Pubertal gynecomastia in boys - a bothersome condition

 Gynecomastia is a benign condition in males, which occurs due to proliferation of glandular elements resulting in concentric enlargement of one or both breasts.

It can be seen during puberty, due to transient relative imbalance between estrogen and testosterone.
Usually this condition can resolve by age 18 years when adult androgen and estrogen ratios are achieved.
If gynecomastia persists even after 18 years better to get evaluated.
By clinical assessment to estimate the testes volume, and by investigations like estimation of levels of testosterone, estradiol, gonadotropins etc and by doing karyotype, the possible cause of problem can be identified and treated.
Usually the mainstay in treatment of pubertal gynecomastia is sympathetic reassurance because of the benign nature of the condition.

 Surgery is needed only in boys who are having persistent gynecomastia even after completing of puberty or after completing 18 years.

Screening methods of breast carcinoma which every women should be aware of

As early detection can decrease the morbidity of breast carcinoma, screening methods of  breast carcinoma are getting popular.
Every woman should be aware of these methods to protect herself from the complications of breast diseases.
Self breast examination, periodic mammography and sonomammography are commonly used and important methods that help in detecting breast problems at the earliest. to  detect breast problems earlier
  Self breast examination should be done monthly at same period of menstrual cycle preferably after completion of menstrual cycle. This is to avoid mistakes due to hormonal influenced breast changes. Woman should do self breast examination by standing in front of mirror. She should use the pads of her fingers to palpate the breast tissue.
First she should observe her breast in positions:
-Arms hanging beside the body

-Arms behind the head

-Arms keeping on waist and bending forward.

-Palpation of breast in circular movements or in longitudinal movements or in wedge pattern.

 Breast tissue should be palate upto axillary tail.
-Palpation of nipple

-Palpation of breast and nipple in lying down position.

If any abnormality is detected, she should consult the doctor and go for mammogram.

In mammography low energy x-rays are used to examine the breat tissue.

By identifying any possible masses or calcifications breast disease can be diagnosed.

Sonomammogram is breast ultrasound, which gives distinct images of the internal structures of the breast and helps in detecting breast diseases.

After 35 years every woman should undergo yearly mammogram or sonomammogram as screening method towards breast carcinoma.

Predicting the possible date of conception

According to the menstrual history of the women and coital history, the possible date of conception can be predicted to some extent.

Usually conception occurs around the time of ovulation.
With regular menstrual history the possibility of the ovulation can be predicted according to the previous cycles.
In case of regular 28 days menstrual cycles ovulation usually occurs between 12th to 16th day of the cycle, whereas in 30 days menstrual cycles ovulation can occur between 14th to 18th day of the cycle.
In case of regular lengthier cycles, usually ovulation is expected to occur during last 14 to 16 days of cycle.
So, if unprotected intercourse occurs around the period of ovulation, that can lead to pregnancy.
Sometimes spermatozoa can survive for around 4 to 5 days in female genital tract and ovum can be alive for 24 hours to 48 hours. This time period should also be considered while predicting the date of conception.
If menstrual cycles are irregular, it is difficult to predict the date of ovulation and conception.
In that case around three weeks prior to the date of first positive pregnancy test can be considered as possible conception period.
Ultrasound also helps in predicting the possible conception date.
Three weeks before appearance of gestational sac or four before appearance of fetal heart beat can be considered as possible conception period.
Uterus becomes abdominal organ usually at around 12 weeks. Ten weeks prior to the date of palpating the uterus per abdominally, can approximately give the date of conception.

Microprolactinoma - possibility of recurrence

 Microprolactinoma is a small sized pituitary tumor which secreat prolactin in larger quantities.
Usually medical treatment can cure this condition.

But sometimes it may take longer periods for the treatment.
In case of persistent elevation of prolactin levels even after treatment, factors should be ruled out like:
-Thyroid hormonal abnormalities and kidney function abnormalities, which can affect prolactin levels.
-Some medicines can lead to increased prolactin levels like:
○The anti-sickness medicines metoclopramide and domperidone.
○Antidepressants of the selective serotonin reuptake inhibitor (SSRI) type.
○Some medicines used to treat schizophrenia or bipolar disorder.
-Prolactinomas can recur even after successful treatment with medication or surgery.
So monitoring with regular blood tests is needed to check that the prolactinoma has not come back.
If it recurs, then treatment should be restarted.

Intercourse during pregnancy

Many people express doubts regarding whether intercourse can be practiced during pregnancy.

