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Female genital mutilation (FGM) is often associated with African and Muslim women, but dealing with its aftermath is a public health concern in the United States. There are several different types of mutilation, which are demonstrated with drawings. FGM is primarily practiced and enforced by women and has cultural significance. FGM is practiced in the United States among some immigrant groups, and women who have immigrated here often need specialized medical care as a result of the mutilation. The most extreme form of FGM is called infibulation which involves removal of all outside genitalia and near closure of the vaginal opening. Infibulated women often must be cut to allow intercourse and childbirth, and are sometimes re-infibulated after delivery, often after each child. Women who have had FGM suffer from a number of serious health complications, including anemia, chronic pelvic infections, infertility, abscesses and keloids, sexual dysfunction, menstrual disorders, urinary problems, and complications in pregnancy and childbirth. The psychological consequences have not been well studied. FGM can cause vaginal lacerations during intercourse, and anal intercourse is common in affected couples. The lacerations and anal intercourse raise concerns about HIV transmission in these women and also from the practice of performing FGM on a group of girls with the same unsterile tools. FGM is being re-introduced in the United States by some immigrant communities, and health care providers need to be sensitive to the needs of affected women. Several issues related to the need for cultural sensitivity are discussed.
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PMID:Female genital mutilation: not just over there. 1136 40

The two words that mean sexual dysfunction, impotence and erectile dysfunction (ED), express two different concepts. Impotence is a general male sexual dysfunction that includes libidinal, orgasmic, and ejaculatory dysfunction. ED is the inability to achieve or maintain an erection sufficient to allow satisfactory sexual intercourse and is part of the general male sexual dysfunction termed impotence that includes libidinal, orgasmic, and ejaculatory dysfunction. Uremic men of different ages report a variety of sexual problems, including sexual hormonal pattern alterations, reduction in or loss of libido, infertility, and impotence, conditioning their well-being status. In evaluating and treating sexual dysfunction, a nephrologist must consider factors involved in its pathogenesis, such as hypothalamic-pituitary-gonadal axis alterations, psychological problems related to chronic disease, secondary hyperparathyroidism, anemia, autonomic neuropathy, derangements in arterial supply or venous outflow, and the normal structure of cavernous body smooth muscle cells. The introduction of sildenafil to treat impotent patients has completely changed the approach to evaluating these subjects because this drug is considered an effective well-tolerated treatment for men with ED. In the past, we proposed an algorithm that gave the opportunity to explore the previously mentioned factors using such instrumental interventions as the nocturnal penile tumescence test, penile echo color Doppler, nervous conduction velocity, and cavernous body biopsy, addressed to prescribe needed surgical or medical interventions. The complexity of the proposed algorithm requires many diagnostic procedures and much time and economic resources to localize the pathological lesions responsible for ED. Because of the new oral drug sildenafil, we propose a new algorithm to test the possibility of obtaining an erection and classify patients as responders or nonresponders to the sildenafil test.
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PMID:Erectile dysfunction in uremic dialysis patients: diagnostic evaluation in the sildenafil era. 1157 35

Some chronic diseases have a favourable course and are cured spontaneously. Allergic diseases such as eczema, hay fever and asthma have a good outcome in more than 75% of cases within 7 to 25 years, depending on the kind of allergy. Migraines have also a good evolution in children and after menopause. Many symptoms due to menstruation such as dysmenorrhea, premenstrual syndrome or anemia, disappear after menopause as well as diseases due to estrogens such as uterine leiomyoma, endometriosis and prolactinoma. The risk of epilepsy relapse after a first seizure is about 40% after 2 years. The risk is lower in children. Attention deficit disorder affects 3 to 5% of children but is present in only 30% of them in adult age. The prevalence of depression decreases in women between 30 and 60 years of age. Functional somatic syndromes such as fibromyalgia, irritable bowel syndrome or dyspepsia decrease in 2/3 of cases within 5 to 10 years if there is no history of anxio-depressive symptoms. However, prognosis is reserved when initial symptoms are severe or if they are connected to sexual abuse, domestic violence or depression. Other diseases have a spontaneous favourable course such as myopia, idiopathic infertility, polycystic ovary disease or ventricular arrhythmia. The knowledge of a good prognosis enables to avoid unnecessary treatments and to reassure many patients.
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PMID:[The benefits of aging. I. Patience and cure: spontaneous beneficial course of certain diseases]. 1172 11

