-SEXUALLY TRANSMITTED
INFECTIONS
•
•
•
•
•
Gonococci
Syphilis
Chlamydia
Herpes genitalis
Condylomata accuminata
•
•
•
•
•
•
•
Vulvovaginitis in children
Atrophic (senile ) vaginitis
B V (Bacterial Vaginosis )
Iatrogenic - Foreign body, IUD
Post abortal, post delivery, HSG
Endometrial biopsy, curettage
Termination of pregnancy
STI > Non STI
TRICHOMONAS VAGINITIS ,
MIXED INFECTIONS
NON STI > STI
CANDIDA.
Infections of Vulva
Vulvitis is local infection of vulva.
Causes
1) Infections
2) Allergic
3) STI
- Folliculitis
- Scabies, ring worm
- Thread worm
- Bartholinitis
- Contact dermatitis
- Synthetic undergarments
- Soap, dettol, detergents
- Deodarant menstrual pad/napkins
- Tight garments.
- Herpes genitals.
- Molluscum contagiosum
- Condylomata accuminata
4) Associated with
medical disorders
5) Secondary to vaginal
discharges
- Anaemia, Vit A, B,
deficiency, diabetes.
- vaginitis or cervicitis.
41
6) Hormonal
Vulvoginitis in
children
Senile
Vaginitis.
7)Psychological
stress.
Symptoms
1.
2.
Itching sensation, persistant prolonged.
Vulval irritation.
- Painful with burning.
- Scratch marks burning.
- Dysuria.
- Dyspareunia.
3. Abormal vaginal discharges.
Signs
Inspection of vulva.
Redness, oedema, Folliculitis, Abrasions, swelling, ulcer, warts, condyloma /
vesicles / depigmented patches.
Introitus may be involved with inflammation.
Speculum examination : Any signs of vaginitis / cervicitis.
Diagnosis :
Clinical - History & Examination.
Laboratory :
1.
Blood - Hb% - Peripheral smear
Routine urine analysis
Stool - ova cyst.
2.
Scrapings from the lesion - with 10% KOH on a glass slide
Hypae can be seen
Fungal
Treatment
SPECIFIC
- Treat Specific etiological factor.
Antimierobia given for secondary bacterial infection.
0.5% Hydrocortisone oitment for 3-4 / day for itching
- Antihistamine Calamine lotion.
Estrogen - ethynyloestradiol 0.01 mg OD for 2-3 weeks
Antifungal c ream - Clotriamazole / Micolozole for 2-3 weeks.
Scabies
- Treat other members of the family & sexual partners.
10% Benzyl Benzoate from chin to toes for 3 days Also to wash all cloths and bed
linen.
42
Pediculosis
Gamma benzene hexachloride applicastion over night or Shampoo for 5 months.
- Clothes bed linen, washed before and after treatment.
Allergic
Avoid allergens
- Topical hyderocortisone.
Systemic
Manage
Specific
Vaginal disease - treat according to the infecting organisim.
Menopausal
Estregen creams x 3 weeks.
Helmenthiasis
Piperazine citrate - 30ml orally
Psychological
Reassurance
Counselling.
PREVENTION
Awarness of STD
Personal , sexual, menstrual hygenie.
Frequent changing of undergarments.
Bath plain water , no soap .
Keep area dry, use cotton panties.
Avoid tight garments.
Good health & nutrition. To reduce weight
PRURITUS VULVAE
a) With Abnormal vaginal discharge ( 70 - 80%)
Trichonomas vaginalis, Candida albicans
Diagnosis by Wet preparation, culture and Papsmear.
b) No vaginal discharge
1. With ST<in lesion
Taenia, Scabies, Psoriasis, Pedicuosis, Allergy.
2. No skin lesion
Systemic diseases - Diabetis, Anemia Jaundice,
VIT B12 deficiency. Psychological.
43
Infections of Vagina
The normal vaginal flora contains beneficial bacteria as well as potentially pathogenic
bacteria. Canadida albicons is seen in 20% and TV in 25% during the reproductive age
period and they remain asymptomatic and so also BV (Bacterial Vaginosis).
Women harbouring organisms without symptoms of vaginitis
•
•
•
•
•
•
•
beneficial bacteria - lactobacillus acidophillus
non - pathogenic - diphtheroids, staphylococcus
potential pathogenic - e.coli, bacteroides, anaerobic, streptococci, cl.welchin
Candida albicans
chlamydia trachomatis
gardneralla vaginalis
trichonomas vaginalis
presence of these organisms may represent either
NORMAL STATE / CARRIER
Normal Vaginal Secretion: is odourless clear to slightly whitish and does not cause any
discomfort such as itching, burning does not soil the undergarments. The discharge also
varies according to the menstrual cycle increasing in the premenstrual phase, ovulation
phase, and also when sexually stimulated.
Vaginitis - The specific causes of vaginitis include infection due to trichomonas. Candida
and chlaymidia bacterial gaginosis (though it is not in real sense vaginitis).
The nonspecific vaginitis can result from tampoons, contraceptine. chemicals, persaries,
foreign body and even cervical or vaginal operations, puerperium. The organisms most
often seen in these conditions are streptococci both haemolytic and anaerobic, E.coli,
staphylococci
Vaginitis following deficenicy of oestrogen seen in children and post menopausal women.
Secondary to chronic cervicitis
44
Vaginal Discharge
Abnormal______________________
Altered colour - yellow,green.brown
Thick, watery, frothy
Profuse copious
Continuous
Normal_______
Clear, flocculent
Small quantity
Slight increase During ovulation and
Few days before periods
Does not stain pads
Not foul smelling
Not irritant
Stains pads
Foul smelling
Irritant & itching around vaginal opening
Normal But Excessive Discharge ( Leukorrhoea )
- Non purulent excessive discharge.
- No foul smell, non irritating, soils under garments,
requires a pad.
- External genitalia - No odema, no smell, only discharge
- Microscopy - No pus cells. No organisms.
Causes i) Physiological: At puberty.
. Ovulation
. Premenstrual
. Sexual excitement
. Pregnancy.
ii) Non infective
1) Cervical causes - erosion, extropian mucus polyp
2) Vaginal causes - Pelvic congestion, (e.g. Prolapse.
retro verted uterus)
. chr. PID, constipation.
. Sedantary life, ill health
. Pill use, anxiety
Management
Improve general health
Reassurance
Personal, genital and menstural hygeine to be maintained
To stop pi IT temporarily.
Cervical conditions are the one which requires surgical treatment.
e.g. Cautery, Cryosurgery
45
Abnormal Vaginal Discharges
Let us deal with some of the common conditions.
CANDIDA VAGINITIS (Vaginal Thrush).
This is caused by canadia albicans a gram positive fungus. The symptoms consists of
profuse vaginal discharge , thick white cheese like tending to form plaques, lightly
adherent to vaginal wall.
Candida Vaginitis / Moniliasis
•
•
•
•
•
causative organism - gram positive fungus Candida albicans
Predispocing factors - pregnancy, diabetes, oral pills, broad spectrumantibotics
Clinical features - profuse curdy discharge intense puritius, soreness and oedema of
vulva.
Diagnosis - one drop discharge + one drop KOH - mycelia seen under microscope.
Treatment - clotrimazole (500mg vaginal tablet single dose)
or ( lOOmg vaginal tablet x 7 days)
- Inchronic cases flucanazole 150 mg single dosage - both partners.
or Ketoconazole lOOmg BD for 5 days for both partners.
Bacterial Vaginosis (B.V)
B V is the most common form of vaginitis in reproductive age with a prevalence rate
varing from 5% in college population to more than 60% in STD clinics. The incidence
increases with IUD usage, multiple sexual partners, increasing parity and lower socio
economic status.
It is more a vaginosis than vaginitis and is due to more than one organism including
gardeneralla vaginalis. This occurs when the normal vaginal milieu (low PH. acidophilic)
is changed as a result of menstruation, hormonal changes or vaginal intercourse.
The normal vaginal flora containing lactobacilli is a defence against other microbes, in
view of its production of hydrogen peroxide. When this defence mechanism breaks down
several microbes, particularly the anerobes (Gardnerella) and mycoplasms invade and
change the PH to the higher range.More than half the women are asymptomatic inspire of
the infection.
Bacterial Vaginosis___________________________
Causes
gardnerella, mycoplasma and other anaerobes
Symptoms - profuse, ‘ rotting fish ‘ odour, non irritating vaginal discharge
Diagnosis - take fresh discharge - add 10 - 20% potassium hydroxide (whiff test)
emits fishy amine odour wet preparation under microscope shows
a) Charecteristic ‘clue ‘ cells (vaginal epithelial cells with
Blurred borders
b) Highly characteristic, motile, crescent shaped microbes
46
Overall the role of sexual transmission of micro organism in BV is controversial. It is note
worthy that the recommended treatment for BV chlamydia and trichomoniasis is the
same - Metronidazole.
The differential diagnosis include vaginitis due to Candida or trichomanal infection.
The treatment options are :
Metronidazole
a)
500mg twice daily for 7 days.
b)
Secnidazole
single dose of 2 gms.
c)
Clindamycin
300mg orally twice daily for 7 days.
d)
Metronidazole Gel
0.75% 1 applicator full ( 5 gms )
intravaginally at bed time for 7 days.
e)
Clindamycin Cream -
2% 1 applicator full ( 5 gms )
intravaginally at bed time for 7 days.
Treatment in pregnancy.
a) First trimester
- vaginal clindamycin is the treatment of choice.
b) Second and third trimesters
- Oral metronidazole may be used.
Asymptomatic patients may also need the same type of treatment particularly in women
undergoing surgery or invasive procedure. As BV is transmitted by unprotected sex or
otherwise, currently the sex partner is treated only when there is recurrent BV infection.
Trichomonas Vaginitis
Is the most common form of vaginitis occuring alone or in combination with other STD.
and is caused by a parasite. Though commonly recognised as STI. it can be transmitted by
other methods also e.g. indirect contact through common towels, personal clothing,
improper sterile instruments, bath tubs and swimming pool.
Cause
trichonomas vaganilis
Symptoms
purulent, frothy, yellow / green colour vaginal discharge with
Pruritis with dysuria, dyspareunia
Diagnosis
swollen oedematous, inflammed labia, introitus saline preparation
of discharge under microscope shows motile trichonomos vaginalis
Treatment
metronidazole 200 mg TDS for 7 days or tab. Tinidazyle 2 gms
Single dose orally
Sexual partner too to be treated in the same dose
47
Vaginitis in pre pubertal period : is a result of poor hygiene and is usually caused by
infection transmitted by clothing utensils, from another child. The common organisms
are Candida albicans, E.coli, streptococci and staphylcocci and worms; also caused by
foreign bodies.
Pre - Pubertal Vulvo - Vaginitis
•
Lack of oestrogen; increased PH; poor hygine
Source of infection
Foreign body, infected towel
Thread worm infestation
•
Organisms
Candida, T.V., E.coli, streptococci, staphylococci, threadworms.
Gonococci
•
Symptoms
Purulent vaginal discharge
Pruritus vulvae
Burning sensation
Dysurea
On examination
Red oedematous vulva with discharge and tender vagina
•
Investigations
Wet smear
Gram stain
Culture & sensitivity
Treatment
General cleanliness, keep the area dry
Non-specific : local application of 1% hydrocortisone for irritation
Local application of oestrogen cream for 2 weeks
Tab. Ethinyl oestradiol 0.01 mg - l/2 tab daily for 3 weeks
Specific
: T.V. - metronidazole lOOmg TDS * 10 days
Monilia - local appilication of antifungal
Remove FB under general anaesthesia
Treat for thread worm disease
Senile Vaginitis :
In view of lower oestrogen levels in the post menopausal period the natural resistance of
the vagina against many organisms are lost, resulting in symptoms of pain yellowish
discharge and dysuria. The treatment consists of oestrogen replacement for three weeks
locally or orally.
48
Atrophic (Senile) Vaginitis
CAUSE
Lack of oestrogen
SYMPTOMS
yellowish or blood stained vaginal discharge
pruritus vulva
dysuria
red oedematous vulva
tender vagina
screen for associated malignancy by cytology / biopsy
ON EXAMINATION
INVESTIGATIONS
TREATMENT
local application of conjugated oestrogen cream
1.25 mg for 2 weeks
ethynil oestradiol 0.01 mg oral daily for 3 weeks
Non specific vaginitis can be due to injury, foreign body, allergy and drug sensitivity.
Non Specific Vaginitis
-
Non STI
Symptoms - offensive vaginal disease, variable colour
Signs - red, swollen, tender vaginal
CAUSES
Endogenous - vaginal defences are lost (following abortion, delivery)
Iatrogenic - IUCD, vaginal operatious, tampons, foreign body, pessarie
Cause organisms
strophylococci, streptococci E.coli.
Diagnosis
gramstain, culture of the disease
Treatment
Treat specific cause
Improve general health
Foriegn body removal
Terramycin vaginal tablet - 100 mg BD x 10 days.
49
Approach to the Problem of Vaginal Discharge
Vaginal discharge is a common problem and the successful management lies in accurate
diagnosis, finding out the oetiological factor/pathogenic organism /hormonal deficiency
and appropriately institution of treatment The successful management ensures better cure
rate and less recurrence rate. The protocol consists of
Detail history
a)
b) Clinical exam
Inspection of vulva vaginal cervix
c)
d) Bimanual pelvic exam
Measurement of PH
e)
Microscope exam of discharge
f)
I) Wet smear - TV
- Monliasis
-BV
ii) Staining of smear- Gram's Stain
- 1% brilliant cresyl violet
- Methelyne blue
iii)Vaginal cytology - papsmear
Investigations of a Patient with Vaginal Discharge
•
Application of antiseptics to vagina should be avoided for 24 hours before testing.
Bivalve cuscos speculum is introduced without any lubricant for visualisation of
vagina and cervix.
•
The discharge material is collected from vagina posterior fornix and cervix
•
PH of the secretions is tested with indicator paper
•
A wet smear is prepared from one drop of vaginal discharge from the posterior fornix
to which is added one drop of normal saline and this is covered with a cover slip.
When observed under microscope the active motile trichomonas vaginalies are seen .
•
One drop of discharge on a slide - to which is added one drop of 10% KOH and is
covered with a cover slip. When observed under the microscope the mycelia of the
fungus Candida albicans can be seen.
•
A smear is*made of a drop of the discharge on a glass slide and dried and stained by
various preparation
Gram stain - for intracellular gram negative gonococci also shows cluecells of
bacterial vagionosis.
One percent brilliant cresyl violet stain shows trichomonas vaginalis very clearly.
Methylene blue stain for visualising mycelia of Candida albicans.