In case of normal low risk pregnancy, intercourse may not cause complications.
But the safety of practicing intercourse during pregnancy depends on factors like:
-If the woman is having risk factors like:
•Previous miscarriages,
•Low lying placenta,

•Intermittent spotting or threatened abortion in present pregnancy,
•Partner with possible sexually transmitted diseases,
•Vaginal infection,
•Cervical incompetence, •Premature rupture of membranes,
•Cervical intraepithelial neoplasia etc,
better to avoid intercourse.
-During intercourse, better to prefer lateral position and avoid pressure on abdomen.
-If the woman develop any problems like postcoital bleeding, pain etc, better to avoid intercourse and have to consult her doctor.
Take care. 

Ultrasound in pregnancy

Nowadays ultrasound has became a very important investigation in pregnancy.
It helps in detecting the pregnancy, in monitoring the well being of the baby and to detect any abnormality, so that necessary action can be taken.
Some procedures like chorionic villi sampling, amniotic fluid reduction etc can be under ultrasound guidance.

Usually in low risk pregnancy ultrasound is advisable during:
-Around 5 to 6 weeks of pregnancy, to confirm the intrauterine pregnancy, to estimate the gestational age and to rule out ectopic pregnancy etc.
- Around 9 to 11 weeks, to estimate the expected date of delivery, to find out the nuchal thickness etc. This helps in  finding out risk factors like chromosomal abnormalities specially down syndrome.
-At around 18 to 20 weeks TIFFA scan 'Targeted imaging for fetal anomalies' is advised, which helps in finding out any fetal anomalies, so that necessary action can be taken accordingly.
Then further ultrasound scans can be planted according to the report.
Usually in normal low risk pregnancy further ultrasound examinations around 28 weeks, 36 weeks and before delivery are recommended to monitor the growth of the baby, estimate the amount of liquor, condition of placenta etc.
Any maternal and fetal complications can alter this schedule and need for more ultrasound examinations may arise depending upon the problem.

How to determine estimated date of delivery(EDD)

Detecting the estimated date of delivery(EDD) is important in the management of pregnancy.

EDD can be calculated according to the last menstrual period. This will be reliable if the woman is having the previous 3 regular menstrual cycles.
 Generally 9 months and 7 days from the last menstrual period can be considered as EDD.
 If woman is having irregular menstrual cycles or if there is any history of usage of birth control like contraceptive pills etc in last three months, the last menstrual period may not help in predicting the estimated date of delivery.
Other methods of evaluating the estimated date of delivery are evaluating the uterine size periodically.
 But sometimes obesity, altered position of the uterus, amount of the liquor etc can influence this method.
 The date of delivery can be calculated according to the first date of hearing the fetal heart tones.

Doppler devices can hear fetal heart tones at around 10 weeks whereas standard obstetrical stethoscope can hear at 20 weeks.
Expected date of delivery can be calculated according to the date of first positive pregnancy test. Adding 4 to 5 weeks to positive pregnancy date can give the approximate date of delivery.
Date of fruitful coitus can also help in finding the EDD. Around 8 months 3 weeks from the date of fruitful coitus or ovulation can approximately estimate the EDD.
 Ultrasound also helps in estimating the expected date of delivery.
 Usually early ultrasound at around 9 to 11 weeks gives accurate EDD. Whereas upto 24 weeks also ultrasound can help in estimating approximate EDD. But usually EDD by ultrasound alone is unreliable after 30 weeks.
Calculating the estimated date of delivery according to two parameters like last menstrual period and early ultrasound is more accurate and reliable compared with any single parameter.
But usually only 4 % of women deliver on expected date of delivery, whereas around 80% percent of women deliver during the period of 2 weeks before and one week after the expected date of delivery.

Are you postponing pregnancy?

