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Dilatation And Curettage

Dilatation and curettage

Dilation and curettage (D&C) is a gynaecological procedure performed on the female reproductive system often as a form of abortion. The procedure involves dilating the cervix and inserting instruments to clean out the lining of the uterus, which usually includes among other things a developing fetus, while the woman is under an anaesthetic. A curettage is performed with a curette, a metal rod with a handle on one end and a sharp loop on the other. D&Cs are most commonly performed for the purposes of abortion, but this is far from the only reason that one may be performed. Other typical reasons for a D&C are to resolve abnormal uterine bleeding (too much, too often or too heavy a menstrual flow); to remove the excess uterine lining in women who have conditions such as PCOS which cause a prolonged buildup of tissue with no natural period to remove it; and to remove uterine fibroids or other suspected abnormalities such as premalignant cells in their uterine lining. Other procedures include dilation and evacuation and dilation and extraction. The latter is often referred to as partial-birth abortion. If the procedure is performed too roughly, scar tissue may form and seal the uterus shut (Asherman's syndrome), resulting in infertility.

External link

- [http://www.kuro5hin.org/story/2004/3/22/20565/6275 HOWTO: Perform the Dilation & Curettage Surgical Procedure] by "ti_dave", March 24th, 2004. Article and discussion published on Kuro5hin. Category:Gynecology

Gynaecology

is kneeling before the woman but cannot see her genitalia. Modern gynaecology has overcome these inhibitions.]] Gynaecology (British) or gynecology (North American) literally means 'the science of women', but in medicine this is the specialty of diseases of the female reproductive system (uterus, vagina and ovaries). Almost all modern gynaecologists are also obstetricians; see Obstetrics and gynaecology.

Examination

Gynaecology is typically a consultant specialty. In most countries, women must see a general practitioner first. If their condition requires knowledge or equipment unavailable to the GP, they are referred to a gynaecologist. However, in the United States, law and many health insurance plans allow gynaecologists to provide primary care, and some women select that option. As in all of medicine, the main tools of diagnosis are clinical history and examination. Gynaecological examination is special in that it is quite intimate, and that it involves special equipment -- the speculum. The speculum consists of two hinged blades of flat metal, which are used to open the vagina, to permit examination of the cervix uteri. Gynaecologists may also do a bimanual examination (one hand on the abdomen, two fingers in the vagina), to palpate the uterus and ovaries. They may occasionally do a rectal exam. Male gynaecologists often have a female chaperone (nurse or medical student) for their examination. Virgins are not usually examined vaginally. An abdominal ultrasound is used normally to confirm the bimanual examination.

Investigations

Some of the investigations used in gynaecology are: # abdominal ultrasound, to give a low-power view of the pelvic organs. # vaginal ultrasound. A probe is passed into the vagina, which allows a detailed view of the uterus and its contents. # blood tests. Levels of hormones such as estradiol, luteinizing hormone, follicle stimulating hormone and progesterone are measured, as well as prolactin. # hysteroscopy -- a fine tube is passed into the uterus via the cervix under a general anaesthetic. # laparoscopy -- tubes are passed into the peritoneal cavity, which is then insufflated with carbon dioxide. This is commonly used to diagnose endometriosis. MRI and CT scans are rarely used, apart from tumor staging in gynecological cancer. Pelvic X-ray is rare. It can be used to delineate the uterine cavity with an injected dye (hysterosalpingogram) and to measure the pelvic girdle.

Diseases

The main conditions dealt with by a gynaecologist are: # cancer of the cervix. The Papanicolaou (Pap) smear is a means of detecting this, by obtaining a sample of cervical epithelial cells and examining them under a microscope for malignant changes. All women are encouraged to have pap smears at regular intervals after commencing intercourse. # incontinence of urine. # amenorrhoea (absent periods) # dysmenorrhoea (painful periods) # infertility # menorrhagia (heavy periods). This is a main indication for hysterectomy. # prolapse Obviously there is some crossover in these areas. Amenorrhoea in a young girl may be referred to a paediatrician, incontinence to a urologist.

Therapies

Occasionally gynaecologists will use drugs, such as clomiphene (which stimulates ovulation), and, most famously, oral contraceptives (which are also used for dysmenorrhoea). Surgery, however, is the mainstay of gynaelogical therapy. For historical reasons, gynaecologists are not usually considered "surgeons" - this has always been the source of some controversy - though modern advancements in both fields have blurred many of the once rigid lines of distinction. The rise of sub-speciatlies within gynaecology which are primarily surgical in nature (for example, urogynaecology and gynecological oncology) have stregthened the reputations of gynaecologists as surgical practitioners, and many surgeons and surgical societies have come to view gynaecologists as comrades of sorts. As proof of this changing attitude, gynaecologists are now eligible for fellowship in both the American and Royal Colleges of Surgerons, and many newer surgical textbooks include chapters on (at least basic) gynecological surgery. Some of the more common operations that gynaecologists perform include: # termination of pregnancy # dilation and curettage (removal of the uterine contents, for various reasons, including miscarriage and menorrhagia; procedurally very similar to the above); # hysterectomy (removal of the uterus); # oophorectomy (removal of the ovaries); # tubal ligation; # Exploratory laporoscopy or laporotomy (used to diagnose and treat sources of pelvic and abdominal pain, dysmenorrhea, vaginal bleeding, etc.) # colposuspension ('tightening' of the ligaments around the vagina, a common therapy for incontinence and discomfort in older women); # Large Loop Excision of the Transition Zone (LLETZ), where the surface of the cervix, containing pre-cancerous cells identified on Pap smear are removed).

Cervix

The cervix (from Latin "neck") is actually the lower, narrow portion of the uterus where it joins with the top end of the vagina. It is cylindrical or conical in shape and protrudes through the upper anterior vaginal wall. Approximately half its length is visible with appropriate medical equipment; the remainder lies above the vagina beyond view. It is occasionally called "cervix uteri", or "neck of the uterus".

Anatomy

Ectocervix

The portion projecting into the vagina is referred to as the portio vaginalis or ectocervix. On average, the ectocervix is 3 cm long and 2.5 cm wide. It has a convex, elliptical surface and is divided into anterior and posterior lips.

External Os

The ectocervix's opening is called the external os. The size and shape of the external os and the ectocervix varies widely with age, hormonal state, and whether the woman has had a vaginal birth. In women who have not had a vaginal birth the external os appears as a small, circular opening. In women who have had a vaginal birth, the ectocervix appears bulkier and the external os appears wider, more slit-like and gaping.

Endocervical Canal

The passageway between the external os and the uterine cavity is referred to as the endocervical canal. It varies widely in length and width, along with the cervix overall. Flattened anterior to posterior, the endocervical canal measures 7 to 8 mm at its widest in reproductive-aged women.

Internal Os

The endocervical canal terminates at the internal os which is the opening of the cervix inside the uterine cavity.

Cervical Mucus

Normally the external os is blocked by a thick mucus that prevents infection, however the mucus thins when ovum are ready to be fertilized, allowing spermatazoa to pass through the cervix. Most oral contraceptives increase their effectiveness by not allowing this mucus to thin, therefore blocking spermatazoa from passing even when ovum are ready to be fertilized. During pregnancy the cervix is completely blocked by a special antibacterial mucosal plug which prevents infection as before. The mucous plug comes out as the cervix dialates in labor or shortly before.

Functionality

During orgasm, the cervix convulses and the external os dilates. Dr. R. Robin Baker and Dr. Mark A. Bellis, both at the University of Manchester, first proposed that this behavior worked in such a way as to draw any semen in the vagina into the uterus, increasing the likelihood of conception. Later researchers, most notably Elisabeth A. Lloyd, have questioned the logic of this theory and the quality of the experimental data used to back it. During menstruation the cervix stretches open slightly to allow the endometrium to be shed. This stretching is believed to be part of the cramping pain that many women experience. Evidence for this is given by the fact that some women's cramps subside or disappear after their first baby because the cervical opening has widened. During childbirth, contractions of the uterus will dilate the cervix up to 10cm in diameter to allow the child to pass through.

Cervical cancer

In humans the cervix is associated with cervical cancer, a particular form of cancer which is detectable by cytological study of epidermal cells removed from the cervix in a process known as the pap smear. Evidence now shows that those with exposure to HPV, or the Human Papilloma Virus are at increased risk for cervical cancer. This virus is related to the virus that causes warts.

Lymphatic Drainage

The lymphatic drainage of the cervix is along the uterine arteries and cardinal ligaments to the parametrial, external iliac, internal iliac, obturator, and presacral lymph nodes. From these pelvic lymph nodes, drainage then proceeds to the paraaortic lymph nodes.

Fetus

:"Foetus" redirects here. For the musical group Foetus, see Foetus (band). A fetus (also foetus) is a developing mammal after the embryonic stage and before birth. In humans, a fetus develops from the end of the 8th week of pregnancy (when the major structures have formed), until birth. Fetus, in Latin, literally means 'young one'. When speaking in the most literal of terms, a fetus is an organism, as yet undeveloped, in the process of becoming a functional individual of a species.

