Office Gynecology: Advanced Management Concepts
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To understand the role of the health system in early diagnosis of gynecological diseases. Emphasize the importance of prevention through the management of gynecological diseases. Highlight the role of family doctors in educating women about the importance of regular gynecological examinations. Made is a descriptive analysis of experience of gynecological and obstetric diseases management described in the articles published in indexed journals retrieved from biomedical databases: PubMed Central, ScopeMed, Google Scholar, etc.
Emphasis is placed on the Guidelines for gynecological diseases because they are basic landmark that doctors should respect and use in the management of any disease and also gynecological. These are guides to whom physicians should adhere and stick to them and their algorithms in the course of their work.
Within this set are: Basic symptoms, how to identify and diagnose and therapy protocols for the most common gynecological diseases, as parameters to procedures in managing gynecological and obstetric diseases. For cervical cancer there are no early symptoms, which will prompt the patients to contact a doctor for review. Symptoms usually occur at a later stage when it came to the erosion that accompanies contact bleeding bleeding is usually sparse and occurs after intercourse, irrigation or gynecological exam.
They can be frequent and persistent, resistant to therapy with concomitant blood secretion and in advanced stage also with severe pain. Diagnostic procedure includes: History general, gynecological, family, targeted family , clinical examination general patient state, physical examination and gynecological speculum examination, bimanual and rectal examination and swab by Papanicolaou method. The standard Papanicolaou test for detection of cervical cancer as the results of several studies indicated is cytological test, which reduces the incidence of cervical cancer in many countries.
Papanicolaou test has limitations such as low sensitivity and poor reproducibility. Additional tests, which are needed to determine the stage of the disease, are: Cystoscopy, rectoscopy, intravenous pyelography and chest X-ray. US, computed tomography, magnetic resonance imaging MRI and abdominal lymphangiography and possible laparoscopy may not be used to determine the clinical stage of disease according to International Federation of Gynecology and Obstetrics FIGO , but are important in planning treatment. The clinical stage of the disease is determined by using the FIGO classification, which is also called morphological classification because it is based on tumor size and histological data for the early stages and the spreading of pelvic masses with disease progression [ Figure 2 ].
Stage I - The cancer is affected only cervix without spreading to the body of the uterus. Stage II - Expansion at the upper and middle third of the vagina or parametrium does not reach the bone. After classification, according to the FIGO classification and staging of disease, the decision and the sequence of therapeutic procedures for each patient individually, is made by a multidisciplinary team of radiologists, pathologists, gynecologists, radiation oncologists and medical oncologists. Only a multidisciplinary approach to treatment may result in properly and successfully treatment and result in an overall improvement of survival.
Surgical therapy should be carried out in institutions that have requirements for specified diagnostic and multidisciplinary treatment planning.
It should aim to total removal of a diseased organ and lymphadenectomy minimum of 10 lymph nodes from the chain of iliac blood vessels, both sides. Adjuvant therapy should begin within a period of weeks after surgery or with advanced disease immediately after the diagnosis and staging of the disease. Concomitant chemo and radiotherapy should be conducted in an institution that has the technology for high voltage radiotherapy and intra-cavitary radiotherapy. Self-examination includes periodic examination that the woman herself done by watching and feeling the texture of the breast and axillary lodge.
For this review she should be taught by a doctor or nurse of family medicine. Self-examination should begin at the age of 20 years. Previously advised monthly self-examination is abandoned in many developed countries and is left to women to choose whether to use it and in what interval and then follows clinical examination.
This includes physical examination by a physician. Doctor carefully observe the breast, their environment and with palpation explores possible changes in the breast and adjacent lymph nodes. Clinical examination should be conducted at least once every three years for all women who do not belong to a risk group, aged years.
From the age of 40 a woman should once a year have clinical examination and then to perform the initial basic mammographs. It is best that clinical examination precedes mammography. If there is a screening program, it in some countries starting with the age of 40, in some at age of 45 or 50 years, to age of 65 or 70 years, depending upon the incidence of cancer, the available resources and the level of population health culture.
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Mammography is a radiological imaging method for breast that uses minimal radiation dose and allows you to see the internal structure of the breast. It is very important that the doctor discussed with the woman and advise her about the best time for her regular mammogram control in accordance with the existing guide for screening, so it does not happened that in the meantime the tumor that was not visible progresses.
US is an additional complementary method for diagnosis using US waves, without ionizing radiation, it is completely harmless and can be used indefinitely even in pregnant women. It is used in finding tumors in the dens breasts, for example in young premenopausal women. MRI is a modern, complementary method. Not a method for mass screening, but in recent years can be used for the diagnosis of tumors in genetically predisposed women, where the screening normally begins in early premenopausal period, then in case of more dense breast tissue.