Because of increasing importance to studies and profession, nowadays women are postponing the pregnancy. 
So planning pregnancy in 30's is becoming common today. Compared with 20's, planning pregnancy in 30's can lead to few problems. 
With increasing age the function of ovaries will get affected, number of ovarian follicles will decrease and remaining follicles may not respond properly to hormones. 
Possibility of problems like hormonal imbalance, pelvic inflammatory disease, endometriosis etc increase with age. 
Adverse effects of using contraceptive measures for prolonged period, possible medical complications diabetes, hypertension etc will increase with age. 
Tensions at work place can also affect fertility by leading to hormonal imbalance. 
Before planning for pregnancy in 30's, the factors to be considered are: 
-Folic acid supplementation should be started around three months before pregnancy. 
It helps in neurological development of baby and helps in conditions like anencephaly. 
-If the woman is having irregular periods, menstrual irregularity should be corrected before planning for pregnancy because menstrual irregularities can lead to difficulty in planning pregnancy and also infertility. Usually menstrual cycle with length of 21 days to 35 days and menstrual flow for 2 to 7 days should be considered as normal only. Deviation from these normalcy needs evaluation.
 Physical examination to access weight, height, BMI, anemia, thyroid abnormalities and gynecological examination to access the size, shape of uterus and adenexal pathology helps in finding out the possible cause of irregular periods. 
Then depending on the findings required investigations like estimating hemoglobin, blood sugar levels, gonadal hormonal profile, thyroid hormonal profile, prolactin levels estimation, ultrasound etc can help finding out the possible cause of irregular periods and treatment can be taken accordingly. 
If decreased ovarian reserve is suspected in ultrasound due to age factor, AMH( (Anti-Mullarian hormone) levels estimation is adviced. AMH is produced by the ovarian anthral follicles. 
Normal AMH levels indicate good ovarian reserve. Women with low AMH levels should plan for pregnancy early without postponing. 
-In case of regular periods or after correction of irregularity, planning intercourse during the time of ovulation increases the possibility of pregnancy. 
Usually ovulation occurs in the middle of the cycle. In case of regular 28 to 30 days cycles, ovulation is possible between 14th to 16th day of the cycle. 
-In case of infertility not getting corrected with medicines, artificial reproductive methods may be needed depending on the problem. 
Like in case of seminal abnormalities depending on spermatozoa count artificial methods ranging from IUI (Intra uterine insemination) to ICSI (intra cytoplasmic sperms injection) may need. After becoming pregnant also elderly women are more to some problems like hyperemesis gravidarum, means excessive vomitings in the first trimester of pregnancy and also pregnancy induced stress is more in elderly pregnant ladies. 
Medical complications like pregnancy induced hypertension, gestational diabetes etc can increase with age. Already existing chronic hypertension, diabetes mellitus, thyroid abnormalities etc can aggrevate during pregnancy. Placental problems like decreased blood supply to placenta due to age related vascular changes and also placenta previa etc are more common in these elderly pregnant women. 
Incidence of operative deliveries also increase in elderly women because of uterine inertia. 
Babies of elderly pregnant women are more prone for chromosomal abnormalities like Down's syndrome, preterm or intrauterine growth retardation etc complications. 
So, better to think once again when you want to postpone the pregnancy. 

General gynaec checkup and routine investigations adviced during checkup

Nowadays because of increased awareness of gynecological problems women are approaching gynecologist early for different complaints. Tests advised during gynecological checkup depends on symptoms of the patient. For those women who come for general gynaec checkup: 
-General examination is performed to access the weight, height, BMI(Body mass index), anemia, thyroid swellings, blood pressure recording etc. 
-For women with age above 35 years or for women having problems related to breast, breast examination and mammography are adviced to rule out pathological conditions like benign or malignant lumps in the breast, fibrocystic changes etc. 
-Abdomen palpation will be done after emptying the bladder to rule out any abdominal lumps, to observe any scars over abdomen etc. 
-External genitalia is examined to find out any discoloration, ulcers, bumps, vaginal discharge etc. 
Perspeculum examination is done to observe the condition of cervix, to rule out erosion, polyps etc. 
Pap smear test is regular screening test to detect changes of cervical cancer, which is advised to all women above the age of 21 years. Yearly once examination is advised for first three years, if all three tests gives negative results, then three years once pap smear test is enough. If unhealthy cervix is noted or frank growth is noticed at the level of cervix, cervical biopsy will be taken. Depending on the reports further management can be planned. 
-Per vaginal examination will be done to observe the size of the uterus, position, mobility and to palate adnexal masses. This helps in finding out uterine pathology and adnexal pathology. 
Depending on the clinical findings if needed specific investigations like blood tests to detect hemoglobin levels, blood sugar levels, thyroid profile, gonadal hormonal profile, prolactin levels estimation, ultrasound etc are advised. 
In case of uterine tumors or ovarian cysts or tumors etc sometimes CT scan or MRI may be needed to confirm the diagnosis and plan the management. 
In case of ovarian cysts or tumors blood CA125 levels estimation is advised to find out the malignant nature of cyst or tumor. 

Effect of tetracyclines on contraceptive pills

What is the effect of tetracyclines on combined oral contraceptive pills?