50
DIFFERENTIAL DIAGNOSIS OF VAGINAL INFECTIONS
CRITERIA
NORMAL
Predisposing factors
None
BACTERIAL
VAGINOSIS
CANDIDA VAGINITIS
TRICHOMONAL
VAGINITIS_______
•
Change in vaginal
mileau
Loss of lactobacilli
Over growth of
bacteroidis
Gardnerells vaginosis
Myoplasma
•
•
•
Diabetes pregnancy
Broad spectrum antibiotic
Oral pill
•
Common during child
bearing age
Discharge, bad odor possibly after
intercourse_________
Fishy odor, vaginal
discharge
•
Itching / burning discharge
•
Frothy discharge, bad odor,
vulvar pruritus, dysuria
•
Discharge lightly adherent
to vaginal wall, when tried
to remove leaves multiple
petichial haemorrhages
•
Swollen inflammed labia,
introitus, multiple small
punctate strawberry spots
at vaginal vault
•
White, curdy, like cottage
cheese, sometimes
increased
•
Yellow to green, frothy,
adherent, increased
•
•
•
•
Symptoms
None
•
Signs
None
•
White, clear,
flocculent
•
U1
B
e
3^ I
V)
o I
Characteristics of
discharge
•
o
Vaginal PH
c
inn
Z o
6X
o/
Amine odor (KOH
‘whiff’ test
Microscopic
3.8-4.2
•
Thin, homogeneous,
white to grey adherent,
often increased
>4.5
< or = 4.5 ( usually )
absent
•
fishy when present
mycelia, budding yeast,
pseudohyphae with KOH
preparation
•
tichomonads,
WBCs> 10/ hpf
absent
•
present (fishy )
lactobacilli
•
clue cells, coccoid
bacteria, no WBCs
•
>4.5
CERVICITIS
Acute cervicitis is part of the lower RTI and is commonly caused by gonococcal or
peurperal infections , consisting of mucopurulent discharge with congested enlarged
tender cervix. The symptoms and management are as per the underlying condition.
Chronic Cervicitis usually caused by endogenous infection of vaginal organisms or as a
result of pureperal injuries and infections. STI (gonococcal), foreign body (pessaries and
lampoons). Symptoms consists of mucopurulent discharge, backache, lower abdominal
pain, mennorhegia contact bleeding and infertility. The most important symptoms being
muccopurulent discharge. Examination shows oedematous conjested cervix. The
treatment consists of diathermy cauterization and cryosurgery.Administration of
antibiotics or local antiseptics is of no use.most often the male is asymptomatic with a
silent infection and it is mandatory to treat the sexual partner to ensure cure and prevent
recurrence.
Inspection of Cervix
(Speculum examination)
NORMAL
* Pink
* clear white/mucoid
discharge
* Round Smooth surface
* No bleeding
ABNORMAL
* Any redness
* Abnormal discharge
^distortion of cervix in shape.
size, contour & surface.
* Contact bleeding without
an obvious growth/ulcer
COMMON ORGANISMS THAT INFECT CERVIX
1. PROTOZOAL
:
2. FUNGAL
trichomonas vaginalis
Candida albicaans
3. VIRAL
:
HSV n, HPV
4. BACTERIAL
:
gardnerella vaginate
5. CHLAMYDIA
6. MIXED INFECTIONS
52
MALIGNANT
* Growth
* Friable
* Bleeding on touch
* Ulcer
CERVICITIS
ACUTE
CHRONIC
Causes : - post delivery, abortion.
Operative injuries
(streptococci, staphy lococci, e.coli)
Causes : - as in acute cervicitis
- STI ( chlamydia, gono cocci)
Symptoms
Copious, mucopurulent foul smelling
discharge
• Pruritus Vulva
Lower abdominal pain
O/E
• Vulva
congested,
swollen
and
inflammed
Speculum exam
: cervix red, may be covered
w'ith discharge, may be thick
and purulent
frothy & greenish yellow
Trichomonas
curd like
- Candida
watery & persistent - B V
vagina congested & covered
with same discharge
Symptoms
• asymptomatic
• persistent vaginal discharge
• post coital bleeding
• chronic backache
• lower abdominal pain
• infertility
Speculum exam
: hypertrophied, congested.
Oedematous, nabothian follicles
Nabothian cysts,
mucous polyps
cervical erosion
may bleed on touch
tears can be on both sides or on
one side
Diagnosis
Diagnosis
Wet smear exam,whiff lest,high
Pap smear.colposcopy.direct biopsy
vaginal and endocervical swab culture and
sensitivity
Treatment
As per the cause
Treatment
Diathermy cautery,cryosurgery
53
UPPER GENITAL TRACT INFECTIONS
Pelvic Inflammatory Diseases (PID)
Definition PEDs are defined as diseases of upper genital tract,unrelated to pregnancy and
surgery.The micro organisms ascend upwards from cervico-vaginal canal to
endometrium,fallopian tubes and contiguous pelvic structures.givig rise to endometritis,
Salpingitis, Oopharitis and peritonitis .However the brunt of acute infection falls on
fallopian tubes.
• The infection occurs from 3 different sources:a) STI ( Gonococci, Chlamydia)
b) Endogenous - BV Micro organisms
c) Iatrogenic - Introduction of IUCD, endometrial biopsy, HSG, etc. (Group A
Streptococci, Pneumococci, E.coli).
PELVIC INFLAMMATORY DISEASE (PID)
DIAGNOSIS :
Minimum criteria
1. lower abdominal pain
2. cervical motion tenderness
3. adnexal tenderness
TREATMENT
Based only on clinical background with out any bacteriological examination for gonococii
or chlamydiae
ADDITIONAL CRITERION
Oral temperature > 38.3 degree centigrade
Abnormal cervical / vaginal discharge
Laboratory documentation of cervical infection
CAUSATIVE ORGANISMS
Gonococci, chlamydia
Post abortal / post pcerperal - streptococci, staphylococci, e.coli
INVESTIGATIONS
Endocervix exam for inflammation, gram stain, culture and Sensitivity
Younger age group
Increased
sexual activities
RISK FACTORS
Multiple sexual partners
Unsafe sex
HSG, IUD
Unsafe abortion
Treat aggressively the initial attack of PED
Treat late sequelae
Treat sexual partner
Prevent re - infection
Treat lower genital tract infection
GOALS OF TREATMENT
54
PELVIC INFLAMMATORY DISEASE (PID)
OPD Treatment ( CDC guidelines )
Regimen A
i.m. ceftriaxone 250 mg ( or equivalent cephalosporin )
Plus
Oral doxycycline 100 mg BD
Both for 14 days
Regimen B
- Oral ofloxacin 400 mg BD for 14 days
Plus
Oral clindamycin 450 mg QDS
Or
Oral metronidazole 500 mg BD for 14 days
INPATIENT TREATMENT ( CDC recommendation )
Cefatoxine 2mg LV * 6 hourly
Doxycyclin lOOmglVBD
Continued for 48 hours after the patients have improved
Then - doxy lOOmg * 14 days
REFERRAL FOR ACTUE PID
• when the diagnosis is uncertain like appendicities, ectopic etc
• to mass, to abscess, pelvic abscess
• adolescent patient ( unpredictable ) to prevent damage to reproductive tract
• severe, nausea and vomitting
• patient has failed to respond to oral regimes to OPD therapy of 48 - 'll hrs and given
parenteral therapy
• serious pt. - pregnant pt
Genital Tuberculosis
This is usually secondary to Tuberculosis else where in the body, whether this is clinically
apparent or not and the spread by haematogeneous route. This is caused by
Myeo.tuberculosis, mainly affecting the fallopian tubes and the endometrium. The disease
is indolent usually detected when the woman is being investigated for infertility, there by
meaning, primary sterility is the commonest manifestation of genital tuberculosis.
Involvement of the tube can occassionly be manifested as ectopic pregnancies. The other
manifestations are menorrhagia, anenorrhoa / Oligomenorrhea. In about 20% of patients
intermittent or chronic lower abdominal pain can be the only symptoms.
55
DIAGNOSIS
Is by high index of suspicion in women who have amenorrhea or sterility with no obvious
cause. This can be confirmed by endometrial curettage for tissue diagnosis. The
management is like any other tuberculous infection in the body for a period of 9-12 months.
GENITAL TUBERCULOSIS
Treatment First 3 months
( 3 drugs )
INH 300 mg
Rifampicin 450 mg
Ethambutol 800 mg
Next nine months
( 2 drugs )
INH 300 mg
Rifampicin 450 mg
Management - prophylaxis
1.
2.
3.
4.
Vaccination at birth to all newborns
Routine health check up of school going girls
To investigate thoroughly In suspected cases
screening of family members for koch’s
Pelvic Inflammatory Disease
SEQUALE
Late__________________
Infertility - 12 %_______
Ectopic - 6-10 fold risk
Chronic pelvic pain_____
Chronic pelvic infection
Hydrosalpinx / pyosalpinx
Immediate_____________
Pelvic abscess to a rupture
Gen. Peritonitis_________
Septicaemia
Preventive Measures
As in most of diseases, prevention obviously, is better and easier than cure and if you look
into the causes of RTI, all the RTI are preventable and it is a pity that such preventable
conditions are responsible for a great percentage of gynaec morbidity. Prevention needs
more of literacy, creating awareness and education at the community level.
The prevention and control of HIV and other STI’s should begin at the primary health
care level.
56
Health eduction through mahila mandal, mass media workshops, individual contacts and
counselling should promote sexual hygenic practices and safe sex paractices and also
proper menstrual hygiene.
Prevention can be implemented at 3 levels
PRIMARY PREVENTION
This can be achieved by education and counselling about the hygenic practices, including
sexual hygenic safe sex practices including promotion of condom use and efforts to
improve safe abortion and safe deliveries.
SECONDARY PREVENTION
This is aimed at prevention of the spread of infection to others and requires
early detection and prompt treatment in addition to counselling regarding the practice of
safe sex.
TERTIARY PREVENTION:
This is to prevent the complications of RTI by prompt diagnosis and adequate and
appropriate treatment. The complications include ascending infections to upper genital
tract leading to tubal damage and if the RTI has occured during pregnancy abortion and
still birth.
Prevention of RTI
Primary
•
•
•
Secondary
Tertiary
detection
and Envisage
controlling
Avoid
infection
by Early
treatment to prevent spread
education
communication and sequale
Counselling about sex
Contraception
In the whole discussion in RTI - STI in women it is important to recognise that many of
the RTI requires the treatment of the partner whether symptomatic or not, and the
medication should be given simultaneously and abstinance should be practised during the
treatment to ensure cure and prevent relapses. The presence of RTI / STI increases the
risk of HIV infection by 5-10 times.
PELVIC INFLAMMATORY DISEASE ( PID)
PREVENTION
1.
2.
3.
4.
5.
To prevent ascending infections
To prevent STD - sexual education barrier contraceptives
Widespread screening for cervical infection and B
Recurrance prevention by treating partners
Health education
57
SYNDROMIC MANAGEMENT
In the absences of clinical expertise and diagnostic laboratory support, the WHO has
recommended syndrome based approach for the diagnosis and treatment of RTI-STI in
symptomatic patients for e.g. when the genital ulcer is detected, therapy is advised for the
two common causative diseases e.g. syphlis and chancroid; similarly for vaginal
dishcarges the therapy targets four common condition - Gonorrhoea candidiasis,
trichomoniasis and bacterial vaginosis; for uretheral discharge therapy for both
Gonococcal and Chlamydian disease; for lower abdominal pain therapy for PID.
REFERENCES
1. Bhatia JC and Cleland J .self reported symptoms of gynaecological morbidity and
their treatment in south india. Studies in family planning 1995, 26 : 203 - 216
2. Mamdani M. - Management of reproductive tract infections in women - lessons from
the field - monograph - Ford Foundation ( new delhi )
3. Reproductive tract infections and sexually transmitted infections. - ( editorial ) Asian
journal of Obst & Gynae practice 1999, 3, 26 - 37
4. Jessica L - Thomason MD and Scaglione N. Protocols Ob /Gy infections, bacterial
vaginosis - contemporary OB / GYN June 1999
5. Khudsen UB. Aagaard J. Acute pelvic pain. Progress in obstetrics & gynaecology, vol
13. Ed John Studd 1998
6. Bhatia JC, Cleland J, Bhagvan L, Rao NSN. Levels & determinants of gynaecological
morbidity in a district of South India. Studies in family planning : 1997, 28, 95 - 103
7. Questions and answers on reproductive tract infections and sexually transmitted
infections - UNFPA ( united nations population fund ) India.
58
SEXUAL TRANSMITTED DISEASES AND HIV
DR. R. NARAYANAN
CONSULTANT GYNAECOLOGIST
FORMER PROF., HEAD DEPT OF OBSTETRICS & GYNAECOLOGY
ST. JOHN’S MEDICAL COLLEGE
BANGALORE
59
SEXUALLY TRANSMITTED DISEASE ( STD )
The Magnitude of the Problem
Worldwide in 1995, the World Health Organization estimated that there are over 330
million new cases of curable STD*.
The report below is based on a number of studies from many countries. It suggests that
prevalence rates of STD seem to be far higher in developing countries than in developed
countries.
Sexually transmitted diseases are a major public health problem in both developed and
developing countries, but prevalence rates apparently are far higher in developing
countries, where STD treatment is less accessible. Among women, syphilis prevalence
rates may be 10 to 100 times higher in developing countries; gonorrhea rates may be 10 to
15 times higher and chlamydia rates may be 2 to 3 times higher. For example, the annual
rate of new gonorrhea infections in large African cities is 3 000 to 10 000 per 100 000
population, or as many as one in every 10 people. By comparison, in the US the annual
incidence of gonorrhea was 233 per 100 000 population in 1991, and in Sweden, about 30
per 100 000 in 1987.
Among developing regions STDs appear to be more common in Africa than in Asia or
Latin America. In a (recent) review ... a median of 20% of women attending family
planning, antenatal, or other clinics in Africa had trichomoniasis, for example, while the
median prevalence in Asian studies was 11%, and in Latin American studies. 12%.
Controlling Sexually Transmitted Diseases.
Population Reports, June 1993, Page 3.
HIS million
16 million
4 14 million
9.7 million
! 36 million
| 23 million I
___
B
_
150 million
65 million
1 million j
|
GLOBAL: 333 million
1
Figure 1. Estimated new cases of curable STD* among adults, 1995.
* gonorrhoea, chlamydial infection, syphilis and trichomoniasis.
60
Distribution of STD by age and sex
STD, including HIV-infection, are widespread throughout the world. They affect
sexually-active people of both sexes, so STD occur in both males and females. However,
statistics rarely show an equal distribution between men and women, nor do they show an
equal distribution between different age groups.
Most children below 14 years of age are free from infection. Other than for congenital
syphilis, ophthalmia neonatorum and HIV-infection, most children under 14 years old
are not affected by STD.
Between the ages of 14 and 19 years, cases occur more commonly among females. This is
due to several factors:
•
The start of sexual activity is usually earlier for girls than for boys;
•
Girls have sex with older partners, who are more experienced and also more likely to
carry infections;
•
Biological vulnerability of young girls - due to characteristics of the genital tract of
young girls, they are especially vulnerable to infection with STD.
For both males and females, rates of STD tend to be highest in the 15-30 age group,
decreasing in later ages.