When the radiologist in the mammography images finds a change that raises doubts on cancer, or is not able to declare it a benign, it is necessary to take a small sample of cells from the area for cytological examination and setting cytological diagnosis. Before treatment the set diagnosis of cancer, allows the duly treatment plan, selection of the best method for treatment for example, type of surgery in consultation between the patient and team of specialists who will treat.
Although breast cancer is a very serious disease, it can be successfully treated if detected at an early stage, when it is not invasive and when tumor cells do not have the ability for displacement-metastasizing. This treatment can be successful if it is carried out by an expert team of specialists comprising of: A surgeon, radiation oncologist, internist-medical oncologist, radiologist, pathologist, oncology nurse, social worker and others as needed. This expert team examines the patient at one place, within joint review and makes decisions on any additional diagnostic tests, treatment method and sequence of methods.
In this way, each patient gets the best possible treatment. If the cancer has not metastasized and if not locally advanced, treatment usually begins with the surgical procedure. If the tumor is small, only the tumor can be removed and part of the surrounding healthy breast tissue sparing surgery so that the breast is not removed.
At the same time will be removed a number of lymph nodes from the armpit. In some cases, it will be necessary to perform radical surgery. After radical surgery plastic reconstructive surgery may follow to make a new breast, immediately during breast removal, or when all other therapies are completed. After this surgery irradiation treatment is carried out. Irradiation therapy last for about 6 weeks and usually does not cause special problems. With the presence of a vulvitis of any etiology, the patient complains of itching and burning sensation and burning of the skin around the vulva and vaginal introitus.
On examination the vulvar skin is bright red, easily swollen, painful and warmer than surrounding tissue. First signs of infection are redness and smaller island of the affected areas of skin. Symptoms include a feeling of itching, burning or light pain. Condyloma are warty growths that occur as a consequence of infection by Papova virus from a group of HPV type 6 and type 11 , first individually around vaginal introitus, usually at first in the area of the perineum and later spread to most of the vulvar skin, mucous membrane of the vagina and cervix.
Usually transmitted by sexual intercourse and formed over a period of few days to months after infection. Individual condyloma is bright red colors on the stalk or tapered at the top.
Later, they can multiply to form a broad plate of compressed and joined individual warts. Diagnosis is made based on history general, gynecological, family, targeted family , clinical examination general condition of the patient, physical examination and gynecological speculum examination, bimanual and rectal examination as well as histological examination of taken biopsy material. If the cause is the infection, the treatment consists of antibiotic, anti-fungal or antiviral medications, depending on the agent. If the infection is cured, to maintain the improved condition can be used for a short time rinsing of the vagina by exact ratio of vinegar and water.
Frequent washing and use of medical type detergents is not advisable because it increases the risk of developing pelvic inflammatory disease. With antibiotics, treatment of bacterial infections may include propionic acid gel that makes more acidic vaginal mucus, which hinders the growth of bacteria.
In case of STDs both partners must be treated simultaneously to prevent re-infection. Thinning of the lining of the vagina after menopause is treated with estrogen supplements. Estrogen can be administered orally or by skin patch, or it can be applied directly to the vulva and vagina. Additional procedures include wearing comfortable and absorbent lingerie that allows air to circulate, such as cotton or cotton padded panties and maintaining the hygiene of the vulva. It is needed to use glycerin soap because other soaps can irritate this area. Sometimes, putting ice on the vagina, sitting in cold baths or cold compresses can ease sensitivity and itching.
Itching that is not caused by infection can be mitigated by corticosteroid creams and ointments, such as those that contain hydrocortisone, as well as antihistamines taken orally. If chronic vulvitis is caused by poor personal hygiene, the first to be given is instructions on proper hygiene. Following are some guidelines for the treatment of vulvovaginitis caused by different agents [ Table 1 ].
The diagnosis of PCOS is based on the case history and physical examination, biochemical tests and US examination of the ovaries. There are a number of data from medical history and physical findings that help in the diagnosis of PCOS. In the family history are important diabetes, hyperandrogenaemia and clinical signs of hyperandrogenism, subfertility.
In personal history is important birth weight, rapid weight gain in infancy, rapid growth and early adrenarhe, obesity in childhood and adolescence, menarche, menstrual cycle characteristics, weight changes, symptoms of hyperandrogenism, infertility and miscarriages. Physical examination includes determination of body mass index, the ratio of waist and hip circumferences, blood pressure measurement and evaluation of hyperandrogenism.