Fetal growth

There is much natural variation in the growth of the fetus. Approximately 40% of the variation in birth weight can be accounted for by genetic factors, whereas 60% can be accounted for by environmental factors. Ultimately, the offspring should be able to live up to its term growth potential. Factors affecting fetal growth can be maternal, placental, or fetal. Maternal factors include maternal size, weight, weight for height, nutritional state, anemia, cigarette smoking, substance abuse, or uterine blood flow. Placental factors include size, microstructure (densities and architecture), umbilical blood flow, transporters and binding proteins, nutrient utilization and nutrient production. Fetal factors include the fetus genome, nutrient production, and hormone output. Inappropriate growth can result in low birth weight. If the newborn is small for gestational age, he or she will have an increased risk for perinatal mortality (death shortly after birth), asphyxia, hypothermia, polycythemia, hypocalcemia, immune dysfunction, neurologic abnormalities, and other long-term health problems. This can be the result of fetal growth restriction.

Circulatory system

The circulatory system of a human fetus works differently from that of born humans, mainly because the lungs are not in use: the fetus obtains oxygen and nutrients from the mother through the placenta and the umbilical cord. Blood from the placenta is carried by the umbilical vein. About half of this enters the ductus venosus and is carried to the inferior vena cava, while the other half enters the liver proper from the inferior border of the liver. The branch of the umbilical vein that supplies the right lobe of the liver first joins with the portal vein. The blood then moves to the right atrium of the heart. In the fetus, there is an opening between the right and left atrium (the foramen ovale), and most of the blood flows from the right into the left atrium, then into the left ventricle from where it is pumped through the aorta into the body. Some of the blood moves from the aorta through the internal iliac arteries to the placental arteries, and re-enters the placenta, where carbon dioxide and other waste products from the fetus are taken up and enter the mother's circulation. Some of the blood from the right atrium does not enter the left atrium, but enters the right ventricle and is pumped into the pulmonary artery. In the fetus, there is a special connection between the pulmonary artery and the aorta, called the ductus arteriosus, which directs most of this blood away from the lungs (which aren't being used for respiration at this point as the fetus is suspended in amniotic fluid).

Postnatal development

See Adaptation to extrauterine life for more details With the first breath after birth, the system changes suddenly. The pulmonary resistance is dramatically reduced. More blood moves from the right atrium to the right ventricle and into the pulmonary arteries, and less flows through the foramen ovale to the left atrium. The blood from the lungs travels through the pulmonary veins to the left atrium, increasing the pressure there. The decreased right atrial pressure and the increased left atrial pressure pushes the septum primum against the septum secundum, closing the foramen ovale, which now becomes the fosse ovalis. This completes the separation of the circulatory system into two halves, the left and the right. The ductus arteriosus normally closes off within one or two days of birth. The umbilical vein and the ductus venosus closes off within two to five days after birth, leaving behind the ligamentum teres and the ligamentum venosus of the liver respectively.

Developmental problems

Infants with certain congenital anomalies of the heart can survive only as long as the ductus remains open: in such cases the closure of the ductus can be delayed by the administration of prostaglandins to permit sufficient time for the surgical correction of the anomalies. Conversely, in cases of patent ductus arteriosus, where the ductus does not properly close, drugs that inhibit prostaglandin synthesis can be used to encourage its closure, so that surgery can be avoided.

Differences to the adult circulatory system

Remnants of the fetal circulation can be found in adults:
- The fetal foramen ovale becomes the adult fosse ovalis.
- The fetal ductus arteriosus becomes the adult ligamentum arteriosum.
- The extra-hepatic portion of the fetal left umbilical vein becomes the adult ligamentum teres hepatis (the "round ligament of the liver").
- The intra-hepatic portion of the fetal left umbilical vein (the ductus venosus) becomes the adult ligamentum venosum.
- The proximal portions of the fetal left and right umbilical arteries become the adult umbilical branches of the internal iliac arteries.
- The distal portions of the fetal left and right umbilical arteries become the adult medial umbilical ligaments. In addition to differences in circulation, the developing fetus also employs a different type of oxygen transport molecule than adults (adults use adult hemoglobin). Fetal hemoglobin enhances the fetus' ability to draw oxygen from the placenta.

Legal issues

USA

An unborn child is a child in utero: "a member of the species homo sapiens, at any stage of development, who is carried in the womb," according to legislation which passed the US Senate in March 2004. Since the 1970s in the United States, a debate has alternately raged or simmered over the "personhood" of the fetus before birth. Arguments regarding the personhood of a fetus are particularly relevant to debates over the legal and moral status of abortions. See also: Unborn Victims of Violence Act

Etymology and spelling variations

The word fetus originates from the Latin fetus meaning "offspring" or "young one". Foetus is an English variation on this rather than a Latin or Greek word, but has been in use since at least 1594 according to the OED, which describes fetus as etymylogically preferable but almost unknown in actual use. In general, the medical community only permits the spelling fetus (preferred by the British Medical Journal, for example), but the spelling foetus persists in general use, especially in Britain.

Abortion

An abortion is the termination of a pregnancy associated with the death of an embryo or a fetus. In medicine, the following terms are used to define an abortion:
- Spontaneous abortion: An abortion due to accidental trauma or natural causes, this is commonly termed a miscarriage.
- Induced abortion: Induced abortions are further subcategorized into therapeutic abortions and elective abortions.
- Therapeutic abortion: An abortion performed because the pregnancy poses physical or mental health risk to the pregnant woman.
- Elective abortion: An abortion performed for any other reason. In common parlance, the term "abortion" is synonymous with induced abortion. A pregnancy that terminates early, but where the fetus survives to become a live infant, is instead termed a premature birth. A pregnancy that ends with an infant dead upon birth, due to causes such as spontaneous abortion or complications during delivery, is termed a stillbirth. Certain forms of birth control are used to prevent implantation before the pregnancy occurs. These acts of emergency contraception are not classified as abortion by medicine. The ethics and morality of induced abortion have become the subject of an intense debate in the past 50 years in various areas of the world, particularly in the United States of America, but also to a lesser extent in Canada and a number of countries in Europe. Any female mammal can experience abortion, however this article focuses exclusively on abortion in women.

Spontaneous abortion

Spontaneous abortions, generally referred to as miscarriages, occur when an embryo or fetus is lost due to natural causes. A miscarriage is spontaneous loss of the embryo or fetus before the 20th week of development. Spontaneous abortions after the 20th week are generally considered preterm deliveries. Up to 78% of all conceptions may fail, in most cases even before pregnancy is confirmed. 15% of all confirmed pregnancies end in a miscarriage. Most miscarriages occur very early in a pregnancy. Early embryonic development is an error prone process, and the body may spontaneously abort if a fetus is not viable (i.e., due to genetic deformities, such as most cases of trisomy), or when the womb is unable to support the development of the fetus. Other causes can be infection (of either the mother or the fetus), immune responses, or serious systemic diseases of the mother. The risk for spontaneous abortion is greater in women over age 35, those with a history of more than three previous (known) spontaneous abortions, and those with systemic diseases. A spontaneous abortion can also be caused by accidental trauma; intentional trauma to cause miscarriage is considered an induced abortion. Some states have laws increasing the criminal liability of a person who causes a miscarriage during an assault or other violent crime.

Induced abortions

The term "abortion" is usually used by lay people to refer to induced abortion. Women from 27 nations reported the following reasons for seeking an induced abortion:
- 25.5% – Want to postpone childbearing
- 21.3% – Cannot afford a baby
- 14.1% – Has relationship problem or partner does not want pregnancy
- 12.2% – Too young; parent(s) or other(s) object to pregnancy
- 10.8% – Having a child will disrupt education or job
-   7.9% – Want no (more) children
-   3.3% – Risk to fetal health
-   2.8% – Risk to mother's health
-   2.1% – Rape, incest, other In many areas of the world, especially the developing nations or where induced abortions are illegal, many women choose or are pushed to perform abortions on themselves. These self-induced abortions are commonly unsafe abortions as described by the World Health Organization. Furthermore, some abortions are induced because of societal pressures, such as stigma of disabled persons and similar eugenic ideals, societal and religious disapproval of single motherhood, insufficient economic support for families, or laws such as under China's one-child policy. These policies and societal pressures can lead to sex-selective abortion and infanticide, which is illegal in most countries, but difficult to stop.

Methods of inducing abortion

Depending on the gestational age of the embryo or fetus, different methods of abortion can be performed to remove the embryo or fetus from the womb.

Medical Abortion

Effective in the first trimester of pregnancy, medical, or non-surgical abortions comprise 10% of all abortions in the United States and Europe. The process begins with the administration of either methotrexate or mifepristone, followed by misoprostol. While misoprostol may also be used alone to induce abortion, the need for surgical intervention is slightly elevated to about 10%, compared to the 8% when medications are combined. When surgical intervention is necessary, primarily vacuum uterine aspiration is used.