Most large studies show that, after the age of 19, cases occur more or less equally in both
sexes. However, there is usually a slight male preponderance. There are several possible
reasons, some perhaps more obvious than others:
•
Sexually transmissible infections often produce no symptoms or only mild symptoms
in women, so fewer women come forward for treatment - and therefore they fail to
appear in statistics;
•
Services in general may be more accessible to men than women. For example, where
men migrate to urban areas for employment, they have access to the urban services and therefore are more likely to appear in statistics;
•
As we have discussed before, cultural and economic constraints might also prevent a
proportion of women from attending for treatment;
•
A large number of men might be infected after practising unsafe sex with a small
number of sex workers;
•
Older men may be more sexually active than women of the same age:
•
Men are more likely to change partners than women.In many developing countries, the
best available indicators of STD levels in women are surveys taken by antenatal,
family planning, or gynaecological clinics. They show a high prevalence of STD
among the women attending.
61
PATHOLOGY/PATHOGENESIS
Sexually Transmitted Pathogens and the disease caused by them are mentioned below:
Agents
1. Bacteria
Neisseria gonorrhoea
Chlamydia trachomatis
Mycoplasma hominis
Ureaplasma urealyticum
Treponema Pallidum
Gardnerella Vaginalis
Haemophilus ducreyi
Calymmatobacterium
Shigella Spp
Campylobacter
Group B Streptococcus
Associated Disease or Syndrome
Urethritis, epididymitis, proctitis, cervicitis, endometritis,
Salpingitis, bartholinitis, pharyngitis, conjunctivitis, prepubertal
vaginitis, PROM, chorioamnonitis premature delivery , prostatitis
in men, disseminated gonococcal infection (DGI)
Same as above + otitis media, rhinitis, Reiter syndrome,
pneuomonia in infants
Salpingitis, post partum fever
Nongonococcal urethiritis, premature labour
Syphilis
Vaginosis
Chancroid
Granuloma Inguinale granulomatis
Shigellosis in homosexual men
Enteritis, procto-colitis
Neonatal sepsis, neonatal meningitis
2. Viruses
HIV
Herpes Simplex
Human Papilloma virus
Hepatitis B
AIDS
Genital Herpes, neonatal herpes, aseptic meningitis
Condyloma'accuminata, CIN. Carcinoma. Cervix, penile carcinoma
Hepatitis, polyarteritis nodosa, polymyalgia rheumatica,
Hepatocellular carcinoma
Hepatitis A
Acute hepatitis A
Cytomegalo virus
Infectious mononucleosis, birth defects cognitive impairment
Molluscum Contagiosum
Genital molluscum contagiosum
Human T-lymphotropic virus T - Cell leukemia or lymphoma retrovirus type - 1
3. Protozoa
Trichomonas Vaginalis
Entamoeba histolytica
Giardia lamblia
Vaginitis
Amoebiasis in homosexual men
Giardiasis in homosexual men
4. Fungi
Candida albicans
Vulvovaginitis, balanitis
5. Ectoparasites
Phthirus pubis
Sarcoptas Scabiei
Pubic lice infestation
Scabies
62
Vulnerable groups
In most communities there are certain people who may be particularly vulnerable to STD.
These people vary from community to community but may include:
• Teenage girls who are sexually active;
• Women who have several partners "in order to make ends meet";
• Commercial sex workers and their clients;
• Men and women whose jobs force them to be away from their families or regular
sexual partners for long periods of time.
How accurate can any figures be ?
Most often, figures on STD are taken from the numbers attending health facilities for
treatment. This tends to underestimate the true extent of STD in the general population for
several reasons, some of which we have already covered:
•
Both men and women with STD may be symptom-free, but women more so than men.
For example:
- 70% of women and 30% of men infected with chlamydia may not have symptoms;
- up to 80% of women and 10% of men infected with gonorrhoea may also not have
symptoms;
•
Clinics offering treatment for STD may not be accessible to many of the population;
•
Many people with STD do not seek treatment, and in developing countries people are
not routinely screened for STD when they seek other health care;
•
Because of the stigma attached to STD. many people seek treatment from alternative
providers who do not report cases (such as traditional healers and pharmacists);
•
Some governments are reluctant to admit to a high prevalence of STD. although the
AIDS epidemic is beginning to change this attitude.
COMPLICATIONS OF STD:
STD can be devastating and sometimes fatal. Their complications include:
1.
Chronic abdominal or pelvic pain or both as the result of chronic PID.
2.
Irreversible damage to fallopian tubes and female infertility.
3.
Urethral strictures in the male
4.
Chronic epididymitis and male infertility.
5.
Spontaneous recurrent abortions.
6.
Increased risk of ectopic pregnancy and its consequent morbidity.
7.
Potentially blinding eye infections and pneumonia in infants.
8.
Social consequences such as domestic disharmony, violence and divorce.
9.
Persons with STD (Gonorrhoea, Chlamydia, Syphilis, Chancroid & Trichomoniasis)
are more likely to become infected when exposed to HIV and are more likely to
transmit HIV.
63
Challenges of Controlling STD
•
Sexual behavior is difficult to change.
•
Sex is embarassing to discuss.A person affected with STD is slow to come for
treatment and reluctant to disclose the truth.
•
Many STD carriers are asymptomatic.
•
Treatment is not always simple or effective. ( For example: Resistance to drugs makes
treatment expensive and complicated. HIV and herpes have no curative treatment.)
•
Use of drugs/alcohol affect decision to take protective measures.
Strategies
Any strategy used to control STD must be feasible, effective and affordable.
•
Early diagnosis and treatment to reduce transmission and complications
•
Education regarding high risk behaviour unsafe sex, protection with condoms,
limitation of sexual partners and importance of compliance to treatment.
•
Treatment and education of sexual partners of people with STD.
•
Targeting vulnerable groups such as sex workers.
64
APPROACH
ADVANTAGES
DISADVANTAGES
EVIDENCE
COMMENTS
1 Aetiological
diagnosis/
specialist centres
• Accurate laboratory based
diagnosis with appropriately
tailored treatment
• Training of staff from rural
health units.
• Expensive
• Delays in diagnosis
• Minimal role as referral centre
• Limited coverage of population
• Asymptomatic infection not detected,
but treatment possible by active
partner notification and
epidemiological) treatment of partners
Mabey, 1995
Not appropriate for
wide-scale use in
resource-poor countries '
2 Clinical diagnosis
• Immediate presumptive
diagnosis & treatment with
good compliance
• Patient does not leave
untreated.
• Poor sensitivity/specificity & positive
predictive value (PPV)
• Does not identify asymptomatics
O'Farrell,
1994
Bogaerts,
1995
Not appropriate for
wide-scale use in
resource-poor countries
3 Syndromic
treatment
• Problem orientated
• Immediate presumptive
diagnosis & treatment of
possible aetiologies Patient
does not leave untreated
• Allows tor standardisation of
management & monitoring of
drug usage & antibiotic
resistance
• Use of non-medical staff
• Use of integrated system of
delivery, eg through PHC
centres, MCHCs etc
• Most cost-effective option
• Low sensitivity/specificity for cervical
gonococcal/chlamydia infections in
women
• Not always acceptable to medical
staff
• Monitoring & modifications to
maintain validity
• Asymptomatic infection not detected,
but treatment possible by active
partner notification and epidemiological
treatment of partners
Bogaerts
1995
Mayaud,
1995
Vuylsteke,
1993
Useful in resource-poor
countries for the
treatment of men and
women with genital
ulcers, but not in
women with vaginal
discharge Leucocyte
esterase dipstick (LED)
test & risk assessment
scores to be further
evaluated, and the
development of other
non-invasive genital
tests for diagnosis.
For women
i) Treat all symptomatic
vaginal discharge as
bacterial vaginosis,
tnchomoniasis and
condidosis
ii) Consider screening
for cervicitis by
speculum examination
or developing locally
valid risk assessment
scores for presence of
gonorrhoea and
chlamydia
4. Private
practitioners
• Often specialists who can
choose aetiological or
syndromic approach, and
immediate diagnosis and
appropriate treatment
• Cost to patient
• Not widely available
• Partner notification often not instituted
5. Alternative
agencies/ therapies
and informal sector
• Widely used - often first line
in offering advice, education
and treatment
• Treatment often empirical and poor
efficacy
65
Can be used in
conjunction with other
approaches, but does
not give wide enough
access and coverage of
STI control in the
population
Mulder,
1994
Formal and informal
sectors must recognise
contribution that each
makes and work in
partnership
Syndromic Management
The main features of syndromic case management are:
• classifying the main causative agents by the clinical syndromes to which they give rise;
• using flow-charts which help the service provider to identify causes of a given syndrome;
• treating the patient for all the important causes of the syndrome;
• ensuring that partners are treated, patients educated on treatment compliance and risk
reduction, and condoms provided.
Identifying the syndromes
Although STDs ore caused by many different organisms, these organisms only give rise to a
limited number of syndromes. A syndrome is simply a group of the symptoms of which a patient
complains, and the signs observed during examination. This table explains the signs and
symptoms for the main STD syndromes and their etiologies.
Syndrome
Symptoms
Signs
Vaginal discharge
Vaginal discharge
Vaginal itching
Dysuria (pain on
urination) Pain during
sexual relations
Vaginal discharge
VAGINITIS: Trichomoniasis Candidiasis
CERVICITIS: Gonorrhoea Chlamydia
Urethral discharge
Urethral discharge
Dysuria Frequent
urination
Urethral discharge (if
necessary ask patient
to milk urethra)
Gonorrhoea
Chlamydia
Genital ulcer
Genital sore
Genital ulcer Enlarged
inguinal lymph nodes
Syphilis Chancroid
Genital herpes
Lower abdominal pain
Lower abdominal pain
and pain during
sexual relations
Vaginal discharge
Lower abdominal
tenderness on
palpation
Temperature >38°
Gonorrhoea
Chlamydia Mixed
anaerobes
Scrotal swelling
Scrotal pain and
swelling
Inguinal bubo
Painful enlarged
inguinal lymph nodes
Neonatal conjunctivitis
Swollen eyelids
Discharge
Baby cannot open eyes
Scrotal swelling
Swollen lymph nodes
Fluctuation
Abscesses or fistulae
Oedema of the eyelids
Purulent discharge
*
66
Most common
etiologies
Gonorrhoea
Chlamydia
LGV Chancroid
Gonorrhoea Chlamydia
The aim of syndromic management is to identify one of these seven syndromes and manage it
accordingly.
It includes only those syndromes that are caused by organisms which both respond to treatment
and lead to severe consequences if left untreated. Other STD syndromes, such as vesicular
lesions (herpes), genital warts and dysuria in women (painful passing urine), are not included
among the seven syndromes in this programme.
Using syndromic flow-charts
Because the seven syndromes are easy to identify, it has been possible to devise a 'flow-chart' for
each one. Each flow-chart takes us carefully through the decisions and actions that we need to
take, leading to guidance on the condition or conditions for which to treat the patient. Once
trained, service providers will find the flow-charts easy to use, so it is possible for non-STD
specialists at any health facility to manage STD cases.
If this is a key benefit of the flow-charts, what other benefits does it offer in turn?
• promptness of treatment, because STD services can be made available at any first-line
health facility. Patients are thus treated at their first visit;
• wider access to treatment, because treatment is available at more health centres, so reaching
far more of the population;
• opportunities for introducing preventive and promotive measures such as education and
distribution of condoms.
Treatment for all the causative agents
While a clinical or etiological diagnosis tries to identify just one causative agent, syndromic
diagnosis includes immediate treatment for all the most important causative agents.
This means that - if all the necessary drugs are available - syndromic treatment will quickly
render the patient non-infectious. Mixed infections occur quite often, so the costs of over
treatment can be balanced against the cost of failing to treat people for mixed or symptom-free
infections.
67
Responding to criticisms of the syndromic approach
The main criticisms made against the syndromic approach are answered below.
'The syndromic approach isn't scientific.'
On the contrary, it is based on a wide range of epidemiological studies over the industrialized and
developing world. A number of validation studies compared syndromic and laboratory diagnosis
to assess the accuracy of syndromic diagnosis. They found syndromic diagnosis to be similar, and
hence accurate. As a result, syndromic diagnosis of STD has been taken up even in hospitals in
both Amsterdam and London.
'Syndromic diagnosis is far too simple for a physician to use - it can even be
used by nurses.'
Simplicity does not prevent physicians from using other tools including thermometer or
stethoscope! And surely it is an advantage that other service providers can use a syndromic
approach to diagnosis? For example, in the Netherlands, nurses have been using syndromic
diagnosis to treat STD patients for a number of years. Simplified diagnosis and treatment also
allows health workers more time to provide education and counselling.
'The syndromic approach fails to make use of a service provider's clinical
skills and experience.'
Many clinicians rely too much on their own clinical judgement. They don't want to face the fact
that they can make a clinical diagnosis in only 50% of STD cases. They also miss all the mixed
infections.
'It would be better to treat the patient first for the most common cause and then, if the symptoms
don't improve, treat for a second cause. Patients who are not cured by the first treatment may not
return to the health centre and may even seek treatment elsewhere. They may also become
asymptomatic in the untreated STD and further spread the infection.
The syndromic approach results in a waste of drugs, because patients are
being over-treated.'
In fact studies have shown that the syndromic approach is the most cost-effective in the long run.
Why? Because of the comparatively large costs of technology, skills and infrastructure of an
etiological approach, and the long-term costs of failed treatment of, and clinical diagnosis based
on experience only.
'Good, simple laboratory tests such as Gram stain should be included in STD
diagnosis.'
Patients have to wait for the results and may not return for treatment. They also stay infectious
and complications can occur. Gram stain is only justified when microscopy is already available,
4rapidly performed and accurate.
68
GUIDELINES FOR MANAGEMENT OF STD
Drug Treatment
GONORRHOEA:
•
•
•
TREATMENT SCHEDULE FOR SYNDROMIC
MANAGEMENT:
Ceftrioxone 250 mg IM Single Dose or
Cefotaxime 500 mg IM Single Dose or
Ciprofloxacin 500 mg Oral Single Dose
1.
In Pregnancy:
•
Same as above or
•
Ampicillin 2 G or 3 G + Probenecid 1 G oral
Single Dose
2.
3.
4.
TRICHOMONAS VAGINALIS:
•
Metronidazole 2 G Oral Single Dose or
•
Metronidazole 400 mg Oral BID for 5-7 Days
Note: Metronidazole is to be avoided during the first
trimester of pregnancy.
Caution the patient not to consume alcohol while on
treatment.
5.
6.
7.