Signs of hyperandrogenaemia and hyperandrogenism, which involves increased activity of androgens, are seborrhea, oily skin and hair, acne, hirsutism, alopecia and virilization. Hirsutism should be distinguished from hypertrichosis in which there is no male-type hair distribution and is not dependent on androgens. Anovulation is often associated with irregular dysfunctional uterine bleeding. Criteria for declaring polycystic ovary according to the latest classification are 12 or more follicles with a diameter of mm and ovarian volume greater than 10 ml and it is enough that only one ovary have these characteristics.
Biochemical analysis includes determining hormonal status: Follicle-stimulating hormone, luteinizing hormone, E2, total testosterone, SHBG, free testosterone, dehydroepiandrostendion sulfate, hydroxyprogesterone androstenedione, the determination of IR glucose tolerance test , fasting glucose, IR and some dynamic tests are performed exceptionally for the differential diagnosis of PCOS with other endocrine disorders.
However, biochemical tests are necessary for girls who are overweight, with pronounced hirsutism or acne resistant to treatment. Regardless of that, women with PCOS should be treated and monitored continuously. Treatment of PCOS depends on the patient's age, symptoms and signs of this syndrome and reproductive desires. For this purpose, the hormonal preparations, insulin-sensitizing medicines and surgical treatments are performed. In adolescents with PCOS treatment is aimed at controlling irregular bleeding, reduce acne and hirsutism and reduction of obesity and IR risk of endometrial cancer in these women is three times increased.
The strongest effect of anti-androgens has oral hormonal contraceptives. From other hormone therapy for PCOS should be noted neandrogene progestogens that are given because of their opposed action to estrogens primarily to protect the endometrium. Surgical treatment of PCOS is laparoscopic ovarian electrocoagulation drilling , which destroys fat ovarian stroma.
Diagnosis is based on the history of irregular bleeding and more abundant bleeding, the existence of secondary anemia that accompanies it and normal palpation findings of patient's genital organs, but if this is the result of anatomical changes, then we cannot talk about these types of bleeding.
Therefore, it is essential that before diagnosis are excluded other possible causes of irregular bleeding, which is usually done by combined rectal-vaginal examination. Also, examination of peripheral blood and bone marrow needle aspiration is needed to exclude blood diseases. Diagnostic curettage is performed in the extreme conditions and can be therapeutic and most often the material is sent for histological evaluation.
Treatment of juvenile bleeding should first stop the bleeding, compensate for lost blood and fluid and improve the general condition. Among drugs are given uterotonic agents and preparations of the anterior pituitary lobe or synthetic preparations with identical actions, together with calcium, vitamin K and nicotinic acid amide. Treatment of metrorrhagia in the generative period is implemented by giving progesterone at a dose of 25 mg and in the second half of treatment, during the 3 months.
If the therapy begins at the stage of irregular bleeding, then progesterone provides 2 or 3 days to regulate the bleeding. Patients with atrophic endometrium and demonstrated lack of estrogen are treated by alternately application of estrogen and progesterone in cycles. Quality and successful management of gynecological diseases cannot be ensured without following certain guidelines recommended by experts in this field.
Good clinical practice concept that is applied in the world puts in front: a Patient education, b counseling patients about healthy life-style, c conducting screening. Necessary and advisable is to follow proper quality parameters of provided gynecological care at certain levels of its organization in the health system given in the documents of the World Health Organization and the comparable results incidence, morbidity, mortality in the countries that did so in relation to the countries that were not able to implement it. Reasons for the latter may be low socioeconomic status, lack of education of patients by their physicians about the importance of regular gynecological examinations, etc.
Although in recent years, the incidence of cervical cancer has decreased there is still a high incidence and high mortality among women with low socio-economic status, which is the result of a lack of screening or irregular screening. Numerous studies have shown that the rate of morbidity and mortality are significantly reduced where there is organized screening.
Office Gynecology - Advanced Management Concepts | John V. Knaus | Springer
Selected family doctor plays an important role in regular referring of woman to systematic gynecological examinations according to the recommendations that are in the National Guide for the prevention of malignant diseases. The disease often affects women from lower socio-economic class, with a lower possibility of regular health care. Hence, it is very important to perform comparisons on the basis of the results obtained from the rich countries to the results from poor countries because the incidence of diseases and mortality rates are significantly higher in poor countries than in rich ones.
Poorer countries due to lack of funds do not have good technological methods for screening that will allow the disease detection at an early stage and thus prevent complications, which does not even have close PHC centers and specialist consultation services in their place of residence. Not only the financial aspect is cited as an important factor in health for an increase of morbidity and mortality in a group of gynecological diseases, but there are also important other factors, such as: Un healthy environment, lack of clean drinking water, inhumane living conditions, which may lead to the occurrence of a number of infections than in rich countries with higher gross national income of the population in which they can provide a means for personal hygiene.