Surgical abortion

In the first fifteen weeks, suction-aspiration or vacuum abortion are the most common methods, replacing the more risky dilation and curettage (D & C). Manual vacuum aspiration, or MVA abortion, consists of removing the fetus or embryo by suction using a manual syringe, while the Electric vacuum aspiration or EVA abortion method uses suction produced by an electric pump to remove the fetus or embryo. From the fifteenth week up until around the eighteenth week, a surgical dilation and evacuation (D & E) is used. D & E consists of opening the cervix of the uterus and emptying it using surgical instruments and suction. Dilation and suction curettage consists of emptying the uterus by suction using a different apparatus. Curettage refers to the cleaning of the walls of the uterus with a curette. Dilation and curettage (D & C) is a standard gynaecological procedure performed for a variety of reasons, such as examination. As the fetus grows, other techniques must be used to induce abortion in the third trimester. Premature delivery of the human fetus can be induced with prostaglandin; this can be coupled with injecting the amniotic fluid with caustic solutions containing saline or urea. Very late abortions can be brought about by the controversial intact dilation and extraction (intact D & X) which requires the surgical decompression of the fetus's head before evacuation and is controversially termed "partial-birth abortion". A hysterotomy abortion, similar to a caesarian section but resulting in a terminated fetus, can also be used at late stages of pregnancy. Hysterotomy abortion can be performed vaginally, with an incision just above the cervix, in the late mid-trimester. An attempted abortion which results in the expulsion of a live infant (known medically as a neonate) is termed a failed abortion. A failed abortion is more likely to occur later in pregnancy. Some doctors who have induced a failed abortion have faced the prospect of having to kill the neonate, but are voicing concerns that doing so may be unethical and possibly subject them to criminal sanctions. As a result, recent investigations have been launched in England by the Confidential Enquiry into Maternal and Child Health (CEMACH) and the Royal College of Obstetricians and Gynaecologists in order to determine how widespread the problem is and an ethical response on how to treat the neonate.

Other means of abortion

A number of herbs are effective abortifacients. Using herbs in this way can cause serious side effects, including multiple organ failure and other serious injury, and are not recommended by physicians. Physical trauma to a pregnant woman's womb can cause an abortion. The severity of the impact required to cause an abortion carries high risk of injury, without necessarily inducing a miscarriage. Both accidental and deliberate abortions of this kind carry criminal liability in many countries.

Health effects

As with most surgical procedures, the most common surgical abortion methods carry the risk of potentially serious complications. These risks include: a perforated uterus, perforated bowel or bladder, septic shock, sterility, and death. It is difficult to accurately assess the risks of induced abortion due to a number of factors. These factors include wide variation in the quality of abortion services in different societies and among different socio-economic groups, a lack of uniform definitions of terms, and difficulties in patient follow-up and after-care. Use of other methods (e.g., overdose of various drugs, insertion of various objects into uterus) for abortion is very dangerous, carrying a significantly elevated risk for permanent injury or death compared to abortions done by physicians.

Physical health

Each phase of the abortion carries separate risks, and practitioners are not in agreement as to the best methods of mitigating those risks. The degree of risk depends upon the skill and experience of the practitioner; maternal age, health, and parity; gestational age; pre-existing conditions; methods and instruments used; medications used; the skill and experience of those assisting the practitioner; and the quality of recovery and follow-up care. A highly-skilled practitioner, operating under ideal conditions, will tend to have a very low rate of complications; an inexperienced practitioner in an ill-equipped and ill-staffed facility, on the other hand, will often have a higher incidence of complications. Some practitioners advocate using the minimal possible anesthesia, so that patient pain can alert the practitioner to possible complications. Others recommend general anesthesia in order to prevent patient movement which might cause a perforation. General anesthesia carries its own risks and most public health officials recommend against its routine use in abortion due to an increased risk of death. Dilation of the cervix carries the risk of cervical tears or perforations, including small tears that might not be apparent and might cause cervical incompetence in future pregnancies. Most practitioners recommend using the smallest possible dilators, and using osmotic rather than mechanical dilators after the first trimester of pregnancy. Instruments are placed within the uterus to remove the fetus. These can, on rare occassions, cause perforation or laceration of the uterus, and damage to structures surrounding the uterus. Laceration or perforation of the uterus or cervix can, again on rare occassions, lead to even more serious complications. Incomplete emptying of the uterus can cause hemorrhage, and infection. Use of ultrasound verification of the location and duration of the pregnancy prior to abortion, with immediate follow-up of patients reporting continuing pregnancy symptoms after the procedure, will virtually eliminate this risk. In rare cases, the abortion will be unsuccessful and the pregnancy will continue. Most practitioners recommend a second procedure to terminate the pregnancy due to the possibility that the abortion attempt had caused injury to the fetus. The sooner a complication is noted and properly treated, the lower the risk of permanent injury or death. A specific and undisputed complication that can arise, especially with repeated abortions by a dilatation and curettage, is the development of Asherman syndrome.

Suggested effects

There is controversy over a number of proposed risks and effects of abortion. Evidence, whether in support of or against such claims, might in part be influenced by the political and religious affiliations of the parties behind it.

Breast cancer

The controversial abortion-breast cancer (ABC) hypothesis posits an association between having an abortion and a higher risk of developing breast cancer. The proposed mechanism is based on the increased estrogen levels found during early pregnancy, which initiate cellular differentiation (growth) in the breast in preparation for lactation. The ABC hypothesis states that if the pregnancy is aborted before full differentiation in the third trimester, then more "vulnerable" undifferentiated cells would be left than prior to the pregnancy, resulting in an elevated risk of breast cancer. The majority of interview-based studies have indicated a link, and some have been demonstrated to be statistically significant, but there remains debate as to their reliability because of possible response bias. According to the National Cancer Institute (NCI), it is "well established" that "induced abortion is not associated with an increase in breast cancer risk." Those findings have been disputed by Dr. Joel Brind, a leading scientific advocate of the ABC hypothesis. Nevertheless, gaps and inconsistencies remain in the research as the "ABC link" continues to be a politicized issue.

Fetal pain

The experience of the fetus during abortion is a matter of consideration among scientists and political activists. Evidence is conflicting, with some authorities claiming that the fetus is capable of feeling pain from the first trimester, while others hold that the neuro-anatomical requirements for such experience do not exist until the second or third trimester. Pain receptors begin to appear in the seventh week of pregnancy. The thalamus, the part of the brain which receives signals from the nervous system and then relays them to the cerebral cortex, starts to form in the fifth week. However, other anatomical structures involved in the nociceptic process are not present until much later in gestation. Links between the thalamus and cerebral cortex aren't forged until around the 23rd week. [http://www.parliament.uk/post/pn094.pdf]. Myelin, an insulation on nerve fibres whichs aids in the conduction of electrical impulses, does not begin to develop until the sixth month. [http://www.pediatrics.emory.edu/neonatology/dpc/brain.htm] Researchers have observed changes in the heart rates and hormonal levels of neonates after circumcision, blood tests, and surgery — effects which were alleviated with the administration of anaesthesia. [http://www.cirp.org/library/pain/anand/#n99] Others suggest that the human experience of pain, being more than just physiological, cannot be measured in such reflexive responses.

Mental health

It is indisputable that some women will experience negative feelings as a result of elective abortion. However, whether this phenomenon is significant enough to warrant a general diagnosis, or even classification as an independent syndrome (see abortion trauma syndrome), is a subject that is debated among members of the medical community. Data on the incidence of clinical depression, mental illness, post-traumatic stress disorder, and suicide in association with abortion remain inconclusive. [http://bmj.bmjjournals.com/cgi/content/abstract/bmj.38623.532384.55v1] A comparative analysis of the suicide rates among postpartum and post-abortive women in Finland found a raw statistical correlation between abortion and suicide. [http://bmj.bmjjournals.com/cgi/content/full/313/7070/1431] Other studies have suggested a link between the elective termination of an unwanted pregnancy and an improvement in reported mental well-being. The majority of evidence would seem to indicate that adverse emotional reactions to the procedure are most strongly influenced by pre-existing psychological conditions and other negative factors. [http://www.apa.org/ppo/issues/womenabortfacts.html] Elective abortion may reduce the occurrence of depression in cases of unwanted pregnancy, as compared to cases in which the pregnancy has been carried to completion, but it is also sometimes reported as an additional stressor. Spontaneous abortion, or miscarriage, presents an increased risk of depression in women. [http://www.medicinenet.com/script/main/art.asp?articlekey=619]