VAGINAL CANDIDIASIS:
•
Nystatin 100 million Units Vaginal Pessary at bed
time for 14 days or
•
Miconozole 200 mg Vaginal Pessary at bed time
for 3 days or
•
Clotrimazole 500 mg Vaginal Pessary at bed
time for 5 days
GENITAL HERPES:
•
Acyclovir 200 mg 5 times Daily for 5 Days
CHLAMYDIA:
•
Doxycycline 100 mg Oral BID for 7 Days or
•
Tetracycline 500 mg Oral QID for 7 days or
•
Erythromycin 500 mg Oral QID for 10 days
SYPHILIS:
•
Benzathine Penicillin G 2.4 million Units IM
Single Dose
•
Non pregnant patient: Tetracycline 500 mg Oral
QID for 15 days or Erythromycin 500 mg Oral
QID for 10 days in case of allergy to penicillin
CHANCROID:
•
Erythromycin 500 mg Oral TID for 7 days or
•
Ciprofloxacin 500 mg Oral Single Dose or
•
Ceftrioxone 250 mg IIM Single Dose or
•
Trimethoprim 80 mg Oral BID for 7 days
CERVICITIS:
•
Ciprofloxacin 500 rr^g Oral Single Dose or
•
Ceftrioxone 250 mg IM Single Dose or
•
Cefixime 400 mg Oral Single Dose or
•
Trimethoprim 80 mg 10 Tablets OD for 3 days
ANAEROBIC INFECTIONS:
•
Metronidazole 400 mg Oral BID for 14 days
LYMPHOGRANULOMA VENEREUM:
•
Doxycycline 100 mg Oral BID for 14 days or
•
Sulphadiazine 1 G Oral QID for 14 days
69
Urethral Discharge: Treat for Gonorrhoea and
Chlamydia
Genital Ulcer: Treat for Syphilis and Chancroid
Vaginal Discharge: Treat for Trichomonas.
Candidiasis, Cervicitis and Chlamidia
Lower Abdominal Pain: Treat for Gonorrhoea,
Chlamydia and Anaerobic Infection
Scrotal Swelling: Treat for Gonorrhoea and
chlamydia
Inguinal Bubo: Treat for Lymphogranuloma
Venereum
Neonatal Conjunctivitis:Treat the baby for
Gonococcal conjunctivitic with :
Ceftriaxone 50 mg/Kg IM Single Dose or
Kanamycin 25 mg/Kg IM Single Dose
Treat the baby for Chlamydia with Erythromycin
syrup 50 mg/Kg/Day Oral QID for 14 days or
Trimethoprim 40 mg Oral BID for 14 days
Clean eyes with saline or clean water
Treat mother and her partner(s) Gonorrhoea and
Chlamydia
Assessing the patient's risk
of further STD
Personal sexual behaviour:
Partner(s) sexual behaviour:
1. Number of sexual partners in the
past year.
Does the patient's partner(s):
• have sex with other partners?
2. Sex with a new or different partner
in the past three months.
• also have an STD?
3. Any other STD in the past year.
• have HIV-infection?
4. Has the patient ever exchanged sex
for money, goods or drugs (include
both giving and receiving)?
• inject drugs?
5. Use of herbs as a drying agent, or
similar sexual practices.
• if male, have sex with other men?
Personal drug use:
1. HIV infection?
The key issue is whether the patient is mixing drugs with
sex - which may increase the risk of spreading STD or
being re-infected. Sharing needles or 'works' also carries
a high risk of transmitting or being infected with HIV. So:
2. Use of skin-piercing instruments
such as:
1. Use of alcohol or other drugs (if so, what?), before or
during sex?
Other persona! risk factors:
• needles (injections, tattoos);
• scarification or body-piercing
tools;
• circumcision knives;
3. Has the patient ever had a blood
transfusion? When?
4. For young children, risk of perinatal
transmission of STD/HIV means
that service providers must
question the parents about their
possible infections, for example,
gonorrhoea, syphilis, chlamydia,
HIV.
2. Exchange of sex for drugs (or drugs for sex)?
Patient's protective behaviour:
1. What does the patient do to protect him/herself from
STD/HIV?
2. Use of condoms? When and how? How often? With
whom?
3. What kinds of low-risk or safe sexual activities does
the patient practise? How often? With whom? Why?
70
PREVENTIVE MEASURES:
1. Limiting sexual act with one faithful partner
2. Using condoms correctly and consistently.
3. Replacing high risk penetrative sex with low risk ( such as masturbation)
4. Dispel wrong notions and myths about STD.
5. Change sexual behavior.
6. Education.
7. Precautions during situations of poverty, social disruption and civil unrest.
8. Need to treat the affected and their sexual partners correctly and completely.
9. Adequate follow up of all cases.
*
71
VAGINAL DISCHARGE
Patient complains of vaginal discharge
Complaint of lower abdominal
pain or partner symptomatic or
specific risk factors positive?*
NO
• Treat for vaginitis
• Educate
• Counsel if needed
• Promote/provide condoms
rd
YES
• Treat for cervicitis and vaginitis
• Educate
• Counsel if needed
• Promote/provide condoms
• Partner management
• Return if necessary
*
Positive = age <21 years; or single; or > 1 partner; or new partner in past 3 months
Patient complains of urethral discharge
URETHRAL DISCHARGE
Examine: milk urethra
if necessary
Discharge
confirmed?
NO
YES
GJ
• Treat for gonorrhoea and
chlamydia
• Educate
• Counsel if needed
• Promote/provide
condoms
• Partner management
• Return if necessary
Ulcer(s)
Present?
Y^S
Use appropriate
Flow-chart
NO
• Educate
• Counsel if
needed
• Promote/provide
condoms
Patient complains of genital sore or ulcer
GENITAL ULCERS
I
Examine
Ulcer
Present?
NO
Vesicular
lesion(s)
present?
JYES
^YES
• Treat for syphilis and chancroid
• Educate
• Counselif needed
• Promote/provide condoms
• Partner management
• Advise to return if necessary
• Management of herpes
• Educate
• Counsel if needed
• Promote/provide condoms
NO
• Educate
• Counsel if needed
• Promote/provide
condoms
Patient complains of scrotal swelling/pain
SCROTAL SWELLING
Take history and examine
CH
Swelling/pain
confirmed?
NO
• Reassure patient/educate
• Promote/provide condoms
YES
Testis
rotated or elevated,
or history of
.
trauma^^
YES
Refer immediately
NO
a Treat for gonorrhoea and
chlamydia
• Educate
• Counsel if needed .
• Promote/provide condoms
• Partner management
• Return if necessary
Patient complains of lower abdominal pain
LOWER ABDOMINAL PAIN
Take history and examine
r
I
/ Missed/overdue period or
Recent delivery/abortion or
Rebound tenderness or
\Guarding or Vaginal bleeding
O)
i
Refer
YES
NO /Temperature 38°C or\
Pain during examination
\ or Vaginal discharge /
NO
Follow
pain persists
___ i___
•Treat for PI D
• Educate
• Counsel if needed
• Promote/provide
condoms
• Partner management
Follow up after 3 days or
sooner if pain persists
NO
^Improved?)
_______▼
YES
Continue treatment
Refer
Neonate with eye discharge
NEONATAL CONJUNCTIVITIS
Take history and examine
/Bilateral or unilateral/
NO
/ (reddish), swollen \
\ eyelids with purulent /
\
discharge?
/
• Reassure mother
• Advise to return if not better
YES
• Treat for gonorrhoea
• Treat mother and partner(s)
for gonorrhoea and chlamydia
• Educate mother
• Counsel mother if needed
• Advise to return in 3 days
<^lmproved?^) -
NO
• Treat for chlamydia
• Advise to return in 7 days
4 YES
Reassure
<Jmproved?^>
j YES
Reassure
NO
Refer
INGUINAL BUBO
Enlarged and painful inguinal lymph nodes?
Take history and examine
YES
Ulcer(s)
>
present?
"J
00
NO
•Treat for lymphogranuloma venereum
• Educate
• Counsel if needed
• Promote/provide condoms
• Partner management
• Advise to return if necessary
Use qenital ulcers flow-chart
HIV/AIDS
Global and Indian Scenario
WHO (1992) estimated that at least 10-12 million adults and children world wide had
been infected with HIV and of these two million had gone on to develop AIDS - the last
stage of HIV infection. WHO estimated that by the year 2000, there will be cumulative
total of 30-40 million men, women and children will have been infected and 12-18
million will have developed AIDS. Nearly 90 per cent of the projected HIV infection for
this decade will occur in developing countries.
Since the first AIDS case was registered in Bombay in 1986, 310 cases have been
reported to the Ministry of Health and Family Welfare from 18 states and union territories
by 31st March. 1993. Maharashtra and Tamil Nadu are leading in the number of cases
followed by Punjab, Delhi and Kerala.
Among the probable means of acquiring these infections, multipartner sex dominates
(75.3%) followed by blood transfusion (12%) and sharing of unsterilized needles by drug
users (6.5%). Eighty-three per cent of all infections were acquired within the country
.Ninety per cent of the cases will die below age of 50 years and more than 2/3 were
between 20 and'40 years. In November, 1992, Ministry of Health and Family Welfare and
WHO undertook the exercise to assess the actual prevalence of HIV in our country.
Having extrapolated the available data on HIV prevalence in commercial sex workers,
drug users using injections, antenatal clinic attendants and blood donors, the team has
concluded that number of HIV infected persons in India in 1991 exceeded 600,000.
Virology
The virus causing AIDS was independently identified by a team of French Scientists led
by Dr Luc Mositagnier of Pasteur Institute and American Scientists led by Dr. Robert
Gallo of National Cancer Institute. The International Committee on nomenclature of
AIDS virus named it "Human Immunodeficiency Virus" or HIV and to date two types of
HIV viz. HIV 1 and HIV 2 are identified. These viruses belong to a unique group of
Retroviruses having a special enzyme named reverse Transcriptase.
Cells Susceptible in Human Host
i
Haemopoetic system
T-lymphocytes (Helper cells), N-lymphocytes macrophages,
dendritic cells, promyelocytes and megakaryocytes.
Brain
Microglia, astrocytes, capillaries endothelial cells and
oligodendrocytes.
Others
Bowel epithelial cells, bowel enterochromaffin cells,
Kupffer cells, cervical endothelial cells, myocardial cells
and cells of prostate and testis. Cells normally not
susceptible to HIV can become infected following viral
infections with CMV and Herpes etc.
79
Fate of Infected Cells
Latent infection : Cell remains normal with normal functions, however progeny of cell
will carry proviral DNA. Lysis of cells due to replication of virus. Formation of giant
cells. Cell is not destroyed but other normal and infected cells stick to this cell and may
fuse resulting in giant cell. These fused cells may or may not function normally. Virus
concentration is high in Blood, semen and vaginal secretion.
Immunology
HIV infection induces humoral as well as cellular immune response. Humoral response
is evidenced by specific antibody production against different viral proteins after a
latent period of 3-6 months. It is called "window period". However the antibodies
do not seem to protect against fatal outcome in AIDS. This may be due to me fact that
antibodies produced after 3 months of infection are incapable of blocking virus entry into
susceptible cells.
How does the virus spread?
•
by sexual intercourse (homo or heterosexual) when one of the partner is infected
•
use of contaminated needles
•
by transfusion of infected blood
•
by an infected mother to her unborn child
•
less commonly in other ways
High Risk Behaviour Group for HIV Infection
•
Everybody who is exposed to the infection, especially: persons with venereal diseases
and sores in their genital part
•
persons who have multiple sexual partners
•
also prostitutes (male/female) with a number of clients per day
•
patients receiving untested blood from unknown donors
HIV Infection in Pregnant and Lactating Mothers
•
HFV infection can spread from the mother to unborn child during pregnancy or
delivery
•
A pregnancy might precipitate the onset of symptoms of AIDS.
•
A woman who knows or suspects that she is an HIV carrier should avoid pregnancy.
•
Any woman who lives in an area with many HIV positive people belongs to high risk
group and should be tested before she decides to have a baby
•
The virus has been found in breast milk in low concentration. The chances that this
low concentration can infect a baby are extremely low
•
Since risks of bottle feeding are well known, mother should be encouraged to breast
feed the infants under all circumstances.
80
Recognition of an Individual with AIDS-Symptoms, Signs and Diagnosis
Recognition
Some person pass through first stage with fever and throat infection like a bad cold.They
can then be without symptoms for a time period. For some period before the final
diagnosis can be made the person might suffer from symptoms of infection. They are
grouped into what is called ARC (AIDS related complex). The manifestations of disease
vary widely in the world. Different signs and symptoms may be predominant in different
areas. For example, "Slim disease" stressing the weight loss is most common in Africa,
while pneumonia is common in USA. Diarrhoea and Tuberculosis may be more common
in other areas.
To make the diagnosis the persons should show at least two major and one minor sign.
Major Signs
Minor Signs
Loss of more than 10% of body weight
Persistent cough
Chronic diarrhoea for more
one month.
Generalised itchy skin disease than
Prolonged fever for more
Swollen glands than one month
To make the diagnosis in infant or child they should show at least two major and two
minor signs.
Major Signs
Minor Signs
Weight loss or slow growlh
Thrush in mouth
Chronic diarrhoea for more
than one month
Swollen glands
Persistent cough
Generalised skin disease
Prolonged fever for more
than one month
If one/both parents have symptoms and
signs of AIDS.
Confirmation of Diagnosis
Laboratory diagnosis of HIV infection is necessary, and no individual should be
identified as HIV positive on the basis of single test.
Laboratory diagnosis is made by:
i)
detection of specific antibodies
ii)
isolation of HIV
iii) detection of HIV antigen
iv) detection of viral nucleic acid
81
Detection of Specific Antibody
Screening
The initial tests used for this purpose are sometimes termed as screening tests. These have
high degree of sensitivity, though their speciticity may not he always high. These may be
divided into 3 main categories e.g. ELISA, RapidTests, Simple Tests. There are about 50
such tests available now.
ELISA : They use enzyme as an indicator system for detection of complex formed due to
reaction between antigen and antibody which is present in the patients sera.
Rapid Tests : They have a total reaction time of less than 30 minutes.They are 3 limes
more expensive than ELISA and do not require complex equipment. They are best suited
for emergency clinics, casualities of trauma clinics where immediate screening of blood
of donar or a recepient may be required. There are two types of tests (a) Latex
Agglutination (b) Dot blot assays.
Simple Tests : Simple tests are similar to rapid test but take longer than 30 minutes (a)
latex agglutination (b) gelatin particle agglutination. They are cheap and easy to handle.
No persons should be identified as HIV infected based on single screening test- The
results must be confirmed by supplementary tests. These are a) Western blot assay (b)
Immunofluroscence assay and (c) pepti-LAV assay.
Detection of HIV Antigen
The antigen test detects P 24 free in the serum. HIV antigen occurs during the early
period and during late disease when patient is symptomatic. HIV antigen is also seen in
newborn. Therefore, this test may be useful:
•
when early infection is suspected and patient is seronegative
•
during late disease
to detect HIV infection in new born
•
when HIV dementia and encephalopathy is suspected and test is performed with
C.S.E
Detection of Viral Nucleic Acid
This is still a* research technique and may be used for diagnosis of HIV infection in
problematic cases.