Hysteroscopic surgery is widely used for the treatment of patients suffering from infertility and menorrhagia. Preoperative and postoperative treatment plays an important role in this kind of surgery. The indications for hormonal pre- and postoperative treatment are very different and depend on the type of surgery and the condition of the patient. For a septum dissection, preoperative treatment is not necessary. Postoperative estrogen therapy can be helpful especially after dissection of a large septum. For intrauterine adhesiolysis, preoperative treatment is without benefit. In cases of adhesions of grades 3 and 4, postoperative treatment entailing insertion of an IUD and application of estrogens for about 3 months is recommended. A higher amenorrhea rate after endometrium ablation can be reached by pretreatment with a GnRH analogue or danazol. For resection methods, pretreatment is not necessary in any case. The success rate of endometrium ablation (reduction of blood loss) is not influenced by pretreatment. Pretreatment can be useful in coagulation techniques in patients suffering from secondary anemia and in high-risk patient. In patients who need hormone replacement therapy after endometrium ablation, gestagen application is necessary. For prevention of bleedings, a continuous combined hormone replacement therapy should be used and so a bleeding-free treatment is possible. The residual endometrium will so be protected against hyperplasia. Another alternative postoperative method after endometrial ablation is insertion of a levonorgestrel IUS. Our studies show advantages for protection of the endometrium, for contraception and a high amenorrhea rate. Prior to a hysteroscopic myoma resection, pretreatment with GnRH analogues is indicated for all myomas with a diameter of more than 3 cm and/or an intramural portion or for patients suffering from secondary anemia. The aim of the pretreatment is not only to obtain a thin endometrium but also to reduce the size and vascularization of the myomas. The failure rate in patients not treated with GnRH analogues is higher especially in large intramural myomas. Pre- and postoperative hormonal treatment can be effective, especially in the treatment of patients suffering from menorrhagia. The indications for hormonal pre- and postoperative treatment should be very strong. A hysteroscopic surgeon should be also have some experience in hormonal treatment.
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PMID:Pre- and postoperative hormonal treatment in patients with hysteroscopic surgery. 1179 Dec 73

The intrauterine device (IUD) is a highly effective method of contraception that, as opposed to other countries around the world, is underutilized in the United States by women of all ages. Lingering concerns about the safety of IUDs are in large part responsible for their lack of adoption, but a systematic review published recently nullified some of the major safety concerns about IUD use. The author summarized the methodologically sound evidence regarding the risk of upper-genital-tract infection and infertility associated with IUD use and reported that a slightly increased risk of pelvic inflammatory disease (PID) exists only in the first month following IUD insertion; that the risk of PID in women with symptomless sexually transmitted diseases (STDs) having an IUD inserted is similar to the risk in women not having an IUD inserted; and that there appears to be no negative effect on fertility following IUD removal. In addition, Mirena provides noncontraceptive benefits, such as treatment for menorrhagia, dysmenorrhea, and anemia, and ParaGard may help protect against endometrial cancer. An IUD is also a safer alternative to sterilization for perimenopausal women seeking a long-term and also reversible method of contraception. While both IUDs are suitable for many women of all ages, there are differences in their mechanisms of action, physical characteristics, and clinical effects that make each more or less appropriate for certain women.
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PMID:Compelling reasons for recommending IUDs to any woman of reproductive age. 1199 35

A retrospective study to determine the incidence, clinical presentation and management of uterine fibromyoma at the University of Ilorin Teaching Hospital, Ilorin, Nigeria. Five hundred and sixty-nine consecutive cases of histologically confirmed uterine fibroid over a ten-year period were reviewed. Uterine fibromyoma constituted 13.4% of gynaecological admission and was responsible for 26.2% of major gynaecological surgery. Majority of the patients (78.4%) were aged between 30 and 44 years and 60.8% were of low parity (0-2). The common presentations were menstrual disorders (64.3%), infertility (56.2%) and lower abdominal swelling (35.5%). Hypertension was present in 26.5% and 42% were obese. Pelvic adhesion was noted in 58.9% of patients. Total abdominal hysterectomy was the surgical procedure in 52% of cases. Pyrexia (32.5%), Anaemia (29.3%), Prolonged hospital stay (24.1%) and Wound infection (20.2%) were the common postoperative morbidities. Fibromyoma at the University of Ilorin Teaching Hospital follows a pattern similar to other parts of the world. It is responsible for a number of gynaecological complaints. Surgery still remains the main mode of treatment.
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PMID:Uterine fibroids: a ten-year clinical review in Ilorin, Nigeria. 1207 94