History of abortion

depression The practice of induced abortion, according to some anthropologists, can be traced to ancient times. There is evidence to suggest that, historically, pregnancies were terminated through a number of methods, including the administration of abortifacient herbs, the use of sharpened implements, the application of abdominal pressure, and other techniques. Soranus, a 2nd century Greek physician, suggested in his work Gynaecology that women wishing to abort their pregnancies should engage in violent exercise, energetic jumping, carrying heavy objects, and riding animals. He also prescribed a number of recipes for herbal bathes, pessaries, and bloodletting, but advised against the use of sharp instruments to induce miscarriage due to the risk of organ perforation. [http://www.stoa.org/diotima/anthology/wlgr/wlgr-medicine355.shtml] It is also known that the ancient Greeks relied upon the herb silphium as both a contraceptive and an abortifacient. The plant, as the chief export of Cyrene, was driven to extinction, but it is suggested that it might have possessed the same abortive properties as some of its closest extant relatives in the Apiaceae family. Such folk remedies, however, varied in effectiveness and were not without risk. Tansy and pennyroyal, for example, are two poisonous herbs with serious side effects that have at times been used to terminate pregnancy. 19th-century medicine saw advances in the fields of surgery, anaesthesia, and sanitation, in the same era that doctors with the American Medical Association lobbied for bans on abortion in The United States and the British Parliament passed the Offences Against the Person Act. Demand for the procedure continued, however, as the disguised, but nonetheless open, advertisement of abortion services in Victorian times would seem to suggest. [http://users.telerama.com/~jdehullu/abortion/abhist.htm]

The abortion debate

Throughout the history of abortion, induced abortions have been a source of considerable debate and controversy regarding the morality and legality of this practice. An individual's position on the complex ethical, moral, philosophical, biological, and legal issues have a strong relationship with that individual's value system. A person's position on abortion may be best described as a combination of their personal beliefs on the morality of induced abortion, and that person's beliefs on the ethical scope and responsibility of legitimate governmental and legal authority. Another factor for many individuals is religious doctrine. See religion and abortion for more. Abortion debates, especially pertaining to abortion laws, are often spearheaded by advocacy groups belonging to one of two camps. Most often those in favor of legal prohibition of abortion describe themselves as pro-life while those against legal restrictions on abortion describe themselves as pro-choice. Both are used to indicate the central principles in arguments for and against abortion: "Is the fetus a human being with a fundamental right to life?" for pro-life advocates, and, for those who are pro-choice, "Should the state or the individual have choice on the matter of abortion?" In both public and private debate, arguments presented in favour of or against abortion focus on either the moral permissibility of an induced abortion, or justification of laws permitting or restricting abortion. Arguments on morality and legality tend to collide and combine, complicating the issue at hand.

Public opinion

Political sides have largely been divided into absolutes. The abortion debate, as such, tends to centre around individuals who hold strong positions. However, public opinion varies from poll to poll, country to country, and region to region:
- Australia: In a February 2005 AC Nielsen poll, as reported in the The Age, 56% thought the current abortion laws were "about right," 16% want changes in law to make abortion "more accessible," and 17% want changes to make it "less accessible." [http://www.theage.com.au/news/National/Poll-backs-abortion-laws/2005/02/15/1108230007300.html] A 1998 poll, conducted by Roy Morgan Research, asked, "Do you approve of the termination of unwanted pregnancies through surgical abortion?" 65% of the Australians polled stated that they approved of surgical abortion and 25% stated that they disapproved of it. [http://oldwww.roymorgan.com/polls/1998/3058]
- Ireland: A 1997 Irish Times/MRBI poll of the Republic of Ireland's electorate found that 18% believe that abortion should never be permitted, 35% that one should be allowed in the event that the mother's life is threatened, 18% if her health is at risk, 28% that "an abortion should be provided to those who need it," and 5% were undecided. [http://www.ireland.com/newspaper/front/1997/1211/archive.97121100003.html]
- Canada: A recent poll of Canadians, conducted in April 2005 by Gallup, found that 52% of those polled want abortion laws to "remain the same," 20% want the laws to be "less strict," and 24% would prefer that the laws become "more strict." An earlier Gallup poll, from December 2001, asked, "Do you think abortions should be legal under any circumstances, legal only under certain circumstances or illegal in all circumstances and in what circumstances?" 32% of Canadians responded that they believe abortion should be legal in all circumstance, 52% that it should be legal in certain circumstances, and 14% that it should be legal in no circumstances. See Abortion in Canada.
- The United Kingdom: An online YouGov/Daily Telegraph poll in August 2005 found that 30% of Britons would back a measure to reduce the legal limit for abortion to 20 weeks, 19% support a limit of 12 weeks, 9% support a limit of less than 12 weeks, and 25% support maintaining the current limit of 24 weeks. 6% responded that abortion should never be allowed while 2% said it should be permitted throughout the entirety of pregnancy. [http://www.yougov.com/archives/pdf/TEL050101042_1.pdf]
- The United States: A CNN/USA Today/Gallup poll conducted in November 2005 revealed that 39% believe that abortion should be legal only in "a few circumstances" and another 16% think that it should be legal under "no circumstances", whereas 26% believe it should remain legal in "all circumstances" (the current law under Roe v. Wade) and 16% said it should be legal under "most circumstances". [http://www.cnn.com/2005/US/11/27/abortion.poll] Additional recent U.S. polling data can be found [http://www.pollingreport.com/abortion.htm here.] [http://www.pollingreport.com/abortion.htm]

Abortion law

Roe v. Wade The Soviet Union (1920) and Iceland (1935) were some of the first countries to generally allow abortion. The second half of the twentieth century saw the liberalization of abortion laws in many other countries. In 1973, the U.S. Supreme Court struck down state laws banning abortion, controversially ruling that such laws violated an inferred right to privacy in the U.S. Constitution. The Supreme Court of Canada, similarly, discarded its criminal code regarding abortion in 1988, after ruling that such restrictions violated the security of person guaranteed to women under in the Canadian Charter of Rights and Freedoms. Ireland, on the other hand, added an amendment to its Constitution in 1983 by popular referendum, recognizing "the right to life of the unborn." (see Abortion in Ireland). Current laws pertaining to abortion are diverse. Religious, moral, and cultural sensibilities continue to influence abortion laws throughout the world. The right to life, the right to liberty, and the right to security of person are major issues of human rights that are sometimes used as justification for the existence or the absence of laws controlling abortion. Many countries in which abortion is legal require that certain criteria be met in order for an abortion to be obtained, often, but not always, using a trimester-based system to regulate the window in which abortion is still legal to perform:
- In the United States, some states impose a 24-hour waiting period before the procedure, prescribe the distribution of information on fetal development, or require that parents be contacted if their minor daughter requests an abortion.
- In the United Kingdom, as in some other countries, two doctors must first certify that an abortion is medically or socially necessitated before it can be performed. Other countries, in which abortion is illegal, will allow one to be performed in the case of rape, incest, or danger to the pregnant woman's life or health. A handful of nations ban abortion entirely, such as Chile, El Salvador, and Malta.

Sources

# Bankole, Akinrinola; Singh, Susheela; Haas, Taylor. "Reasons Why Women Have Induced Abortions: Evidence from 27 Countries." International Family Planning Perspectives, 1998 # Moreau, C. et al, [http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15777440&query_hl=8 "Previous induced abortions and the risk of very preterm delivery"], BJOG. 2005; 112(4):430-7 #[http://www.timesonline.co.uk/article/0,,2087-1892696,00.html The Sunday Times (Britain)] November 27, 2005 # [http://news.telegraph.co.uk/news/main.jhtml?xml=/news/2005/05/15/nabort15.xml http://news.telegraph.co.uk/news/main.jhtml?xml=/news/2005/05/15/nabort15.xml] # Beral V, Bull D, Doll R, Peto R, Reeves G; Collaborative Group on Hormonal Factors in Breast Cancer. Breast cancer and abortion: collaborative reanalysis of data from 53 epidemiological studies, including 83?000 women with breast cancer from 16 countries. Lancet. 2004 Mar 27;363(9414):1007-16. PMID 15051280 # Ciganda C, Laborde A., [http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=12807304&query_hl=9 "Herbal infusions used for induced abortion"], J Toxicol Clin Toxicol. 2003; 41(3):235-9 # [http://www.efc.org.uk/Foryoungpeople/Factsaboutabortion/Unsafeabortion Education For Choice] – Unsafe abortion

External links

- [http://www.johnstonsarchive.net/policy/abortion Abortion Statistics and Other Data]
- [http://annualreview.law.harvard.edu/population/abortion/abortionlaws.htm Abortion Laws of the World]
- [http://www.un.org/esa/population/publications/abortion Abortion Policies: A Global Review] The following links may be biased:
- [http://www.abortion.com/ Abortion.com]
- [http://agi-usa.org/ The Alan Guttmacher Institute]
- [http://www.all.org/ American Life League]
- [http://www.care-net.org/ CareNet]
- [http://justfacts.com/abortion.htm Just Facts: Abortion]
- [http://www.plannedparenthood.com Planned Parenthood] Category:Abortion Category:Abortion by country Category:Obstetrics Category:Issue in the Culture Wars ja:妊娠中絶 simple:Abortion