*
Indirect Predictors
Cellular - TLC, Cd4/CD8 cell count and skin hypersensitivity test Serological - B-2
microglobilin, neopterin, interleukin-2 and gene marker
82
Management
There is still no drug available to cure AIDS. A few drugs such asAZT can help to slow
down death process but they are very expensive and in short supply Patients suffering
from symptoms, because they cannot fight infection, should be given treatment to ease
their discomfort.
Patients who suffer from fever, diarrhoea and pain may need to be cared for in a hospital
for sometime for symptomatic treatment and nursing care.
Persons who can be cared at home should be sent home. Families can respond better to
the social and psychological needs of the sick member.
There is no need to isolate the AIDS patients for the sake of protecting others. On the
other hand, it may be necessary to isolate a patient to protect her/him from surrounding
infection. AIDS patients should be helped with their personal hygiene.This can normally
be done without risk. But one thing should be remembered, that soiled or blood stained
linen can transmit the virus and also bleeding or infected wounds can transmit the virus.
Care of Infected Equipment and Soiled Linen
The AIDS virus can spread through use of syringes, needles and instruments which have
been in contact with the blood of a person who is carrying HIVeven if he is not sick. The
virus is very fragile and dies at 56° or when soaked in common disinfectant.
There are three ways to sterlise equipment:
a) Boiling for 20 minutes
b) Steam or pressure cooking or autoclaving
c) Soaking for 20 minutes in disinfectant solution:
i) Chlorine 5 gr per litre or 1 part household bleach in 10 parts of water
ii) Alcohol, 700 gr ethanol in 1 litre of water solution freshly prepared
Sources and References for further reading:
i)
WHO Work Books No. 1 - 7 on STD: WHO/GPA/PMT/05. 18D.
ii)
Sexually Transmitted Infections; Guidelines for Prevention and Treatment: Health
and Population-Occasional paper DFID: Adler et al, 1998.
iii)
Reproductive Health: PGDMCH-IGNOU School of Health Sciences, 1998.
iv)
National Guidelines for the Management of STD, 1999; 75 (Suppl 1) S 13-55.
v)
Excerpts from the Simplified STD Treatment Guidelines: National AIDS Control
Organization, Ministry of Health and Family Welfare, New Delhi, July 1993.
vi)
Controlling Sexually transmitted Diseases, Population Reports: Series L, No.9,
June 1993.
83
MENTAL HEALTH ISSUES RELATED TO REPRODUCTIVE
HEALTH IN WOMEN
DR. PRABHA S. CHANDRA
DEPT OF PSYCHIATRY
NIMH ANS,
BANGALORE.
*
84
THE INTERFACE BETWEEN PSYCHIATRY AND WOMEN'S
REPRODUCTIVE HEALTH
There is probably no other area in medicine which is fraught with so many
emotional issues as reproductive health. For women, issues such as fertility, pregnancy,
abortion and contraception have always been areas of concern and debate. The
reproductive health framework goes beyond the narrow confines of maternal and child
health and family planning, to encompass all aspects of human sexuality.
It is important to recognize and describe psychiatric and psychological syndromes
linked to reproductive health in women. Particularly in India and the rest of the
developing world, there is an under recognition of these conditions by health
professionals and a tendency to label some of these as 'normal' based on cultural
expectations.
Three main forms of mental health problems have been linked to reproductive
function:
1.
Those related to physiological changes such as menstrual cycle, pregnancy and
menopause.
2.
Complications of surgeries/procedures/gynaecological pathology.
3.
Preexisting psychiatric problems and reproductive health.
Investigations in this field have been confronted with the problems which relate to
the ways in which people have viewed mental health & reproductive issues. Medicalizing
all problems takes a very narrow perspective and ignores the cultural, psychological and
social perspective in which a problem occurs. Workers in this area have only recently
acknowledged the value of understanding medical and psychosocial issues in an
interactive manner and its relation to treatment compliance and help seeking.
Reproductive health is a large canvas and to be more focused and to describe the
complex interplay of biological, hormonal and psychosocial factors, the chapter focuses
on the following major areas - sterilization, menopause, psychiatric issues in relation to
the menstrual cycle, gynaecological somatization and psychiatric syndromes related to
reproductive pathology.
Sterilisation in Women and Mental Health
Several psychiatric problems have been described in relation to tubal ligation and
laproscopic sterilisation among Indian women.
85
Clinical Presentation
1.
History of vague pains and aches specially in the lower abdomen or low back for
which no cause can be found.
2.
Inability to work and fatigue
3.
Disinterest and irritability
4.
Decreased libido, dyspareunia
This usually occurs a few months after the procedure.
Women often tend to attribute several of their somatic and psychological problems to
tubectomy even when there is no definite temporal correlation. Post tubectomy
somatisation is a common presentation to primary health care clinics. An analysis of
self-reported symptoms of gynaecological problems among 3,600 recent mothers in
Karnataka , South India revealed a strong relationship between self reported symptoms
and nature of contraceptive use. Nonusers or users of reversible contraceptive methods
were less likely to report symptoms of morbid conditions than were sterilized women.
Risk Factors for post tubal ligation Mental health Problems
Risk factors associated with post tubectomy psychiatric problems have been
1. Poor motivation to undergo the surgery
2. Inadequate knowledge and myths about ligation
3. Fears related to laproscopic sterilisation being an electrical surgical technique
4. Poor family supports
5. Marital problems
6. Premorbid health anxiety
7. Fear of negative evaluation by others
8. Preoperative psychological distress
It has been found that the above factors are robust predictors of adverse
psychosexual outcome immediately and 1 year after sterilization among women.
Pre and Post Sterilisation Counselling
In view of the high prevalence of somatic complaints attributable to tubectomy, it
is important to emphasize the need for adequate pre and post sterilization counselling by
trained professional and counsellors.
Presterilization counselling
2.
3.
4.
5.
6.
Assessment of the woman's acceptance of the procedure
Existence of any pre existing minor psychological problems such as depression or
anxiety (see appendix)
An evaluation of marital relationships
The couple/woman should be educated regarding the procedure
Dispel myths regarding sterilisation
Depression and anxiety if detected should be treated according to its severity.
86
If depression or anxiety is mild , it can be handled by simple counselling ,
however if it is severe it needs referral to a mental health professional ( See appendix for
guidelines for Referral )
Post Sterilization Counselling
1.
2.
3.
4.
Discuss with the woman her experiences of the procedure.
Education regarding any physical problems that the woman is falsely attributing to
the procedure.
Couple counselling regarding sexual activity
Scope for follow up discussions in case a problem arises
Very often it is lack of knowledge which makes women falsely attribute all their
physical and emotional problems to the sterilisation which needs to be handled at any
early stage itself.
Assessment and Management of
the Premenstrual Phase
Psychological Problems Related to
The influence of menstrual cycle on behaviour and mood has been
described widely. By virtue of their disabling effects, premenstrual changes and more
often the syndrome can interfere with women’s performance at work and influence
adversely their interpersonal relationships. For some women (nearly 5%) these can be
very disruptive and will necessitate treatment. Most women may not be aware of the
relationship between their mood and menstrual cycle and it is upto the discerning
clinician to detect it.
Premenstrual Changes and the Premenstrual Syndrome
Premenstrual problems can be divided into three broad categories -
1.
Premenstrual changes:
A large majority of women (nearly 80-90%) experience some form of change in
the premenstrual period. Usually these changes are physical in nature and are mild in
severity. In most women they do not cause any impairment and only help in heralding the
onset of the menstrual period.
2.
a.
b.
c.
d.
Premenstrual syndrome :
The PMS generally refers to
A constellation of changes in the following areas
Mood, Physical symptoms and Behaviour ( described in detail below)
These occur with a repetitive cyclical relationship to the luteal phase of the menstrual cycle
Is present in most cycles
The symptoms may be of sufficient severity to cause distress and/or significant
impairment in social, occupational and personal life.
The syndrome equivalent of premenstrual changes is found in nearly 4-5% of
women and usually warrants treatment.
87
Premenstrual syndrome superimposed on an already existing disorder:
Some women experience a constellation of all the changes described under
PMS on the background of a preexisting psychiatric or medical condition. The physician
needs to hence differentiate between a pre existing problem that increases during
the premenstrual period and independent PMS. This can be easily obtained from the
relative or the patient when one takes a detailed history of problems that occur even in
between periods.
3.
Clinical Presentation
The premenstrual syndrome (PMS) has often been described as a heterogenous
disorder. Nearly 100 symptoms have been described under the rubric of premenstrual
changes and the syndrome. Usually, women with premenstrual distress have more than
one symptom and not infrequently have clusters of symptoms relating to various aspects
of psychological and physical functioning. Some women with PMS have an additional
increase in symptoms during the ovulatory phase.
Symptoms and Subsyndromes in the PMS
Description of commonly occurring symptoms
1.
Mood changes : The commonly occurring mood changes are irritability, mood
swings, feelings of guilt, suicidal ideation, depression and anxiety . The irritability
is recognised as being unwanted and out of proportion to the situation.
Depression usually manifests as crying spells, a feeling of inability to cope,
moodiness and feelings of worthlessness, death wish and less commonly , suicidal
ideation. Anxiety is another common symptom with accompanying motor
restlessness, feeling 'on edge' and occasionally agitation.
2.
Somatic symptoms : The commonest somatic symptom described is decreased
energy levels and fatigue. In some women mental symptoms of fatigue such as
decreased concentration and slowed thinking may also be found. Pain is another
common presenting complaint specially abdominal or low back pain.
Sleep disturbances are also sometimes evident which can present both as
insomnia and hypersomnia. In addition there are changes in appetite and some
women report craving for certain foods, specially carbohydrates. Changes in
sexual desire are also mentioned as a frequent complaint.
3.
Behavioural symptoms : Lack of self control, easy weeping and impulsivity are
some df the symptoms reported. There is a tendency to get angry at small slights
and becoming increasingly rejection sensitive. A number of women also report
lack of interest in socialisation.
4.
Cognitive changes: Women with PMS report having muddled thinking,
impairment in memory and poor judgement. Indecisiveness and an impairment in
concentration have also been reported.
*
88
5.
Changes associated with water retention : Engorgement of the breast with
mastalgia. weight gain, and swelling of the feet have been reported. Glaucoma, with
pain in the eyes and blurred vision may occur in the premenstruum. Water retention
may also be responsible for headaches occurring during the premenstrual phase.
6.
Positive symptoms in PMS : Though the usual manifestation of PMS is in the
form of distress, a number of women also report an improvement in one or more
areas of functioning. Nearly 15-40% of women report increased well being.
In a majority of women the changes in the premenstruum are bidirectional and
include both positive and negative changes.
Diagnosis of RMS
PMS is diagnosed if a woman has several of the above symptoms (with at least
one mood symptom) occurring at least for two consecutive cycles during the premenstrual
phase and remitting in the postmenstrual week. The symptoms should cause significant
impairment at work or with interpersonal relationships.
In a large community based study in Bangalore, 10% of women from the whole
sample reported having a premenstrual syndrome. On relating phase to scores on various
feeling and performance parameters it was observed that both
menstrual and
premenstrual distress was common rather than the distress being exclusively
premenstrual.
Pains and aches and fatigue were the commonest symptoms reported in all these
groups followed by irritability and losing temper - 10% of the whole group felt the
symptoms were intolerable and 13% reported abstinence from work. The results indicate
therefore that a large number of women have at least some changes premenstrually with a
smaller number experiencing a large proportion of symptoms.
Premenstrual Subsyndromes
A number of studies carried out on PMS and premenstrual changes have revealed
the existence of discrete subsyndromes.
It is easier to discuss subsyndromes in women with mild to moderate degrees of
premenstrual changes rather than in the more severe cases. In the latter group there
probably occurs an overlap of several syndromes with one of them predominating. The
following subtypes have been described
1.
Depressive syndrome - sadness of mood, crying spells, irritability
2.
Organic mental syndrome - poor concentration, clumsiness
3.
Impulsive syndrome - mood swings, anger outbursts, aggression
4.
Water retention syndrome - mastodynia, swelling of feet, heaviness
5.
General discomfort syndrome - pains and aches
6.
Increased well being syndrome - positive feelings, increased energy levels
The importance of subtyping is mainly for management and charting the course of
89
the disorder.
MANAGEMENT
Assessment and Diagnosis
The initial step in treatment of PMS remains the establishment of definite PMS
prospectively at least over two cycles. This is important for two reasons. Firstly, it
differentiates between premenstrual exacerbations of preexisting disorders and a
premenstrual syndrome and secondly helps the clinician in identifying which sub
syndrome or syndromes characterize the PMS in the identified patients.
Other conditions to be ruled out
Once a diagnosis of PMS is reached, several gynaecological conditions such as
endometriosis, polycystic ovarian disease and uterine fibroids and medical conditions
such as hypothyroidism and hypoglycaemia need to be ruled out as these might mimic
or worsen PMS.
A careful psychiatric evaluation to detect the presence of comorbid depressive
disorder is also necessary ( use guidelines given in appendix for diagnosis of depression).
If in doubt consider referring to a mental health professional.
Treatment of the PMS
The management of PMS can be divided into two broad headings
pharmacological and non pharmacological.
Nonpharmacological methods are particularly useful in milder cases of PMS.
These are in the form of
Regular exercise
1.
2.
Stress reduction techniques such as Yoga, planning the day in advance,
minimising stressful activities during the premenstrual period.
3.
Dietary modification.
- Caffeine and alcohol should be avoided
- women are encouraged to eat complex carbohydrates such as fruits, whole wheat
bread, rotis etc. at frequent intervals rather than simple sugars such as sweets or
chocolates. This prevents frequent changes in blood sugar levels which contributes
to hypoglycaemic symptoms which often occur in PMS and cause fatigue, anxiety
and irritability caused during this period.
Pharmacological Methods
Several pharmacological agents have been used and the decision to use a
particular drug depends on the subsyndrome identified and the constellation of symptoms.
Hormones
90
Progesterone , Oral contraceptives , Gonadotrophin releasing hormone and
Synthetic androgens have been used for treating PMS.
Though progesterone was initially the drug of choice in PMS, its usefulness is
limited to cases where a definite progesterone deficiency can be demonstrated. Oral
contraceptives have been found to decrease premenstrual moodiness, irritability, fatigue
and depression and are used commonly.
Recent studies have used 'medical ovariectomy' by Gonadotrophin releasing
hormone agonist (GnRH) as a means of treatment in severe cases. Improvement has been
reported with doses ranging from 400-600 mg/day.
Danazol , a synthetic androgenic derivative of ethisterone has been used as an
antigonadotrophin and has been found to decrease depression and pain at doses of
100-400 mg/day.
Hormones are useful when a woman has a combination ofpsychological and somatic
symptoms of PMS and are best administered under the supervision of a gynaecologist.
Drugs That Alter Salt & Water Balance
Diuretics such as triamterene, benzthiazide and spironolactone have been found
useful in treating depression and irritability in association with water retention symptoms.
Prostaglandin Antagonists and Precursors
Levels of certain prostaglandins such as PGF2 & and PGE2 are altered during the
luteal phase. Based on these findings both prostaglandin antagonists such as mefenamic
aid and precursors such as gamma linoleic acid (GLA 120) have been used with
beneficial results both on mood and somatic symptoms, specially pain.