Women's perceptions of the hazards of birth control devices centers on fears of sterility from IUD use and the permanence of bilateral tubal ligation. In March, 1992, an International Conference on the IUD gathered scientists and physicians from around the world to compare and contrast research findings on the risk and benefits of IUD use. Scientific examination pertained to IUD clinical performance, mechanisms of action, medical problems and their prevention, ectopic pregnancy, infertility, and post removed conception rates. Some of the findings were summarized. 1) The copper T 380 was recommended by WHO, because of the very low pregnancy rates, the long duration and relative ease of use, and low manufacturing costs. 2) IUD users, who are at low risk of contracting sexually transmitted diseases (STDs), do not have an elevated risk of pelvic inflammatory diseases (PID) due to use. Those who have multiple partners are strongly advised to use other forms of contraception. 3) Pregnancy rates are high after discontinuation; 80% conceive in the first year, and 90% within 2 years. 4) The mechanism of action is to decrease the number of viable sperm and interfere with egg transport, before the fertilization process. 5) The monofilament string is not associated with an increased risk of PID; PID is related to introduction of bacteria during insertion. 6) The IUD may be unsuitable in areas with high prevalence of STDs and/or anemia; screening may present a challenge. In areas with poor infrastructure, IUD use can be optimized by improving method selection and providing interventions for those who may develop problems. consensus was very high that all women planning IUD use should be screened for risk of infections that could lead to PID. Clients would need to be interviewed about their own sexual behavior and the behavior of their male partners. If programs are not capable of identifying women at risk or testing and treating STDs, the IUD should either not be used or be used only if incidence of venereal disease is low.
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PMID:Allaying the fears in the use of intrauterine devices. 1217 3

Celiac disease is a permanent intolerance to dietary gluten. Its well known features are abdominal symptoms, malabsorption of nutrients, and small-bowel mucosal inflammation with villous atrophy, which recover on a gluten-free diet. Diagnosis is challenging in that patients often suffer from subtle, if any, symptoms. The risk of clinically silent celiac disease is increased in various autoimmune conditions. The endocrinologist, especially, should maintain high suspicion and alertness to celiac disease, which is to be found in 2-5% of patients with insulin-dependent diabetes mellitus or autoimmune thyroid disease. Patients with multiple endocrine disorders, Addison's disease, alopecia, or hypophysitis may also have concomitant celiac disease. Similar heredity and proneness to autoimmune conditions are considered to be explanations for these associations. A gluten-free diet is essential to prevent celiac complications such as anemia, osteoporosis, and infertility. The diet may also be beneficial in the treatment of the underlying endocrinological disease; prolonged gluten exposure may even contribute to the development of autoimmune diseases. The diagnosis of celiac disease requires endoscopic biopsy, but serological screening with antiendomysial and antitissue transglutaminase antibody assays is an easy method for preliminary case finding. Celiac disease will be increasingly detected provided the close association with autoimmune endocrinological diseases is recognized.
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PMID:Endocrinological disorders and celiac disease. 1220 61

Medical services have reported significant social distress in and around Almaty, the capital of Kazakhstan. A generally unhealthy female population relies upon abortion for contraception, with each women having an average of five abortions over the course of her reproductive lifetime. Many of these women have gynecological problems, the level of infertility is on the rise, and 70% of all registered pregnant women have some kind of disease. Anemia is most frequently observed, increasing four-fold over the last four years. Diseases of the urogenital system have doubled over the same period, while the number of premature deliveries grows annually, currently 8% of all deliveries. The City Health Care Department has declared a state of emergency for gynecological and obstetrical services. Order 33 of February 12, 1994, however, approved the Family Planning Program requiring all medical institutions to provide family planning services with the goal of reducing the number of abortions by 50%, thereby decreasing the levels of maternal and perinatal mortality. The program covered the integration of obstetrical and gynecological services with medical services to boost cohesion and access to both patients and services. It also defined the duties of obstetricians, gynecologists, general practitioners, pediatricians, and other medical experts. The authors describe the program's structure.
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PMID:City profile: Almaty, Kazakhstan. 1222 57

Various psychological aspects related to childbearing are discussed, most of which can be treated by the obstetrician but some of which will require the services of a psychiatrist and psychoanalyst. The types of psychological reactions an obstetrician should be aware of are: 1) psychosomatic factors causing infertility; 2) normal emotional reactions to pregnancy; 3) emotion-caused diseases in pregnancy, such as excessive vomoting; 4) psychiatric symptoms that seem to develop in pregnancies characterized by severe anemia, toxemia, and infections; 5) neurotic symptoms, which most often appear in a first pregnancy, when the woman is still immature; 6) psychological preparation for painless childbirth; and 7) emotional reactions to legal abortion and sterilization. Cases of functional psychosis should be referred to a psychiatrist.
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PMID:Psychological aspects of childbearing. 1225 63


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