Richer countries have the resources to invest in a variety of methods of prevention, such as the development of educational advertisements, posters and brochures for health promotion and education of the population at all levels: Local communities, schools, companies, medical facilities, etc. It is also very important to stress the importance of sexual education, especially in schools, which can contribute to reduced incidence of sexually transmitted diseases, especially human immunodeficiency virus HIV and the HPV which is considered as important in the development of dysplasia with consequential occurrence of cervical cancer.
Because of the high incidence of cervical cancer it is necessary to organize a screening examination of women. Numerous studies have shown that the rate of morbidity and mortality significantly reduced where there is organized screening. Selected family doctor has a very important role in referring to regular systematic gynecological examinations according to the recommendations that are in the National Guide for the prevention of malignant diseases.
Furthermore, the physician has a duty to educate women about the risk factors for malignant diseases, as well as preventive measures. Cervical cancer is an ideal disease for screening because it typically has a long preclinical phase, which allows early detection. Taking a cervical smear and staining by method of Papanikolaou is the best method available to reduce the morbidity and mortality of invasive cancer of the uterus cervix.
According to the recommendations the screening should begin as early as at the age of 18 years or from the moment of sexual relations start because the age of this disease occurrence moves toward the younger generations. Control Papa test should be done once a year and if two consecutive findings are negative then is recommended control every 2 years. Any patient with persistent or progressive cervical intraepithelial neoplasia regardless of age, according to new studies and each patient aged over 30 years should do HPV deoxyribonucleic acid screening test.
Regular and proper implementation of the screening program is also the best way to prevent the appearance of clinical symptoms.
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It is necessary to improve information and increase awareness about the importance of women about the possibilities and the importance of preventive measures and examinations. Mammography is recommended to start at age of 40 year and continue each year until a woman is in good health.
Clinical breast examination as part of a periodic health examination every 3 years for women aged years, then every year. Women should know how their breasts look normal and that any changes immediately and without delay leads them to the doctor. Self-examination is an option according to the will of women and it should begin at the age of 20 years. Women at increased risk family history, genetic predisposition, previous cancer in the other breast should talk with their doctor about the possible consequences of the irregular examinations.
Screening as an organized program of secondary prevention for breast cancer usually starts at the age of 45 in women who do not belong to the risk group of the first category and in high-risk even earlier, i. It is needed to raise self-awareness of women by education from physicians and polyvalent nurses. It is necessary to create awareness among medical staff in PHC, particularly family doctor about the possibilities, needs and the importance of early detection of breast cancer.
It is necessary to provide human and material resources to carry out the screening, especially mammography machines, radiology technicians and radiologists trained to perform quality interpretation of the findings. Establish centers at the secondary or tertiary health-care level for the setting of explicit diagnosis and treatment of breast cancer. Create conditions for exact and timely histopathological examination of biopsy material at the secondary or tertiary health-care level. A particular problem is the issue of taboo in our society about sexuality, which is of a systemic character and it should be a deal with by the multi-disciplinary teams in health care and education educators at all levels of education, teachers, psychologists, sociologists, family doctors, gynecologists, sexologists etc.
Our society is patriarchal and this issue is becoming a burning issue. The system should ensure the introduction of the health education in primary and secondary schools in the framework of which the students, as age-appropriate, are informed about sexually transmitted diseases, their prevention, diagnosis, treatment. Click on the cover image above to read some pages of this book! As office technology has exploded and decision-making become increasingly complex, physicians are faced with an endless list of treatment options for commonly presenting gynecologic disorders.
This book reviews all state-of-the-art tools of diagnosis, investigation, and management to provide an invaluable guide for the office practitioner. Actively practicing experts in the field examine the most current and controversial issues in the discipline from endocrine disorders to breast disease from preventive measures for osteoporosis and cardiovascular disease to management of an abnormal pap smear, from the use of ultrasonography to minimally invasive diagnostic procedures.
Office-based physicians are expected to be knowledgeable in these areas, and this book leads the way. For gynecologists and residents, here is a solid-foundation and ready reference source enhanced by more than 60 detailed illustrations. Country of Publication: US Dimensions cm : Help Centre. My Wishlist Sign In Join. Knaus Editor , John H. Isaacs Editor. Be the first to write a review. Add to Wishlist. Ships in 15 business days. Link Either by signing into your account or linking your membership details before your order is placed. Description Table of Contents Product Details Click on the cover image above to read some pages of this book!