Nutritional therapy (Vitamins and Minerals)
Pyridoxine (Vit B6) has been used in PMS based on its efficacy in treating oral
contraceptive induced depression and has been found to have some benefit in doses as
high as 500 mg daily. Vitamin E has been studied in the PMS and positive effects on
motor coordination reported with some improvement on mood and anxiety.
Psychotropic drugs
In viev# of the frequent occurrence of depression and anxiety in PMS, a number
of antidepressants and antianxiety agents have been tried with varying degrees of
therapeutic success.
Drugs commonly used have been
Antidepressants - Selective Serotonin Reuptake Inhibitors such as Fluoxetine, Tricyclic
antidepressants such as imipramine and amitryptiline.
91
Anxiolytics such as buspirone and clonazepam for short term use.
Referral to a mental health professional
Most women with minor problems can be handled by the family physician. If the
woman has depression that interferes with functioning during the premenstrual period or
has suicidal ideas , aggression or marked irritability, a referral to a mental health
professional should be considered. In minor cases the primary care physician can handle
premenstrual problems , preferably in liaison with a gynaecologist and/or a psychiatrist
depending on which symptom cluster predominates, specially when hormonal treatment
or psychotropic drugs are being considered.
Conclusions
PMS is a potentially treatable but underdetected disorder and has special relevance
in the context of mental health as it is a common condition associated with mood
disorders in women. Appropriate management of the disorder helps in decreasing
disability in a significant proportion of women.
Psychiatric Problems Related to Gynaecological Pathology
Pelvic surgical procedures of any form have been reported to cause increased
psychiatric morbidity. Depression and a post hysterectomy syndrome characterised by
headaches, insomnia and tiredness have also been reported. However, recent literature
using vigorous methodology reveals this problem only in women with preexisting
psychopathology.
There is also evidence to indicate a high prevalence of depression among those
with pelvic pain, menstrual irregularities and gynaecological cancers.
Infertility
Another important gynaecological pathology that has important mental health
implications is infertility. Infertility in any culture imposes severe emotional stress
on women. High rates of depression, anxiety and suicidal ideation have been reported in
this group. Societal and cultural values regarding procreation, hold the women
responsible for reproduction and a failure to do so in seen as a sign of weakness.
Studies in India have reported high rates of mental health problems, marital
disharmony and social ostracization. Despite the new 'high tech' reproductive culture,
few facilities are available to handle the emotional needs of such women and their
spouses .The impact of sophisticated IVF technologies which are being utilized by
couples in India on their emotional health is not known. These technologies are taxing,
emotionally, financially and physically and there isza need to study the psychological
impact of these in the Indian setting.
92
Gynaecological Cancers
Among the gynaecological cancers, cancer of the cervix is probably the
commonest in India.
Clinical Problems in Women with Gynec. Cancers
a.
b.
c.
d.
e.
A high prevalence of depression and anxiety has been seen
Social support has been found to be an important factor modulating the psychosocial
adjustment in cancer patients.
Women with cervical cancers have concerns related to body image, sexuality, pain,
radiotherapy and terminality.
Sexual problems are very common among women with gynaecological cancers,
These are related to spreading the disease to the sexual partner, feelings of
contamination and fears that the cancer may spread because of sexual activity.
Pain is a common correlate of advanced cervical cancers and studies done among
Indian women have reported unrelieved cancer pain as the commonest cause of
depression.
It is obvious that women with gynaecological cancers need psychosocial
assessments and support. This is particularly relevant in countries like India where delay
in seeking treatment is common and factors such as poor financial resources, decreased
treatment options, inadequate knowledge and myths related to treatment and family
burden increase the propensity to develop psychiatric problems.
MENTAL HEALTH & THE MENOPAUSE
Clinical Features
Several physical symptoms have been described in the menopause that are related
to decrease in levels of oestrogen. These are mainly in the form of flushing, bone pains
and vasomotor symptoms. Though it is well know that physical symptoms occur
frequently in the perimenopausal period, the status of the psychological syndrome of
menopause is far from clear.
The following psychological symptoms have been reported in the
climacteric :
Depression (20-30%), anxiety (15-20%), sexual dysfunction (10%) and difficulties
in concentration (5-8%).
Cross Cultural Variations
Several cross cultural variations in the perception of menopause have also been
noted with Western women showing a higher incidence of depression. This has been
accounted for by negative attitudes towards ageing and menopause in cultures where
higher psychiatric morbidity has been reported.
Factors Contributing to mental health problems in menopausal women
Mental health of women in the climacteric appears to be related to
93
a.
Psychosocial factors - attitudes towards ageing, role in the family, death or illness in
spouse, marital relationship.
b. Premorbid functioning
c. Physical health than only to the menopausal status.
Though in most cases, menopause may not directly cause psychological problems,
a small minority do have the problems which were described earlier. Surgical menopause
appears to have a higher incidence of psychiatric morbidity compared to natural
menopause.
Hormone Replacement Therapy & the Menopause
The role of HRT (hormone replacement therapy) in relieving symptoms of
menopause has been fairly well established. Problems related to menopause that benefit
with HRT include relief of vasomotor symptoms, prevention of osteoporosis and
prevention of cardiovascular disease.
However, similar conclusions cannot be drawn regarding the beneficial effects of
HRT on psychological symptoms. The only situation in which HRT has a definite role in
ameliorating psychological symptoms are in surgical menopause (ie. following a
hysterectomy with bilateral oophorectomy or in primary ovarian failure). In surgical
menopause, HRT appears to have a two pronged approach. Firstly, its causes a 'domino
effect' i.e. it improves well being by decreasing physical distress. More importantly,
however it improves sleep, cognitive and sexual functioning and has a definite beneficial
effect on mood.
Assessment and Management
It is very important that a perimenopausal woman with psychological distress be
assessed in detail. Factors that need to be considered are psychological, social and cultural
attitudes towards ageing and other family and role related issues. Several changes occur in a
woman's life around the perimenopausal period which include loss of loved ones including
spouse, change in roles and the 'empty nest syndrome' which may occur once the children
leave home. All these factors may contribute to the depression or anxiety.
With the current state of knowledge considerable caution must be exercised when
using HRT for psychological symptoms alone in natural menopause. However, women
with degenerative disorders , cardiovascular disease & psychiatric problems in the
context of surgical menopause should not be denied a trial of HRT.
GYNAECOLOGICAL SOMATIZATION
Several clinical conditions in gynaecological practice are known to have social
and psychological associations. Among these the commonest and probably the least
adequately understood are - chronic pelvic pain and vaginal discharge.
CHRONIC PELVIC PAIN
Clinical Features
1.
Chronic pelvic pain (CPP) is defined as a general symptom of persistent pain and
94
heaviness located in the pelvis of at least several months duration without any
identifiable cause.
2.
Usually accompanied by anxiety, dullness, irritability and sleep disturbances in the
form of insomnia
3.
The pain usually worsens in emotionally stressful conditions
4.
Sexual problems such as lack of libido, pain during intercourse
It can be a major problem for those afflicted because of the associated distress and
for health services because of the large number of patients presenting with it . In at least
two thirds of women with CPP, there is no obvious identifiable pathology. The most
important theory explaining pelvic pain has been that of pelvic congestion syndrome.
Mental Health Issues in Chronic Pelvic Pain
1.
2.
3.
4.
Several psychological factors are linked to CPP
'The meaning of pain' - very often the pain being a way of communicating emotional
distress.
Sexual abuse has been associated with CPP and eliciting history of abuse is very
important.
The fact that women with CPP often go through several surgical procedures for pain
relief that might contribute to the pain are often ignored.
In some women the condition may have a psychosomatic nature , with pain and
discomfort getting worse in situations of emotional stress.
Management of CPP
1.
2.
3.
4.
5.
6.
7.
8.
9.
Rule out an identifiable local cause for the Pelvic Pain
Explore areas of stress including marital and sexual adjustment
Other causes such as sexual abuse that might be contributing
Assess for presence of co existing depression and anxiety
Reassurance regarding benign nature of pain
Acknowledging the problem the condition is causing
Explaining the link between emotional factors and bodily symptoms
Non specific techniques like relaxation exercises, yoga and exercise that might
decrease vascular congestion.
Referral to appropriate professional if co existing psychological problems are
identified.
SYNDROME OF NON PATHOLOGICAL VAGINAL DISCHARGE
General Description
*
The belief that the passage of white discharge per vagina (WDPV) is associated
with bodily complaints of weakness, tiredness, exhaustion and body aches is widely
prevalent in certain groups of Indian women.The passing of vaginal discharge ( non
pathological ) is perceived as being abnormal and a loss of vital fluid leading to depletion
of energy. Nichter (1981) discussed this as an 'idiom of distress’ and described WDPV as
95
a symptom state associated with complex cultural meanings. In a study conducted at
Bangalore among 210 women with somatic complaints attending a psychiatric outpatient,
it was found that 61 % reported passing white discharge that was not attributable to a
gynaecological problem. 31 % of these women felt that it was abnormal to pass WDPV
and considered it a sign of illness. Prevalent etiological notions for causation of illness by
WDPV included a dissolving of bones, loss of dhatu or vital fluid and overheat.
Clinical Features
Women often present primary care physicians or gynaecological clinics with
complaints of:
Exhaustion
a.
b. Decreased Concentration and Efficiency
c. Vague pains and aches
d. Feeling Weak
e.
Listlessness and Dullness
f.
Decreased sexual satisfaction.
g- Anxiety and mental tension
h. Decreased desire to speak to others
i.
Decreased productivity
They attribute all these features to excessive vaginal discharge
Jk. The discharge is usually non pathological and careful questioning also reveals that it
is indeed not excessive
Explanatory Models for Causation given by women
Vaginal discharge
a.
is because of dietary factors
b.
indicated excess of heat in the body
c.
a result of tubectomy
d.
because of emotional stress
e.
excessive physical activity
f.
the belief that WDPV was harmful to their health
Most of the symptoms describe a syndrome that includes physical, mental and
sexual elements and probably include psychiatric syndromes such as depression, anxiety
and somatisation.
In many women a complaint of white discharge appears to be a medium of
communication regarding health issues. It is important for health workers to enquire
regarding explanatory models for physical complaints. The intricate relationship between
their symptoms and WDPV would otherwise remain 'hidden' and lead to dissatisfaction
and poor compliance to health care.
Help Seeking for WDPV
Women in both the above study samples reported that there is a secrecy
surrounding their condition and associated sense of guilt and shame with the fear of
96
disgrace. Only 8 % of the women go to practitioners of modern medicine while among
others shyness, fears and lack of women doctors prevent adequate help seeking. There are
nearly 50 types of indigenous treatments for WDPV that includes preventive therapy.
According to Nichter (1981), prevalent etiological notions of WDPV include a
dissolving of bones, loss of dhatu and overheat. Ujla ( whiteness), Sweta Pradara ( white
discharge), Safed paani ( white water ), white bleeding and bill hogovudu ( going white)
where some of the common terms used by these women. A similar syndrome in men is
the Dhat syndrome which is characterised by neurasthenia related to excessive seminal
discharge.
Community studies done regarding the perception of white discharge among rural
women from India have also revealed several interesting findings . Perceived causes in
addition to those mentioned above have been - husband having extramarital relationships,
contraceptive methods including vasectomy in the husband, following childbirth and
abortion and sexual tension.
Management of Syndrome Related to Non Pathological White Discharge
1.
2.
3.
4.
5.
Understanding the woman's perception of the condition and her attribution patterns
ie. how she links the vaginal discharge to physical and psychological symptoms
Careful explanation of the difference between pathological and non pathological
vaginal discharge.
Reassurance and suggesting alternate explanations for each of the symptoms that
the woman attributes to the vaginal discharge
Management of the woman's presenting complaints eg. anaemia causing exhaustion
or anxiety leading to decreased concentration, tremors and decreased efficiency
Dealing with Sexual problems if any
Sexual Health and Partner Counselling
One of the major areas of intervention in the context of RTI s and STDs is
discussions regarding sexual relationships. This is obviously a very intimate area of a
couple's life and requires sensitivity and careful handling. However, being a very
important area it should not be neglected and a routine enquiry regarding sexual
functioning should be made as part of the general history taking.
Who should be interviewed ?
Ideally, the sexual history should be obtained from both the partners. Some
couples may feel comfortable talking about these matters together while others may feel
diffident. The physician should take a decision based on the situation whether to see the
couple as a unit or individually. Sometimes it might help to interview them individually
and then have a joint session.
What are the areas to be assessed ?
a. Mutual Sexual Satisfaction
97
b. Any sexual dysfunction - male or female ? this includes
- decreased desire
- vaginismus or dyspareunia
- erectile failure
- premature ejaculation
- orgasmic problems
c. What is the level of openness and communication regarding sexual matters ?
d. Contraceptive use and any conflicts regarding nature of contraception.
e. In case of RTIs, specifically enquire regarding acceptance of condoms, awareness
regarding proper use and disposal of condoms and any myths regarding condom use.
f. Awareness in both partners regarding signs and symptoms of common RTIs and
STDs. - very often it may be a lack of awareness that delays treatment.
g- History of STDs and treatment
h. Sexual Practices - including nature of sexual intercourse ( vaginal sex, oral sex, anal
sex etc. ) - this is important because if the physician counsels regarding safe sex
practices only in the context of vaginal sexual intercourse, many other routes of
infection may be missed out.
i.
Presence of other sex partners
j- Type of other sex partners ie - another single partner, sex with unknown persons or
commercial sex workers, sex with persons who may have other partners
k. Use of alcohol during sexual activity - this is important because very often men may
not be able to use a condom properly if under the influence of alcohol
I. Sexual Orientation - This might be a delicate topic and needs to be enquired into very
sensitively but with increasing awareness regarding homosexual and bisexual
behaviour , if there is any evidence or if the physician has sufficient rapport these
should be assessed.
PARTNER COUNSELLING
Key Points
1. Very often it is the woman alone who might come to a physician for help. Once a
detailed assessment regarding sexual functioning is done , it will be clear to the
physician what the level of sexual communication is between the partners. If the level
of communication is open then the woman can take the initiative of bringing in the
partner.
2. Majority of women , specially in our cultural context may not be able to discuss
openly regarding these matters with their spouse and may not be able to negotiate
options of safe sex or condom use.
3. It is best for the partner to be involved in treatment as early as possible and the
physician should make efforts at bringing in the partner into treatment.
4. Sessions with the partner should focus on
a. Education regarding STDs and RTIs and how treatment of both partners is important
in preventing re infection.
b. Dispelling myths about condom use and encouraging acceptance of condoms if
needed.
98
c. Approaching the spouse as a partner in treatment. The spouse should not feel that he
is being blamed for the infection.
Reluctant spouses may need individual sessions in order to discuss any other
factor that may be contributing to sexual dissatisfaction, problems and lack of mutual
understanding in the area.
Some points to remember are 1. Approach the area with sensitivity and without offending the patient.