Menses

The menstrual cycle is the set of recurring physiological changes in a female's body that are under the control of the reproductive hormone system and necessary for reproduction. In women, menstrual cycles occur typically on a monthly basis between puberty and menopause. Besides humans, only other great apes exhibit menstrual cycles, in contrast to the estrus cycle of most mammalian species. During the menstrual cycle, the sexually mature female body releases one egg (or occasionally two, which might result in dizygotic, or non-identical, twins) at the time of ovulation. The lining of the uterus, the endometrium, builds up in a synchronised fashion. After ovulation, this lining changes to prepare for potential implantation of the fertilised egg to establish a pregnancy. If fertilisation and pregnancy do not ensue, the uterus sheds the lining and a new menstrual cycle begins. The process of the shedding of the lining is called menstruation. Menstruation manifests itself to the outer world in the form of the menses (also menstruum): essentially part of the endometrium and blood products that pass out of the body through the vagina. Although this is commonly referred to as blood, it differs in composition from venous blood. Common usage refers to menstruation and menses as a period. This bleeding serves as a sign that a woman has not become pregnant. (However, this cannot be taken as certainty, as sometimes there is some bleeding in early pregnancy.) During the reproductive years, failure to menstruate may provide the first indication to a woman that she may have become pregnant. A woman might say that her "period is late" when an expected menstruation has not started and she might have become pregnant. Menstruation forms a normal part of a natural cyclic process occurring in healthy women between puberty and the end of the reproductive years. The onset of menstruation, known as menarche, occurs at an average age of 12, but can occur any time between the ages of 8 and 16. The last period, menopause, usually occurs between the ages of 45 and 55. Deviations from this pattern deserve medical attention. Amenorrhea refers to a prolonged absence of menses during the reproductive years of a woman for reasons other than pregnancy. For example, women with very low body fat, such as athletes, may cease to menstruate. The presence of menstruation does not prove that ovulation took place; women who do not ovulate may have menstrual cycles. Those anovulatory cycles tend to take place less regularly and show greater variation in cycle length. In addition, the absence of menstruation also does not prove that ovulation did not take place, because hormone disruptions in non-pregnant women can suppress bleeding on occasion.

The normal menstrual cycle in humans

Women show considerable variation in the lengths of their menstrual cycles, and the length of the menstrual cycle differs in different animals (see below). While cycle length may vary, 28 days is generally taken as representative of the average ovulatory cycle in women. Convention uses the onset of menstrual bleeding to mark the beginning of the cycle, so the first day of bleeding is called "Cycle Day one". One can divide the menstrual cycle into four phases:

Menstruation

Menstruation lasts for a few days (usually 3 to 5 days, but anywhere from 2 to 7 days is considered normal) and involves the loss of about 50 millilitres of blood (including shed lining). An enzyme called plasmin — contained in the endometrium — inhibits the blood from clotting. Because of this blood loss, women have higher dietary requirements for iron than do males to prevent iron deficiency. Many women experience uterine cramps, also referred to as dysmenorrhea, during this time. A vast industry has grown to provide sanitary products to help women to manage their menses. The tampon is a common product.

Follicular phase

Through the influence of a rise in Follicle stimulating hormone (FSH), five to seven tertiary-stage ovarian follicles are recruited for entry into the menstrual cycle. These follicles, that have been growing for the better part of a year in a process known as folliculogenesis, compete with each other for dominance. In a signal cascade kicked off by luteinizing hormone (LH), the follicles secrete estradiol, a steroid that acts to inhibit pituitary secretion of FSH. With diminished FSH supply comes a slowing in growth that eventually leads to follicle death, known as atresia. The largest follicle secretes inhibin that serves as a finishing blow to less competent follicles by further suppressing FSH. This dominant follicle continues growing, forms a bulge near the surface of the ovary, and soon becomes competent to ovulate. The follicles also secrete estrogens (of which estradiol is a member). Estrogens initiate the formation of a new layer of endometrium in the uterus, histologically identified as the proliferative endometrium. If fertilised, the embryo will implant itself within this hospitable flesh.

Ovulation

embryo When the follicle has matured, it secretes enough estradiol to trigger the acute release of luteinizing hormone (LH). In the average cycle this LH surge starts around cycle day 12 and may last 48 hours. The release of LH matures the egg and weakens the wall of the follicle in the ovary. This process leads to ovulation: the release of the now mature ovum, the largest cell of the body (with a diameter of about 0.5 mm). Which of the two ovaries — left or right — ovulates appears essentially random; no known left/right co-ordination exists. The Fallopian tube needs to capture the egg and provide the site for fertilisation. A characteristic clear and stringy mucus exhibiting spinnbarkeit develops at the cervix, ready to accept sperm from intercourse. In some women, ovulation features a characteristic pain called Mittelschmerz which lasts for several hours. The sudden change in hormones at the time of ovulation also causes light mid-cycle bleeding for some women. Many women perceive the vaginal and cervical mucus changes at ovulation, particularly if they are monitoring themselves for signs of fertility. An unfertilised egg will eventually disintegrate or dissolve in the uterus. Scientific investigations have indicated that the olfactory acuity or the sense of smell is greatest during ovulation in women.

Luteal phase

The corpus luteum is the solid body formed in the ovaries after the egg has been released from the fallopian tube which continues to grow and divide for a while. After ovulation, the residual follicle transforms into the corpus luteum under the support of the pituitary hormones. This corpus luteum will produce progesterone in addition to estrogens for approximately the next 2 weeks. Progesterone plays a vital role in converting the proliferative endometrium into a secretory lining receptive for implantation and supportive of the early pregnancy. It raises the body temperature by half- to one degree Fahrenheit (one-quarter to one-half degree Celsius), thus women who record their temperature on a daily basis will notice that they have entered the luteal phase. If fertilisation of an egg has occurred, it will travel as an early embryo through the tube to the uterine cavity and implant itself 6 to 12 days after ovulation. Shortly after implantation, the growing embryo will signal its existence to the maternal system. One very early signal consists of human chorionic gonadotropin (hCG), a hormone that pregnancy tests can measure. This signal has an important role in maintaining the corpus luteum and enabling it to continue to produce progesterone. In the absence of a pregnancy and without hCG, the corpus luteum demises and inhibin and progesterone levels fall. This will set the stage for the next cycle. Progesterone withdrawal leads to menstrual shedding (progesterone withdrawal bleeding), and falling inhibin levels allow FSH levels to rise to raise a new crop of follicles.

Menstrual symptoms

In many women, various unpleasant symptoms caused by the involved hormones and by cramping of the uterus can precede or accompany menstruation. More severe symptoms may include significant menstrual pain (dysmenorrhea), abdominal pain, migraine headaches, depression and irritability. Some women encounter premenstrual stress syndrome (PMS or premenstrual syndrome), a cyclic clinical entity. Breast discomfort caused by premenstrual water retention is very common. The list of symptoms experienced varies from person to person. Furthermore, within an individual, the severity of the symptoms may vary from cycle to cycle.

The fertile window

The length of the follicular phase — and consequently the length of the menstrual cycle — may vary widely. The luteal phase, however, almost always takes the same number of days. Some women have a luteal phase of 10 days, others of 16 days (the average is 14 days), but for each individual woman, this length will remain constant. Sperm survive inside a woman for 3 days on average, with survival time up to five days considered normal. A pregnancy resulting from sperm life of eight days has been documented . The most fertile period (the time with the highest likelihood of sexual intercourse leading to pregnancy) covers the time from some 5 days before ovulation until 1–2 days after ovulation. In an average 28 day cycle with a 14-day luteal phase, this corresponds to the second and the beginning of the third week of the cycle. Fertility awareness methods of birth control attempt to determine the precise time of ovulation in order to find the relatively fertile and the relatively infertile days in the cycle. People who have heard about the menstrual cycle and ovulation may commonly and mistakenly assume, for contraceptive purposes, that menstrual cycles always take a regular 28 days, and that ovulation always occurs 14 days after beginning of the menses. This assumption may lead to unintended pregnancies. Note too that not every bleeding event counts as a menstruation, and this can mislead people in their calculation of the fertile window. If a woman wants to conceive, the most fertile time occurs between 19 and 10 days prior to the expected menses. Many women use ovulation detection kits that detect the presence of the LH surge in the urine to indicate the most fertile time. Other ovulation detection systems rely on observation of one or more of the three primary fertility signs (basal body temperature, cervical fluid, and cervical position). Among women living closely together, the onsets of menstruation may tend to synchronise somewhat. Researchers first described this phenomenon in 1971, and explained it by the action of pheromones in 1998 (Stern and McClintock 1998). However, subsequent research has called this conclusion into question.