Tetracyclines like doxycycline, mini cycling etc can affect the function of combined oral contraceptive pills by affecting the absorption of hormones especially oestogen component.
So, during the usage of tetracyclines, additional contraceptive measures like condoms are advised.
Take care.

Galactorrhea with oc pills

Can oral contraceptive pills can lead to Galactorrhea?

Yes. Sometimes combined oral contraceptive pills can lead to galactorrhea(milk secretion from breast) in non pregnant women due to the estrogen component in them.
Estrogen can suppress the prolactin inhibitory factor from hypothalamus and also can stimulate pituitary lactotrophs leading to galactorrhea. Sometimes estrogen withdrawal can also lead to galactorrhea. Because lack of estrogen leads to absence of the inhibitory effect on prolactin hormone at the breast and can cause galactorrhea. 

Emergency pill while on IUCD

Is emergency pill intake is required after intercourse while being on IUCD?

Usually intrauterine contraceptive device is inserted around 5th or 6th day of menstrual cycle.
So, if IUCD is inserted during the end of  menstrual period, it will start giving protection from that month itself and protection will be continued till the period mentioned on IUCD like 3 years, 5years etc depending on the hormone content in it.
So, additional protection like emergency pill is not required while using IUCD.

Treatment options for endometriosis

 The treatment options of endometriosis depends on the severity of the symptoms and the extent of the tissue involvement.
Hysterectomy is not the treatment of choice in all the cases.
If endometriosis involvement is minimal with mild symptoms, that can be dealt with analgesics to relieve the pain and hormonal therapy to shrink the tissue.
In severe cases only surgery may be needed, in that also laparoscopic surgery can be done to remove the endometriotic tissue.
In extreme cases and in women who have completed their family, hysterectomy may be attempted.
Ultrasound helps in identifying the extent of the tissue. Sometimes diagnostic laparoscopy may be needed to identify the endometriosis and its extent. 

Continuous bleeding after emergency contraceptive pill

Emergency contraceptive pill should be used for emergency purpose only.
Because repeated and frequent intake of emergency contraceptive pills can lead to menstrual irregularities.
There should be at least two months gap between two pills.
Frequent intake of emergency pills can cause prolonged bleeding in some women as a side effect.
If bleeding doesn't get controlled even after one week, better to consult gynecologist once and get examined.
Antifibrinolytic drugs can help in controlling the bleeding to some extent.
If bleeding is doesn't get controlled with them, hormone pills may be needed.
To prevent these side effects regular contraceptive methods are advisable to couple with history of frequent intercourse. 

Causes of secondary infertility

If couple who are fertile once
(having first child or children or with previous miscarriage), not able to conceive again for one year with regular unprotected intercourse history, that is called secondary infertility.

The possible causes of secondary infertility are:
Gonadal hormonal imbalance which can cause irregular menstrual cycles, anovulation etc
Fallopian tubal block
Uterine causes like endometrial abnormalities, fibroids, adhesions etc.
Thyroid hormonal or prolactin level abnormalities giving rise to irregular periods etc.

Male factors can also lead to secondary infertility like:
Abnormal seminal parameters like low sperm count, decreased motility etc.
Genital abnormalities like varicocele, ejaculatory duct obstruction etc.
 By examination and by investigations like ultrasound, hysterosalpingography, gonadal hormonal analysis, thyroid profile, prolactin levels estimation for female partner and by physical examination and semen  analysis for male partner the possible cause of the problem can be identified and treated. 

Feeling periods as burden?

Some women think that having periods monthly is a burden to their life.
As they have completed their families or they don't want pregnancy, they want to get rid of periods either by hysterectomy or by other methods.
But this is not correct.
Because the gonadal hormones which are responsible for regular menstrual cycles, also help in many other functions of the body like cardiac function, bone health, neurological function etc.
Having uterus is important for gonadal function. Because if end organ is lost, ovaries function will get affected.
So having menstrual cycles is important for general health also.

Subchorinic hematoma

Live fetus with subchorionic hematoma

Subchorionic hematoma is collection of blood between chorion and uterus.
This is a common ultrasound finding in early pregnancy.
 The possible causes of subchorionic hematoma are   damage of the surrounding blood vessels by growing  gestational sac, during the process of abortion separation of gestational sac can lead to collection of blood etc.
Usually small subchorionic hematomas will get absorb soon.
But if pain abdomen, bleeding per vaginum etc occurs there is possibility of miscarriage and needs evaluation.
 Ultrasound should be repeated after two to three weeks, which can help in finding out whether hematoma got absorbed or not.