2. Confidentiality is very important as it encourages an open and honest discussion with
the physician. The physician should emphasize this fact.
3. Use language that the patient understands rather than technical words
4. Use visual illustrations if necessary
5. Do not indicate embarrassment or reluctance - remember that if you treat the whole
problem in a calm and confident manner , the patient will feel more relaxed, ask more
questions and understand more.
Methods of Providing Adequate and Comprehensive Mental Health Care
In Existing Reproductive Health Care Settings.
Most women may not seek advice for mental health issues unless the problem
becomes severe. Women however may more frequently seek help for gynaecological
complaints specially in primary health care . It would also be more acceptable for women
seek help for their problems from a gynaecologist rather than from a mental health
professional. Under these circumstances the communication of both physical and
emotional distress might occur in contacts with a primary care physician or health worker
rather than with a trained mental health professional. Help seeking regarding
reproduction linked mental health issues is related to explanatory models, communication
regarding dysfunction and attitudes towards illness.
Limited choices and poor
accessibility to appropriate information may often lead to poor detection and treatment.
It is important hence to integrate mental health in the care of those who came into
reproductive and gynaecological health clinics. One of the ways in which morbidity could
be reduced is "by early assessment and identification of mental health problems. Simple
screening methods can identify 'at risk' cases and consider appropriate referrals.
Women's health programmes tend to compartmentalise programs on mental
health, reproductive health and family planning, however, women's lives very often no
such compartments! Integration of mental health issues in all aspects of women's health is
the requirement of the times.
99
APPENDIX
Diagnosis and Management of Minor Psychological Problems Related to
Reproductive Health
Diagnosing Anxiety
1.
2.
3.
Check for the presence of the following symptoms
Apprehension, difficulty in concentrating, excessive worrying
Motor Tension, restlessness, tension headaches, tremulousness
Autonomic overactivity in the form of sweating, tachycardia, dry mouth, epigastric
discomfort
Anxiety maybe related to specific situations or chronic. It needs treatment if it is
present most of the time ( weeks to months continuously) and interferes with a woman’s
day to day functioning.
Diagnosing Depression
Check for the presence of the following symptoms
Women have a higher incidence of women than men. Symptoms of depression
include 1. Pervasive sadness of mood
2. Loss of interest and enjoyment
3. Reduced energy leading to increased fatiguability other features include
a. reduced concentration
b. reduced self confidence
c. pessimistic views about the future
d. ideas of self harm or suicide
e. disturbed sleep
f. diminished appetite
In a depressive episode the lowered mood varies little from day to day and varies
little with circumstances. In more minor forms of depression the mood worsens during
stressful periods. To diagnose clinical depression it should be present continuosly for at
least two weeks.
Diagnosing Somatisation Disorder
The main features are multiple, recurrent and frequently changing physical
symptoms for a long period of time. Most patients have a long and complicated history of
contact with both primary and specialist medical professionals during which many
fruitless investigations are carried out. Common symptoms reported are
1. GI symptoms such as pain, belching, nausea
2. Neurological symptoms such as tingling, numbness, pains and aches
3. Vaginal discharge, menstrual irregularities and sexual problems
4. Depression and anxiety often co- exist
100
Handling Depression and Anxiety in Primary Health Care
Minor Features of Depression and Anxiety (ie . which are situation specific and not
continuous and do not interfere with personal, social or occupational functions)
1. Reassurance
2. Education regarding nature of problems and their cause
3. Simple Counselling techniques to improve methods of coping such as
- ventilation regarding the problem
- helping the patient identify alternative ways of solving the problem
- finding activities that will help patient be busy and serve as a distraction technique
4. Marital or Family Counselling if a problem is identified which includes
- helping the family or couple identify and express areas of maladjustment
- improving communication between the couple or family members
- education and explanation regarding the impact of problems within the family on
the mental state of the patient
- finding alternative methods of problem resolution within the family
Referral to a Mental Health Professional Should be Considered
1.
If the problems are continuous and severe
2.
Simple reassurance and education does not work
3.
There is more than one problem area in the patient or family eg. patient has
depression, husband has an alcohol problem and the children have emotional or
school related problems.
4.
History of suicidal ideation or attempt
5.
History of Sexual Abuse
6.
Marked sleep and appetite disturbances indicating the need for
medication
7.
Presence of associated medical conditions which will require careful use of
psychotropics
101
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psychotropic
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BIBLIOGRAPHY
1.
Agarwal P., Khastgir,U.,Bhatia. M.S.,Bohra,N and Malik,S.C. Psychological
profile of females with chronic pelvic pain. Indian Journal of
Psychiatry,39,4,1996,212-216.
2.
Bang R., Bang A. Women's perceptions of white vaginal discharge : Ethnographic
data from rural Maharashtra. 79 -94. In , Listening to Women Talk about their
Health- Issues and Evidence from India. Ford Foundation. Har Anand
publications, 1994, New Delhi.
3.
Bhatia JC, Cleland J. Self-reported symptoms of gynaecological morbidity and
their treatment in South India. Stud Fam Plann 1995 Jul-Aug;26(4):203-16
4.
Chandra PS, Chaturvedi SK, Channabasavanna SM, Anantha N, Reddy BKM ,
Parameswara J. Concerns and distress among women with cervical cancers
attending a supportive care project. Supportive Care in Cancer. r5, 172, 1997.
5.
Chandra P.S. and Chaturvedi S.K. Cultural variations of premenstrual experience.
International Journal of Social Psychiatry, 35,1989, 343-349.
6.
Chandra P.S. Sexual Issues in Cancer. In Psycho oncology - Current Issues, eds.
Chandra P.S., Chaturvedi SK. Bangalore, 1998.p. 141 -153.
7.
Chandra,P.S., Chaturvedi,S.K.,Issac.M.K.,Chitra, H.,Sudarshan. C.Y. and Beena
M.B. Marital Life among infertile spouses: the wife's perspective and its
implications in therapy. Family Therapy, 18,2,1991,145-154.
8.
Chandra P.S. and Chaturvedi, S.K. Premenstrual experiences, explanatory models
and help seeking in Indian Women. Indian Journal of Social Psychiatry. 11,1,
1995,73-77.
9.
Chaturvedi S.K., Chandra P.S. and Issac M.K. Premenstrual experiences- the four
profiles and factorial patterns.Journal of Psychosomatic Obstetrics and
Gynecology, 14,1993,23-235.
10.
Chaturvedi S.K., Gururaj G, Chandra P.S. An epidemiological study of
premenstrual symptoms and syndromes among women in Bangalore. Report of
NIMHANS funded project, 1994.
11.
Chaturvedi S.K., Chandra P.S.Jssac, MK..Sudarshan C.Y. and Rao. S. Is there a
Female Dhat syndrome ? NIMHANS Journal, 11,2,1993,89-93.
12.
Chaturvedi S.K, Chandra P.S. Prema S.V., Issac, MK..Sudarshan C.Y. , Beena
M.B., Kulkarni S., and Rangan U. Detection of psychiatric morbidity in
gynaecology patients by two brief screening methods. Journal of Psychosomatic
Obstetrics and Gynaecology, 1994, 53 -58.
13.
Clare, A.W. (1983). Psychiatric and Social aspects of premenstrual complaints.
102
Psychological Medicine (Monograph supplement 4). Cambridge, UK: Cambridge
University Press, 5-49.
14.
Dalton K. The premenstrual syndrome and progesterone therapy. London,
Heinemann, 1977.
15.
Gitlin MJ, Pasnau RO. Psychiatric syndromes linked to reproductive function in
women : a review of current knowledge. American journal of psychiatry, 1989,
146:1413-22.
16.
Harrop-Griffiths J, Katon W, Walker E. The association between chronic pelvic
pain, psychiatric diagnosis and childhood sexual abuse. Obstetrics and
gynaecology, 1988, 71 : 589 - 94.
17.
Hunter M, Battersby R. Whitehead M. Relationships between psychological
symptoms, somatic complaints and menopausal
status. Maturitas, 1986,
8:217-88.
18.
MM. Dennerstein L, Pepperell R. Psychological aspects of hysterectomy. A
prospective study. British Journal of Psychiatry, 1989, 154 : 516 - 22.
19.
Nichter, M. Idioms of distress: Alternatives in the expression of psychosocial
distress: a case study from South India. Culture Medicine and Psychiatry. 5,1981,
379-408.
20.
Pearce J.,Hawton. K., Blake, F. Psychological and Sexual Symptoms Associated
with the Menopause and the effects of Hormone Replacement Therapy, British
Journal of Psychiatry, 1995.167,163-173.
21.
Pilowsy I. Editors Introduction. British J of Psychiatry. 1991,158,7-8.
22.
Tewari S. Rathee S. Practice of standards in female sterilisation. J Indian Med
Assoc 1997 May;95(5): 136-7, 141
23.
Umesh Babu S.B. Psychosocial aspects of cancers in women. In Psycho oncology
- Current Issues, eds. Chandra P.S., Chaturvedi SK. Bangalore, 1998.p. 141 -153.
24.
Vyas JN. Rathore RS. Sharma P, Singhal AK. Psychiatric aspects of hysterectomy.
Indian Journal of Psychiatry. 1989, 31, 64-68.
25.
Wig NN, Gupta AN, Khatri R, Verma SK. A prospective study of psychiatric and
menstrual disturbances following tubal ligation. Indian J Med Res 1977
Oct;66(4):581-90
103
DOCTOR PATIENT COMMUNICATION
DR.KISHORE MURTHY
HEALTH MANAGEMENT CONSULTANT
A.F. FERGUSON & COMPANY
BANGALORE
104
Effective communication between doctor and patients is a central clinical
function. Most of the essential diagnostic information arises from the interview and the
physician’s interpersonal skills also largely determine the patient’s satisfaction and compliance
and positively influence health outcome. Most complaints by the public about physicians deal
not with clinical competency but with communication problems. Only a small proportion of
visits with doctors include any patient education and a surprisingly high proportion of patients
do not understand or remember what their physicians tell them about diagnosis and treatment.
Patient’s anxiety and dissatisfaction is related to positive health outcome.
Explaining and understanding patient concerns, even when they cannot be resolved results
in a significant fall in anxiety. Greater participation by the patients in the encounter
improves satisfaction and compliance and outcome of treatment. Patients may be able to
participate in making decisions about their investigations and management, if informed
properly. Informed patients are likely to be more satisfied and possibly more compliant
with doctor’s recommendations.
The fulfillment of patient’s expectations and requirements will depend upon the
effectiveness of communication between patient and doctor, the validity of the patient”
expectations and the ability of the doctor to fulfil them or, if he is unable to do so, to take
an appropriate referral.
1.
The purpose of communication is not just to deliver a message but to effect a
change in the recipient in respect of his knowledge, his attitude or. eventually, in
his behaviour.
2.
The value of a communication is to be judged not on its purpose or content but on
its effect on the recipient. An elegant or witty communication may satisfy the
communicator but leave the recipient uninformed and unmoved.
3.
Communication is effected not only by words which must have the same meaning
for giver and receiver, but also by attitudes, expressions and gestures. This is
especially relevant to a consultation where patient and doctor are both givers and
receivers.
4.
To make sure that a communication has succeeded, information about its effects
(‘feedback’) both immediate or subsequent is needed.
It is irfiportant that the training of Doctors does not become too focussed on the
technological and biomedical dimensions of healthcare to the exclusion of a more holistic
view of the patient. One major task of healthcare is to provide reassurance and comfort for
those in distress about their illness. There is also a need to provide the patient with an
explanation for illness as well as instructions as to how best to deal with it. Giving such
information and support may be one of the most important tasks performed by the Doctors.
105
This module focuses on the need for better communication
information and emotional support for patient. These skills are needed:
a)
In the process of diagnosis of treatment. This includes the doctor ascertaining the
patients concerns, worries and theories about the illness and responding
appropriately.
b)
To give information to patient regarding illness, its treatment and any side effects
and making sure that these have been understood and remembered.
c)
To give emotional support and care to patients of their families recognising their
feelings, fears, distress and anxiety.
d)
This module will help you to refine your skills in communication and patient
physician interaction and relationship.
• To the patient, information is power.
•
Proactive is better than reactive.
• Continuity of communication helps build loyalty.
•
Patients aren’t happy with you unless you treat them as a whole person, not a
disease.
•
You can make patients comfortable or break the ice or reduce fear by using
some very specific, very simple behaviors that matter to the patient.
• Technical skills aren’t the challenge. Interpersonal skills are.
• The successful physicians gain great satisfaction from their interpersonal skills,
which they claim differentiate them from less successful physicians.
• The key skills are listening and seeing the patient as a whole person with a
life apart from their ailments.
1.
2.
3.
4.
5.
Patients prefer doctors who:
Maintain eye contact;
Smile often;
Appear relaxed, not rushed or nervous;
Lean towards patients during conversations; and
Assume a relaxed posture while interviewing.
It’s not what you say... but the way that you say it.’
‘Good communication is a patient’s right.!
‘Communication competence is seen as essential for all Doctors.
There are four elements to communication :
•
Speaking
•
Writing
Listening
Body language
We are far mpre influenced by what we see than by what we hear :
•
Words : 70%
• Tone of voice : 38%
• Body language : 55%
The aims of communicating are:
•
To be heard • To be accepted
To be understood
• To get action.
If one of these aims is not achieved, then good communication has not taken place.
Communication is an interaction which takes place between two or more persons.
106
It can be through, talking, writing, expression of face and eyes, gestures, listening,
observing. We impart, pass on and transmit a message, ideas or information. We also
share and exchange information. The word communication is derived from Latin word
‘Communis’ meaning common when two people communicate ideas, facts, feelings etc.
are exchange to establish commonness.
Interpersonal Communication
When two or three persons communicate with each other then it is called as
interpersonal communication. It is also called face to face communication. It is intimate
and complete as feedback is immediate. It is a two-way process e.g. Doctor discussing
with a lady about her menstrual problems.
Advantages
1.
Communication gets feedback promptly.
2.
It creates goodwill between the communicator and the receiver.
3.
Discussion of sensitive topics like, gynecological problems etc. is possible in one
to one situations.
4.
Sender and receiver can maintain confidentiality.
5.
As it is face to face the communicator can understand the needs of the receiver and
make changes accordingly.
Establishing a good rapport with the patient
How can we can establish a good rapport with a patient? This is where our
communication skills come in:
•
Our verbal skills : the way we talk to the patient and ask questions:
•
Our non-verbal skills : how we behave towards the patient.
1.
Verbal
Most of the time when we communicate it is through verbal messages. It is
difficult for the receiver to remember all that is said verbally and therefore there are
chances of the message getting shortened, change or distorted.
Guidelines to communicate verbally.
Make sure your listener is relaxed and ready to listen.
1.
While communicating a message remember to give reference in context to what is
2.
being said.
Proceed in some logical order.
3.
4.
Ask questions.
5.
Repeat the message.