Hormonal control

Extreme intricacies regulate the menstrual cycle. For many years, researchers have argued over which regulatory system has ultimate control: the hypothalamus, the pituitary, or the ovary with its growing follicle; but all three systems have to interact. In any scenario, the growing follicle has a critical role: it matures the lining, provides the appropriate feedback to the hypothalamus and pituitary, and modifies the mucus changes at the cervix. Two sex hormones play a role in the control of the menstrual cycle: estradiol and progesterone. While estrogen peaks twice, during follicular growth and during the luteal phase, progesterone remains virtually absent prior to ovulation, but becomes critical in the luteal phase and during pregnancy. Many tests for ovulation check for the presence of progesterone. These sex hormones come under the influence of the pituitary gland, and both FSH and LH play necessary roles. FSH stimulates immature follicles in the ovaries to grow. LH triggers ovulation. The gonadotropin-releasing hormone of the hypothalamus controls the pituitary, yet both the pituitary and the hypothalamus receive feedback from the follicle. After ovulation the corpus luteum — which develops from the burst follicle and remains in the ovary — secretes both estradiol and progesterone. Only if pregnancy occurs do hormones appear in order to suspend the menstrual cycle, while production of estradiol and progesterone continues. Abnormal hormonal regulation leads to disturbance in the menstrual cycle. Some women with neurological conditions experience increased activity of their conditions at about the same time every month. 80 percent of women with epilepsy have more seizures than usual in the phase of their cycle when progresterone declines and estrogen increases. Mice have been used as an experimental system to investigate possible mechanisms by which levels of sex steroid hormones might regulate nervous system function. During the part of the mouse estrous cycle when progesterone is highest, the level of nerve-cell GABA receptor subtype delta was high. Since these GABA receptors are inhibitory, nerve cells with more delta receptors are less likely to fire than cells with lower numbers of delta receptors. During the part of the mouse estrous cycle when estrogen levels are higher than progesterone levels, the number of delta receptors decrease, increasing nerve cell activity, in turn increasing anxiety and seizure susceptibility. (Maguire et al., 2005)

Hidden ovulation

Unlike other species, human women have concealed ovulation. A woman may sense her own ovulation while it may remain indiscernible to others; this is considered to have sociobiological significance. In contrast, other species often signal receptivity through heat. In this context, evidence suggests that women's preferences for men may change during their most fertile days; that is, before and shortly after ovulation. During this time, they may prefer different male scents, more masculine faces, and social presence in males considered as partners. (Gangestad 2004; debated) Women, especially young teens, have been noted to dress more provocatively, to say that they feel sexier, to flirt more, and to be more likely to initiate sexual activity around the time of ovulation than they did at other points in their menstrual cycle. Most of this, especially in younger women, appears to be subconscious.

The ovary as an egg-bank

Evidence suggests that eggs are formed from germ cells early in fetal life. The number is reduced to an estimated 400,000 to 450,000 immature eggs residing in each ovary at puberty. The menstrual cycle, as a biologic event, allows for ovulation of one egg typically each month. Thus over her lifetime a woman will ovulate approximately 400 to 450 times. All the other eggs dissolve by a process called atresia. As a woman's total egg supply is formed in fetal life, to be ovulated decades later, it has been suggested that this long lifetime may make the chromatin of eggs more vulnerable to division problems, breakage, and mutation than the chromatin of sperm, which are produced continuously during a man's reproductive life. This possibility is supported by the observation that fetuses and infants of older mothers have higher rates of chromosome abnormalities than those of older fathers.

The anovulatory menstrual cycle

Not all menstruations result from an ovulatory menstrual cycle. In some women, follicular development may start but not complete, nevertheless estrogens will form and will stimulate the uterine lining. Sooner or later the uterus will shed this lining. As no ovulation and no progesterone involvement occurs, doctors call this type of bleeding an estrogen breakthrough bleeding, and cannot always predict its duration or frequency. Anovulatory bleeding commonly occurs prior to menopause (premenopause) or in women with polycystic ovary syndrome.

Cycle abnormalities

Frequency

The "normal menstrual cycle" occurs every 28 days ± 7 days. The medical term for cycles with intervals of 21 days or fewer is polymenorrhea and, on the other hand, the term for cycles with intervals exceeding 35 days is oligomenorrhea (or amenorrhea if intervals exceed 180 days).

Flow

The normal menstrual flow amounts to 50 ml ± 30 ml. It follows a "crescendo-decrescendo" pattern; that is, it starts at a moderate level, increases somewhat, and then slowly tapers. Sudden heavy flows or amounts in excess of 80 ml (hypermenorrhea or menorrhagia) may stem from hormonal disturbance, uterine abnormalities, including uterine leiomyoma or cancer, and other causes. Doctors call the opposite phenomenon, of bleeding very little, hypomenorrhea.

Duration

The typical woman bleeds ("is on her period") for three to seven days out of each month. Prolonged bleeding (metrorrhagia, also meno-metrorrhagia) no longer shows a clear interval pattern. Dysfunctional uterine bleeding refers to hormonally caused bleeding abnormalities, typically anovulation. All these bleeding abnormalities need medical attention; they may indicate hormone imbalances, uterine fibroids, or other problems. As pregnant patients may bleed, a pregnancy test forms part of the evaluation of abnormal bleeding.

The birth control pill

Estrogens and progesterone-like hormones make up the main active ingredients of birth control pills. Typically they tend to mimic a menstrual cycle in appearance, but to suppress the critical event of the ovulatory cycle, namely ovulation. Normally, a woman takes hormone pills for 21 days, followed by 7 days of non-functional placebo sugar pills or no pills at all; then the cycle starts again. During the 7 placebo days, a withdrawal bleeding occurs; this differs from ordinary menstruation, and skipping the placebos and continuing with the next batch of hormone pills may suppress it. (Two main versions of the pill exist: monophasic and triphasic. With triphasic pills, skipping of the placebos and continuing with the next month's dose can remove the pill's pregnancy protection.) In 2003 the United States Food and Drug Administration (FDA) approved low-dose monophasic birth control pills which induce withdrawal bleedings only every 3 months.

Etymology and the lunar month

The terms "menstruation" and "menses" come from the Latin mensis (month), which in turn relates to the Greek mene (moon) and to the roots of the English words month and moon — reflecting the fact that the moon also takes close to 28 days to revolve around the Earth (actually 27.32 days). The synodical lunar month, the period between two new moons (or full moons), is 29.53 days long. Many women, after a period of not being exposed to artificial nighttime lighting, find their menstrual cycles begin to occur in rhythm with the lunar cycle.

Menstrual products

While some women allow their menses to flow freely or learn to recognise when their menses will flow, most women prefer to use some artifical means to absorb or catch their menses to prevent soiling their clothes. There are a number of different methods used:
- Sanitary towels, sanitary napkins, or pads - Rectangular pieces of material worn in the underpants to absorb menstrual flow, often with "wings," pieces that fold around the panties, or a sticky backing to hold the pad in place. Reusable cloth pads are made of cotton (often organic), terrycloth, or flannel, and may be handsewn (from material or reused old clothes and towels) or storebought. Disposable synthetic pads are made of wood pulp or synthetic products, usually with a plastic lining and bleached.
- Tampons - Disposable wads of treated rayon/cotton blends or all-cotton fleece, usually bleached, that are inserted into the vagina to absorb menstrual flow. Some women also make their own tampons from rolled up cotton strips.
- Menstrual cups - A firm, flexible cup- or bell-shaped device worn inside the vagina to catch menstrual flow. Reusable versions include rubber or silcone cups (like the Keeper, Divacup, [http://www.lunette.fi Lunette] and Mooncup). Disposable versions come in soft plastic cups (like Instead).
- Sea sponges - Reuseable soft sponges from plant-like animals that grow on the ocean floor, worn internally to absorb blood.
- Padettes - Disposable wads of treated rayon/cotton blend fleece that are placed within the inner labia to absorb menstrual flow.
- Padded panties - Reuseable cloth (usually cotton) underwear with extra absorbent layers sewn in to absorb flow.
- Blanket, towel, or "bleeding blankie" - Large reuseable piece of cloth, most often used at night, placed between legs to absorb menstrual flow. Pharmaceutical companies also provide products — commonly Non-steroidal anti-inflammatory drugs (NSAIDs) — to relieve menstrual cramps.

Debate

Much debate centers around which menstrual products to use. The main debate can be summarized as one between the convenience, availability, and general knowledge of disposables versus the environmental, monetary, and potential health benefits of reuseables. A secondary aspect of this is commercial responsibility. Disposable menstrual products compose a large and powerful industry in the West, with a near monopoly on advertising, supermarket shelves, and menstrual education, leading many people to believe that these corporate products are their only options. Many people object to the negative portrayal of menstruation in advertising as shameful, unnatural, stinking, and hindering. In contrast, the reuseable menstrual products industry is composed mostly of small, independent, and woman-owned, woman-positive businesses. Finally, some believe that the disposable menstrual products industry is imperialist, forcing or coercing women of other cultures to leave their resueable, inexpensive or free menstrual products to become consumers of disposables. A summary of the main issues of debate: ; Environmental waste : Tampons, pads, disposable cups and their packaging generate tons of bulky waste per year, much of which is not biodegradable. ; Cost : Many disposables have a cheaper upfront cost than reuseables, but over time (a period of a few months), this cost is recouped many times over from savings on reuseables. Many reuseables can also be made for free from old clothes or scraps of cloth. ; Health concerns : 1. Bleaching - Many women object to the chlorine bleaching of disposable menstrual products, which leaves trace amounts of dioxin, a carcinogen, in them. 2. Scents and deodorizers - Chemical scents and deodorizers can cause rashes, irritation, and allergic reactions. They can upset the pH balance of the vagina and cause yeast infections. ; Health concerns specific to tampons : Toxic Shock Syndrome is caused by Staphylococcus aureus, which can thrive the environment found in tampon fibers. It is important to remember that TSS is very rare, with only approx. 40 cases per year in the UK. Tampon-associated TSS is not a staph infection. It is caused when the bacteria release a protein called toxic shock syndrome toxin (TSST). TSST is absorbed into the body where it acts as a toxin. Toxic Shock Syndrome can, and does, cause death. TSS can be avoided by using the least absorbent tampon possible for one's flow, and changing tampons at least every 8 hours, or by avoiding tampons altogether. This may apply to sea sponges also, though no cases of TSS with sea sponge use have been reported.

Culture and menstruation

Mysticism

Mystics have sometimes elaborated "equivalencies", analogising the waxing and waning of the moon with influences on human menstruation. In this spiritual, moon goddess, or astrological context some women call menstruation their "moontime". Some ancient views also regarded menstruation as a cleansing of the body: compare bloodletting as a major medical treatment of pre-modern times.

Religion

Some religions consider women "unclean" during menstruation.

Islam on menstruation

The Islamic world considers a woman "not in a state to have intercourse" during menstruation. A verse from the Qur'an (with parenthesised interpolations by Dr. Muhammed Muhsin Khan) affirms this:

"They ask you concerning menstruation. Say: that is an Adha (a harmful thing for a husband to have sexual intercourse with his wife while she is having her menses), therefore keep away from women during menses and go not unto them till they have purified (from menses and have taken a bath). And when they have purified themselves, then go in unto them as Allâh has ordained for you. Truly, Allâh loves those who turn unto Him in repentance and loves those who purify themselves (by taking a bath and cleaning and washing thoroughly their private parts, bodies, for their prayers, etc.)." (Al-Baqarah 2:222)

See [http://63.175.194.25/index.php?ln=eng&ds=qa&lv=browse&QR=43028&dgn=4 an Islamic review] on the subject.

Judaism on menstruation

A ritual exclusion applies to a woman while menstruating and for about a week thereafter, until she immerses herself in a mikvah (ritual bath).

Menstruation in other mammals

A regular menstrual cycle as described here only occurs in the great apes. Menstrual cycles vary in length from an average of 29 days in orangutans to an average of 37 days in chimpanzees. Females of other mammalian species go through certain episodes called "estrus" or "heat" in each breeding season. During these times, ovulation occurs and females become receptive to mating, a fact advertised to males in some way. If no fertilisation takes place, the uterus reabsorbs the endometrium: no menstrual bleeding occurs. Significant differences exist between the estrus and the menstrual cycle. Some animals, such as domestic cats and dogs do produce a very short and mild menstural flow, however due to its small amount (and personal cleanliness in cats) it passes pet owners largely unnoticed.

References

- K. Stern and M. K. McClintock: "[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=9515961 Regulation of ovulation by human pheromones.]" Nature, 392 (1998), pages 177 – 179.
- Gangestad et al.: "[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15016293 Women's preferences for male behavioral displays change across the menstrual cycle.]" Psychological Science, March 2004, vol. 15, no. 3, pages 203 - 207
-

Notes

# "[http://www.4woman.gov/faq/menstru.htm#6 At what age does a girl get her first period?]," from Menstruation and the Menstrual Cycle, National Women's Health Information Center (accessed June 11, 2005). # Ibid., "[http://www.4woman.gov/faq/menstru.htm#4 What is a typical menstrual period like?]" (accessed June 11, 2005). # "Lower olfactory threshold during the ovulatory phase of the menstrual cycle" by E. Navarrete-Palacios, R. Hudson, G. Reyes-Guerrero and R. Guevara-Guzman in Biol Psychol. (2003) volume 63 page 269-279 . # M. Ball, "A prospective field trial of the Ovulation Method", European Journal of Obstetrical and Gynaecological Reproductive Biology, 6/2, 63-6, 1976. (Summarized at [http://www.woomb.org/bom/trials/index.html Trials of the Billings Ovulation Method] accessed November 3, 2005) # "Medical Microbiology" 4th ed. [http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Search&db=books&doptcmdl=GenBookHL&term=toxic+shock+syndrome+AND+mmed%5Bbook%5D+AND+147524%5Buid%5D&rid=mmed.section.769#775 Online textbook] Samule Baron, editor. (1996) Published by University of Texas Medical Branch; Galveston (TX)

External links

- Harry Finley: Online museum of menstruation and women's health, http://mum.org/
- [http://www.powerhousemuseum.com/rags/ The rags: paraphernalia of menstruation]
- Menstral - track your periods and fertility on your cell phone: http://procod.com/menstral/
- [http://www.bloodays.com/ Bloodays - Software for tracking ovulation, natural conception and contraceptions]
- [http://www.ovusoft.com/ Ovusoft - Software for tracking ovulation and other cycle-related events, community message boards]
- Track your likely ovulatory date with this free [http://www.ovulation-calendar.net/ Ovulation Calendar]
- [http://www.perimon.com/ Free Software to watch the menstrual cycle etc.]
- Mencal - calendar software for UNIX-style operating systems with the ability to highlight repeating cycles: http://kyberdigi.cz/projects/mencal/english.html
- Leslie Botha-Williams, Women's Health Educator: A Woman's Guide to Understanding Her Hormone Cycle, http://www.holyhormones.com
- [http://63.175.194.25/index.php?ln=eng&ds=qa&lv=browse&QR=43028&dgn=4 An Islamic answer for the ruling of women menstruating]
- Menstrual Suppression With Birth Control Pills http://www.noperiod.com
- [http://www.livejournal.com/users/incendiaryfs/204904.html Love Your Blood: An info-zine on menstrual products and their alternatives]
- [http://www.seac.org/tampons/ Tampaction] and [http://bloodsisters.org/bloodsisters/ The Bloodsisters Project]- Menstrual activism against chlorine bleaching, excessive packaging, and negative attitudes toward menstruation in the West
- [http://www.scarleteen.com/body/ontherag.html On The Rag: Everything you need to know about your fertility cycles and menstruation...period] - Article on the menstrual cycle by notable sex activist and educator Heather Corinna
- [http://www.scarleteen.com/pink/washable.html Eight Myths About Washable Menstrual Pads Dispelled] Category:Reproductive system Category:Gynecology ja:月経

PCOS

Polycystic ovary syndrome (PCOS, also known clinically as Stein-Leventhal syndrome), is an endocrine disorder that affects 5–10% of women. It occurs amongst all races and nationalities, is the most common hormonal disorder among women of reproductive age, and is a leading cause of infertility. The symptoms and severity of the syndrome vary greatly between women. While the causes are unknown, insulin resistance (often secondary to obesity) is heavily correlated with PCOS.

Nomenclature

Other names for this disorder include:
- Polycystic ovary disease (although this is not correct, as PCOS is characterised as a syndrome rather than a disease)
- Functional ovarian hyperandrogenism
- Hyperandrogenic chronic anovulation
- Ovarian dysmetabolic syndrome
- Ovarian androgen excess

Definition

There are two definitions that are commonly used: #In 1990 a consensus workshop sponsored by the NIH/NICHD suggested that a patient has PCOS if she has (1) signs of androgen excess (clinical or biochemical), (2) oligoovulation, and (3) other entities are excluded that would cause polycystic ovaries. #In 2003 a consensus workshop sponsored by ESHRE/ASRM in Rotterdam indicated PCOS to be present if 2 out of 3 criteria are met: (1) oligoovulation and/or anovulation, (2) excess androgen activity, (3) polycystic ovaries (by gynecologic ultrasonography), and other causes of PCOS are excluded. The Rotterdam definition is wider, including many more patients, notably patients without androgen excess, while in the NIH/NICHD definiton androgen excess is a prerequisite. Critics maintain that findings obtained from the study of patients with androgen excess cannot be necessarily extrapolated to patients without androgen excess.