107
Verbal skills
•
Always phrase your questions politely and respectfully, however busy or rushed
you may be;
•
Use words that the patient understands. Avoid using medical terms they may not
understand;
•
Make your questions specific, so that the patient knows exactly how to answer
you;
•
Ask one question at a time: double questions confuse;
•
Keep your questions free of moral judgements;
•
Avoid leading questions that ask the patient to agree with you: let people answer
in their own words;
•
Ask the patient’s permission to question them about their STD or their sexual
behaviour.
For better communication communicator (Doctor) must have following
skills.
Communicate clearly - he/she should be able to construct the message clearly so
that the receiver can understand it correctly.
Listen actively - he/she should be good listener. This will help him to understand
the problems of receiver.
Knowledge - he/she should have knowledge of the subject on which he/she is
communicating.
Understand others - other person’s attitude always affect the communication so
he/she must be able to understand other persons attitude.
Language - the communicator must have command over the language in which
he/she has to communicate with other.
Ask for feed back - he/she should have the ability to ask questions to get feed
back about communication.
Along with all this skills he/she should have positive regard and respect for
people.
Open and closed questions
When talking to anyone, there are broadly two sorts of questions we can ask :
closed questions and open questions.
Closed questions are ones that ask a patient to answer in one word or a short
phrase, often with “yes” or “no”:
108
“Is the swelling painful?”
“Is your period late?”
“Do you have a regular partner?”
Open questions enable the patient to give a longer reply:
“What is troubling you?”
“What kind of medicines are you taking at the moment?”
Open-ended questions allow the patient to explain what’s wrong or how they feel in
their own words, and to tell you everything they think is important. Closed questions, on the
other hand, ask the patient to answer a precise question in the service provider’s words.
How can we best use the two types of question? Patients often have trouble
revealing information about their own sexuality, so open questions will help them to be
more comfortable when you begin the questions. Generally, you will also gather much
more information from one open question than you can from a closed one.
There is another difficulty with using closed questions early in the interview - this
is the danger of missing important information.
Experts in interviewing STD patients suggests that we need to ask “Anything
else?” several times, because some patients are so embarrassed about STD symptoms that
they present first with other, quite unrelated symptoms - such as a headache!
Once you are sure that you have a complete understanding of the patient’s problem
as he or she sees it, closed questions may be very helpful to draw out specific details that
you need to know.
Other verbal skills
In addition to positive non-verbal behaviour and appropriate, respectful
questioning, there are a number of additional skills which can be extremely useful when
interviewing patients with STD. They can help you to deal supportively with the patient’s
emotions as well as to gather information effectively.
These are the six skills:
•
facilitaxion
•
summarising and checking
•
reassurance
•
direction
•
empathy
•
partnership.
109
Facilitation
Nodding the head and raising the eyebrows are two examples of non-verbal
facilitation. Here is an example of spoken facilitation in practice:
I’m not sure... it’s embarrassing.
Patient
That’s all right, I’m listening.
Service provider
Patient
Well, it’s that...
Yes?
Service provider
There’s this sore...
Patient
The service provider can use words, phrases or other sounds to encourage the
patient to continue speaking.
Direction
This is a useful approach when a patient is confused and doesn’t know where to
begin, or when they are talking quickly and mixing up issues of concern.
Patient
I don’t know, it’s been there for three weeks. What am I
going to tell my husband? Will anyone get to know? I mean
it, it is curable isn’t it?
Service provider
Let’s find out what the problem is first. We can deal with
that, and then we can talk about your husband.
Direction relieves the frustration of the service provider and allows the patient to
share concerns and worries more easily.
Summarising and checking
Summarising and checking allow you to ensure you have understood the patient correctly.
The patient is also able to correct any misunderstanding.
Service provider
(Summarising) So you’re worried what to say to your
husband, and you feel very embarrassed about this condition.
You want to know whether we can cure it. (Checking) Have I
got that right?
Patient
That’s right, What IS wrong with me?
Use this skill when the patient has mentioned a number of things that you want to
confirm.
110
Empathy
This may be the most important skill of all when dealing with the patient’s feelings. Upon
noticing that a patient is tense or anxious, for example, you can express your empathy by
commenting on what you have noticed:
Service provider
I can see that this is worrying you a good deal.
Yes, it’s been bothering me for over a week now. I’m
worried sick.
By showing empathy, you allow the patient to express his or her fears, and establish more
open communication between you. Like facilitation, it encourages the patient to continue
speaking.
Patient
Reassurance
While no-one likes to be patronised with expressions like “Don’t worry, it will be all
right”, reassurance is important to show that you accept the patient’s feelings and that the
problem need not last forever:
Service provider
I can understand that you feel worried about symptoms like
these. As soon as I confirm what’s wrong with you, we can
try to begin treatment that will make you better.
Patient
That’s good. So what else do you need to know?
Partnership
This skill enables you to offer the patient a commitment - with you personally or the team
of people you work with:
Service provider
You’ve done the right thing to come here for treatment.
Before you leave I’ll make quite sure you know everything
you need to about preventing further infection. And we’ll
also find the best way to discuss this with your husband.
Patient
Oh thank you. I don’t want this to happen again.
Most good service providers use some of these interviewing skills some of the time. The key
to interviewing patients who may have an STD/RTI is to use all six skills most of the time.
2.
Non Verbal:
Following aspects communicate the feelings emotion and interest to the receiver.
Looks : Simple and friendly of the communicator.
1.
Tone of voice : Courtesy and kindness are important.
2.
Body posture : Can convey anger, rudeness, courtesy, kindness.
3.
Gesture hands and feet:
Communicate authority, friendliness concern.
111
The key to effective non-verbal behaviour is to treat the patient with respect, and
give him or her your full attention:
•
Provide the patient with privacy. Clearly, privacy and confidentiality are essential,
so the interview must take place some where quiet where you won’t be disturbed;
•
Establish eye contact with the patient. Look directly at him or her; in this way you
can watch for key feelings that will help you to respond appropriately. The only
time to avoid eye contact is when a patient seems very angry, since a direct gaze
could be interpreted as aggressive.
•
Listen carefully to what the patient says. Show that you are listening by leaning
forward slightly towards the patient; nod your head or comment occasionally to
encourage them. Don’t fidget or write while the patient is talking, and don’t
interrupt him or her.
•
Sit if the patient is sitting and stand when the patient stands; stay as close to the
patient as is culturally acceptable - much better to be beside a table or desk than
behind one.
These four points are very simple and they can make the difference between
gaining or losing the patient’s trust or confidence.
Importance of interpersonal communication in Reproductive Health
Programme
Interpersonal communication is very useful for the implementation of
Reproductive Health programme at the grass root level as the family physician needs to
build rapport with the patients as they are the first contact for seeking help / treatment.
Through interpersonal communication they can create friendly and co-operative
atmosphere with the patients. Interpersonal communication can help them to get
information about health problems of the patient. They can educate people about safe
motherhood, family planning, contraception, communicable diseases etc. Inter personal is
face to face and only two persons take part in it. The physician win the heart of the client
and their confidence. She can understand and give education to him/her. He/she can
maintain their privacy and dignity.
Listening and questioning
To help your clients, you must talk to them and they must talk to you. You have
information to give them. But they have information that you need in order to help them.
Some clients may find it hard to talk. You can help by LISTENING ACTIVELY and
QUESTIONING EFFECTIVELY.
How Can You ‘Listen Actively’
Meet with your clients in a private, comfortable place.
Accept your clients as they are. Treat each as an individual.
Listen to what your clients say and how they say it. Notice their tone of voice,
choice of words, facial expressions and gestures.
Put yourself in your client’s place as she or he talks.
Keep silent sometimes. Give your clients time to think, as questions, and talk.
Move at the client’s speed.
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Listen to your client carefully instead of thinking what you are going to say next.
Every now and then repeat what you have heard. Then both you and your client
know whether you have understood.
Sit comfortably, avoid distracting movements, and look directly at your client.
How Can You “Question Effectively”?
Use a tone of voice that shows interest, concern and friendliness.
Ask one question at a time. Wait for an answer.
Ask questions that let clients tell you their reproductive health needs.
Ask questions that cannot be answered “yes” or “no”.
These questions encourage clients to say more.
Examples are: “How can I help you?” “What have you heard about... 9”
Use words such as “then?” “and?” “oh?” These encourage clients to keep talking.
Avoid starting questions with “why.” Sometimes “why” sounds as if you were
finding fault with a person.
Ask the same question in different ways if you think the client has not understood.
Reproductive health is a very private part of client’s lives. When they talk about
Reproductive health, they may feel embarrassed, confused, worried or afraid. These
feelings may make choices difficult. Some feelings may lead to choices that clients are
sorry about later.
Listening skills are crucial. Think of the benefits for the patient when you listen
well. The patient:
1.
Feels accepted as a person.
2.
Is able to express himself or herself.
3.
Feels less anxious or tense.
4.
Feels good about you.
5.
Becomes clearer about what is on his or her mind.
You reap just as many benefits. The doctor:
1.
Develops a positive relationship with the patient.
2.
Gains additional insights & understandings, which enhance future communication.
3.
Obtains a complete, accurate message and can act on it correctly, if action is
needed.
4.
Saves time in the long run by listening in the short run.
5.
Gets to know problems, attitudes, feelings, interests, ambitions, hobbies and many
other things that can help you treat the patient.
How can you help clients deal with their feelings?
First, let them show their feelings. Help them talk about their feelings. Give them your
full attention. Listen actively and question effectively. Watch their body movements and their
expressions. These can tell you what clients are feeling.
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Aims of Patient Interaction
1.
2.
3.
4.
5.
6.
7.
8.
9.
Talk to the patient/couple
Listen to what is said and what is not said.
Identify concerns and help the patient to manage them.
Provide information about Reproductive health.
Assess psychological and emotional impact of these concerns of the patient.
Assure the patient that his views have been heard.
Help patient make informed decisions which might influence his / her behaviour.
Identify the patients ways of coping.
Encourage patients to make decisions and manage his or her life as circumstances
Permit.
How to achieve these aims?
i
G
A
T
H
E
R
Objective should be specific and achievable.
Listen to patient’s story and guide the conversation.
Help the patient to view their problems differently.
Assess patient’s Mental state
i)
Main concern
ii)
Additional Resources needed
iii)
Help patient to manage anxiety.
Avoid dependency.
Respect patient’s own ways of coping.
Set boundaries, do not make false promises.
Assumptions should not be noted, take nothing for granted.
Make the patient comfortable.
Pay attention - listen actively to verbal and non-verbal communication.
Physician must never allow their own values or prejudices to influence their
decisions.
Confidentiality should be maintained.
Physician should show empathy (putting oneself in patient’s position).
Physician needs to be sensitive to cultural issues.
Physician must keep up with current knowledge and confine their knowledge with
skills of listening, supporting and guiding.
Physician gives new information separating facts from myths & instructing about
available and potential resources.
The word “Gather” to be kept in mind.
Greet the client in a friendly way.
Ask the client about his needs.
Tell the client about the available methods of treatment.
Help the client to decide.
Explain how to choose.
Return visit should be planned.
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Summary
Appreciate the importance of demonstrating your respect for each STD/RTI
patient, by your welcome, the privacy and confidentiality you offer and your
respect for their opinions and views.
Keep your questions free of moral judgement;
Use the patient’s terms, or words that he or she understands easily;
Request permission to ask personal questions or examine the patient;
Distinguish between open and closed questions;
Identify when to use an open or closed question;
Recognise six additional verbal skills that will help you gather information and
support the patient effectively:
facilitation
direction
summarising and checking
empathy
reassurance
partnership.
Compliance Instructions
Patients appreciate complete written instructions when they leave your office. For the
main conditions you treat, you can preprint these or make a checklist that you can quickly fill
out. To excel in the instructions you provide, ask patients in a focus group or waiting room
conversation to look at the forms you use and point to anything they consider vague or
obscure. For instance, if you say to take a certain medication three times a day, how should the
patient handle night time? Can they take the medication at mealtime, on an empty stomach, or
exactly when and how? The practice that preempts feelings of insecurity and wondering on the
pail of their patients stands out as user-friendly and patient-centered.
Also regarding style, show a few patients the items you’re planning to make
available. Ask a few patients kept waiting to take a look while they’re waiting. Get
consumer input into color, type style and layout.
Also, print big and bold. Especially for the sake of older patients, make sure the
print isn’t tiny. You want your patients to understand and remember their post-visit
instructions-their medication doses and schedules. Your instruction sheets that show the
current list of their medications with dosage and frequency can probably be enlarged on
your copier, to make the print more readable. This tends to eliminate phone calls from
some patients, and also shows consideration on your part.
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There are several kinds of what is called noncompliance.
First, there are those patients who do not take your prescribed
drugs because they did not understand the instructions.
Learn to communicate in their language.
Second, there are those patients who do not take your recommended
drugs because they do not trust your opinion.
Learn to build trust and respect.
Third, there are those patients who do not take your drugs
because they make them feel bad.
Learn to hear these people
They are often correct
Language is the most important tool the physician has.
Learn to respect and use it wisely.
*
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CONTRIBUTORS
Professor Jagdish C. Bhatia is a Consultant in Health Systems Management and
has provided consultancy services to a number of national and international
organizations. He was a Professor of Health Services Management at the Indian Institute
of management for about two decades. He also held senior positions in prestigious
institutions in India and abroad. Professor Bhatia has published extensively in
demography, health economics, and health and population programme management. He
has also been a member of several expert committees and advisor panels at the national
and international level.
Dr. Leela Bhagwan is a Senior Consultant Gynaecologist with The Bangalore Hospital
for the last several years. Prior to this she has worked extensively in leading hospitals in
the Middle East and Western countries.
Dr. Pushpa Srinivas is presently Professor and Head of the Department of Gynaecology
at the Ambedkar Medical College, Bangalore. Prior to her retirement from Government
Service she was Professor and Head at the Bangalore Medical College for over 2 decades.
She was on the staff of St. John’s Medical College and MR Medical College, Gulbarga.
She is presently the President of the Bangalore Society of OBG. She has a number of
research publications to her credit.
Dr. R. Narayanan, is a Senior Consultant Gynaecology with several leading hospitals
and nursing homes in Bangalore. Earlier he was Professor and Head of the Department of
Gynaecology at St. John’s Medical College for over 2 decades. He was on the staff of
JIPMER, Pondicherry. He has published a number of research papers in Infertility and
Endocrinology in leading national and interational journals.
Dr. Prabha Chandra is presently Associate Professor of Psychiatry at the National
Institute of Mental Health and Neurosciences, Bangalore for more than a decade. She is
member of the executive committee of Women’s Mental Health Division of the World
Psychiatric Association. She is an investigator and several international collaborative
research projects on mental health and women.
Dr. Kishore Murthy is presently Consultant and Advisor, Health and Hospital
Management with A.F. Ferguson and Company, Health Care Management Consultancy
Services Division. Bangalore. He has over 20 years of experience in the field of Hospital
and Health Management. His areas of specialisation include Project management,
Feasibility studies, System studies. Health Care and Hospital Research Studies and
Training programmes.
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