Signs and symptoms

Common symptoms of PCOS include:
- Oligomenorrhea, amenorrhea - irregular/few, or absent, menstrual periods; cycles that do occur may comprise heavy bleeding (check with a gynaecologist, since heavy bleeding is also an early warning sign of endometrial cancer, for which women with PCOS are at higher risk)
- Infertility, generally resulting from chronic anovulation (lack of ovulation)
- Elevated serum (blood) levels of androgens (male hormones), specifically testosterone, androstenedione, and dehydroepiandrosterone sulfate (DHEAS), causing hirsutism and occasionally masculinization
- Central obesity - "apple-shaped" obesity centered around the lower half of the torso
- Androgenic alopecia (male-pattern baldness)
- Acne / oily skin / seborrhea
- Acanthosis nigricans (dark patches of skin, tan to dark brown/black)
- Acrochordons (skin tags) - tiny flaps of skin
- Prolonged periods of PMS-like symptoms (bloating, mood swings, pelvic pain, backaches)
- Sleep apnea Signs are:
- Multiple cysts on the ovaries. Sonographycally they may present as a "string of pearls".
- Enlarged ovaries, generally 1.5 to 3 times larger than normal, resulting from multiple cysts
- Thickened, smooth, pearl-white outer surface of ovary
- Chronic pelvic pain, possibly due to pelvic crowding from enlarged ovaries; however, the actual cause is not yet known
- The ratio of LH (Luteinizing hormone) to FSH (Follicle stimulating hormone) is 2:1 or more, particularly in the early phase of the menstrual cycle.
- Increased levels of testosterone.
- Decreased levels of sex hormone binding globulin.
- Hyperinsulinemia.

Risks

Women with PCOS are at risk for the following:
- Endometrial hyperplasia and endometrial cancer (cancer of the uterine lining) are possible, due to overaccumulation of uterine lining, and also lack of progesterone resulting in prolonged stimulation of uterine cells by estrogen
- Insulin resistance/Type II diabetes, generally thought to be caused by hyperinsulinaemia
- High blood pressure
- Dyslipidaemia (disorders of lipid metabolism - cholesterol and triglycerides)
- Cardiovascular disease Some data suggest that women with PCOS have an increased risk of miscarriages. As well, many women with PCOS have a difficult time conceiving, due to the irregular cycles and lack of ovulation. However, it is possible for these women to have normal pregnancies with the aid of medication and diet.

Diagnosis

It is vital to note that not all women with PCOS have polycystic ovaries, nor do all women with ovarian cysts have PCOS; although a pelvic ultrasound is a major diagnostic tool, it is not the only one. Diagnosis can be difficult, particularly because of the wide range of symptoms, and the variability of how they present themselves in individuals (which is why this disorder is characterized as a syndrome rather than a disease). There is a lot of controversy about the appropriate testing:
- gynecologic ultrasonography
- testosterone: free more sensitive than total
- Fasting biochemical screen and lipid profile
- 2-hour oral glucose tolerance test (GTT) in patients with risk factors (obesity, family history, history of gestational diabetes)and may indicate impaired glucose tolerance in 15-30% of obese women with PCOS. Frank diabetes can be seen in 6-8% of women with this condition.
- For exclusion purpose:
- Prolactin
- TSH
- 17-hydroxyprogesterone The role of other tests is more controversial, including:
- fasting insulin level or GTT with insulin levels (also called IGTT). Elevated insulin levels have been helpful to predict response to medication and may indicate women who will require either higher doses of metformin or the use of a second medication to significantly lower insulin levels. Elevated blood sugar and insulin values do not predict who responds to an insulin lowering medicaiton, low glycemic diet and exercise. Many women with normal levels may benefit from combination therapy. A hypoglycemic response where the two hour insulin level is higher and the blood sugar lower than fasting, is consistent with insulin resistance.
- LH:FSH ratio
- DHEAS
- SHBG
- Androstenedione

Differential diagnosis

As well, other causes of irregular/absent menstruation and hirsutism such as congenital adrenal hyperplasia, Cushing's syndrome, hyperprolactinemia and other pituitary and/or adrenal disorders, should be investigated.

Pathogenesis

PCOS develops when the ovaries are stimulated to produce excessive amounts of male hormones (androgens), particularly testosterone - either through the release of excessive luteinizing hormone (LH) by the pituitary gland, or due to high levels of insulin in the blood (hyperinsulinaemia) in women whose ovaries are sensitive to this stimulus. This syndrome acquired its most widely-used name because a common symptom is multiple (poly) ovarian cysts. These form where egg follicles matured, but were never released from the ovary due to abnormal hormone levels. These generally take on a 'string of pearls' appearance. The condition was first described in 1935 by Dr. Stein and Dr. Leventhal, hence its original name of Stein-Leventhal syndrome. Although the cause of PCOS is not known, research to date suggests that obesity is a prime indicator. It may have a genetic predisposition and further research into this possibility is currently taking place. No specific gene has been identified, and it is thought that there are many genes that could contribute to the development of PCOS. A majority of patients with PCOS -some investigators may say all - have insulin resistance. Their increased insulin levels contribute to or cause the abnormalities seen in the hypothalamic-pituitary-ovarian axis that lead to PCOS. Specifically hyperinsulinemia increases GnRH pulse frequency, LH over FSH dominance, increased ovarian androgen production, decreased follicular maturation, and decreased SHBG binding: all these steps leading to the development of PCOS. Insulin resistance is a common finding in obese people.

Treatment

Medical treatment of PCOS used to be directed mainly at the symptoms (ovarian and adrenal suppression, and anti-androgen therapy) and restoring ovulation. Some medications used for these purposes are:
- Oral contraceptives (ovarian suppression) - since these cause regular menstruation, they reduce the risk of endometrial carcinoma
- Spironolactone or finasteride (anti-androgen therapy) - reduce the excessive hair growth by blocking the effects of male hormones
- Clomiphene citrate and/or human chorionic gonadotropin or dexamethasone (inducing ovulation) Recent research suggests that the insulin resistance and over-release of insulin may be at the root of PCOS. Many women find [http://www.ivf.com/pcostreat.html insulin-lowering medications] such as metformin hydrochloride (Glucophage®), pioglitazone hydrochloride (Actos®), and rosiglitazone maleate (Avandia®) helpful to them, and indeed ovulation may resume when using these agents. Many women report that metformin use is associated with upset stomach , diarrhea and weight-loss. Both symptoms and weight-loss appear to be less with the extended release versions. Most published studies use either generic metformin or the regular, non- extended release version. Starting with a lower dose and gradually increasing the dosage over 2-3 weeks and taking the medication towards the end of a meal may reduce side effects. The use of basal body temperature charts or BBT charts is an effective way to follow progress. It may take up to six months to see results, but when combined with exercise and a low-glycemic diet up to 85% will improve menstrual cycle regularity and ovulation. Low-carbohydrate diets and sustained regular exercise are also beneficial. As well, initial research suggests that the risk of miscarriage is significantly reduced when Metformin is taken throughout pregnancy (9% as opposed to as much as 45%); however, further research needs to be done in this area. For patients who do not respond to these and related medications/procedures, the polycystic ovaries can be treated with surgical procedures such as:
- laparoscopy electrocauterization or laser cauterization
- ovarian wedge resection (rarely done now, because it is more invasive and has a 30% risk of adhesions, sometimes very severe, which can obstruct fertility)
- ovarian drilling

Reference

- Ehrmann DA. Polycystic ovary syndrome. N Engl J Med 2005;352:1223-36. PMID 15788499.

External links

-
- [http://www.ivf.com/pcostreat.html PCOS Treatment Overview from IVF.com]
- [http://centerforpcos.bsd.uchicago.edu/default.html The University of Chicago Center for Polycystic Ovary Syndrome]
- [http://www.pcosupport.org/ The Polycystic Ovarian Syndrome Association (PCOSA)]
- [http://www.soulcysters.com/ Soulcysters.com (support site for women with PCOS)]
- [http://www.posaa.asn.au/ Polycystic Ovarian Syndrome Association of Australia]
- [http://www.inciid.org/faq/pcos.html International Council on Infertility Information Dissemination - PCOS Frequenty Asked Questions]
- [http://www.infertilityblues.com InfertilityBlues.com - Mind Body Resources to Support Coping with PCOS]
- [http://www.ovarian-cysts-pcos.com Ovarian-cysts-pcos.com: Natural therapies and self-help strategies for PCOS]
- [http://www.pcoscoach.com PCOS Coach] Category:Gynecology Category:Endocrinology Category:Medical_conditions_related_to_obesity

Dilation and evacuation

Dilation and evacuation is the most common form of second trimester abortion. It is commonly referred to as a D&E. =Description= Approximately 11% of abortions are performed in the second trimester. In 2002, there were an estimated 142,000 second-trimester abortions¹. The first step in a D&E is to dilate the cervix. This is often begun about a day before the surgical procedure. Enlarging the opening of the cervix enables surgical instruments such as a currette or forceps to be inserted into the uterus. The second step is to remove the fetus. Either a local anesthetic or general aneasthesia is given to the woman. If the pregnancy is less than 16 weeks, the fetus may be removed with a currette (a scraping instrument). Later-term pregnancies generally require that forceps be used to separate the fetus into components, which are removed one at a time. The head of the fetus might need to be crushed in order to fit through the cervix. Lastly, vacuum aspiration is used to ensure no fetal tissue remains in the uterus (such tissue can cause serious infections in the woman). The components are also examined to check that the entire fetus was removed. If the fetus is removed intact, the procedure is referred to as intact dilation and extraction or partial-birth abortion. =References=
- [http://www.agi-usa.org/pubs/fb_induced_abortion.html Alan Guttmacher Institute: "Induced Aborti

Dilatation and curettage

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PCOS

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