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What Is Reproductive Therapy

Center head : Good evening all, myself Center head. And I would like to welcome Dr. Garima Sharma. We are having, rather we are facing so many misconceptions and myths regarding the assisted reproductive therapy or the treatment, and for the same thing like clearing all our doubts about it, Dr. Garima is here. So, I again welcome Dr. Garima Sharma.

Dr. Garima: Thank you Center head. So, welcome all of you back. I am Dr. Garima Sharma, Consultant Reproductive Medicine & Fertility Specialist, attached to Currae Hospital. So, as very rightly said by Center head, there are a few general queries, myths, which are related to day to day procedures of ART, specifically IUI. So, we decided to let’s try to do justice in clearing all the doubts and myths and also bring about the various facts that are related to a very simplified treatment, which is called us intrauterine insemination. Thank you once again, Center head, for inviting me for this.

Center head: Thank you, Garima. Basically, we hear the word IUI, it is a very common word nowadays, so I would like to know like what exactly IUI means and who needs IUI.

Dr. Garima: Okay, so IUI basically stands for intrauterine insemination. So, as the very name suggests, the meaning is there in its name; intra meaning your inside, uterine is the uterine cavity, and insemination is installation. This is the procedure whereby the semen sample is prepared and this prepared sample is instilled into the uterine cavity of the female partner, using a very fine catheter. And this is done usually around the time of ovulation of the female and this is a day care procedure, which does not require any anaesthesia.

Center head: That’s so nice, but then how does it work, I mean how does IUI increase the chances of pregnancy?

Dr. Garima: Yeah, so before coming onto that question, it is imperative for us to understand who actually are the candidates or who are the couples who would require this kind of a modality.

Center head: Right.

Dr. Garima: So to list a few ones would be a couple where there is a mild male factor in terms of mild derangement in the semen parameters, whereby the count is affected or the motility or the morphology or a combination of them. Another couple who would benefit from IUI would be those who have unexplained infertility. So, when I use this word, ‘unexplained infertility’, these are the couples who basically have everything normal. When you investigate them in terms of biochemical profile, the ultrasound assessment, the semen parameters, the tubal patency has been ensured, but despite taking certain normal or the basic fertility treatments, they have not been able to achieve pregnancy, so this subset would definitely benefit from IUI. There are other couples: in few cases like females with minimal-to-mild endometriosis; couples facing issues with coital problem, this is something which we are seeing day-to-day, particularly with the working class whereby the couples have a travelling job, the couples don’t get time to meet during the ovulatory phase or because of the stress-related issues, there are certain erectile issues which these couples face. Another subset would be typically PCOS females who have undergone you know those basic fertility, ovulation induction treatments and still they have not been able to achieve pregnancy. So, these would be a few indications where I would recommend IUI as a treatment option for fertility management. So now, addressing to your next question, how does IUI… so I would not say how does IUI bring about success, I would say how does IUI optimize your pregnancy rate over and above the natural conception or the basic fertility management.

Center head: Right, right.

Dr. Garima: The idea is you are using a prepared sample and why do you need to prepare that, you tend to increase the intensity or the density of the motile sperm count and also you want to remove the seminal plasma which basically contains certain antigens that are detrimental to the success of the fertility treatment. Secondly, when I do an IUI, I said that the sample is instilled directly into the uterine cavity, so the idea is you want to bypass all those negative barriers which these sperms face at the level of the cervix.

Center head: Right.

Dr. Garima: Also, by this procedure, you are actually reducing the distance that now the sperm has to go and meet the egg in order to achieve the pregnancy. And last of all, because the timing is around the ovulation, so you are increasing the chance that the sperm meets the egg at the right time and that’s how all these four mechanisms will optimize your pregnancy chances.

Center head: So, it’s like assisting the sperms to just go…

Dr. Garima: Exactly, you are… it’s a…

Center head: Yeah, right.

Dr. Garima: It’s a kind of a supernatural you know intercourse, whereby we are pushing this sperm to reach its destination.

Center head: That’s very nice. Are there any conditions where IUI cannot be done or it is contraindicated and all that?

Dr. Garima: Again, this is a very gray area, but there would be two conditions where I would say straight no to an IUI: one where the female has you know blocked fallopian tubes, both of them are affected, and secondly with the severe male factor that is severe reduction in the sperm count, motility and the morphology. Other parameters like severe endometriosis, prolonged duration of marriage, IUIs can be attempted but with little less success rates.

Center head: Okay. So, it seems it’s like very useful procedure, but then like, does the female patient, like she has to undergo various investigations before IUI or the male partner has to… like what are the investigations?

Dr. Garima: So per se, for the procedure of IUI, you don’t need any specific investigations because most of these couples are already investigated for the same. So, we clinicians have a checklist whereby we ascertain that your ovarian function, the endometrial thickness on an ultrasound, tubal patency, and the semen parameters have been ascertained and then we go about the IUI.

Center head: Okay. Can be like just enlist few factors which might increase the success rate of IUI?

Dr. Garima: Okay, so there are huge… there are a couple of factors which determine your success rate, so I would broadly classify them into two categories. There would be factors which are static that is they are just there and you cannot do anything about them, so to enlist them would be age, like age of the female more than 35, a prolonged duration of infertility which is counted as more than 5 years of infertility, severe endometriosis or severe male factor as the cause of infertility, and higher BMI generally considered as greater than 30 kg/ meter square for the Indian population. Now, these are static factors whereby you cannot make much changes except for yes, of course, for BMI, you can still ensure weight loss regimes. But for the other factors, the IUI success rates are little lower. Now, coming on to the dynamic factors which we clinicians can do, so as to improve our success over in terms of pregnancy rates, would be what kind of a cycle do you want to do, you want to stimulate the ovaries or you want to take it a natural cycle. If you are stimulating the ovaries, how many follicles do you actually target during your stimulation, the semen parameters, the way of preparing the semen sample, the timing of the IUI, number of IUI attempts that you would advocate or advice to the couple before resorting on to the further advanced technologies, the luteal phase support, whether to consider a single IUI or double IUI, so these factors generally in the hands of a clinician can improve your IUI success rates when done properly.

Center head: All right. So as you said, like the ovulatory what we say like stimulation, is it like mandatory?

Dr. Garima: So, I would not say ovulation induction is mandatory, you can attempt a natural cycle IUI but this is of benefit to those females where the issue is with the male partner and all the investigations or all the tests for the females are okay. In other subset, we prefer doing minimal ovarian stimulation and this rationally attached to it. So the idea is that you want to have one or two follicles so as to improve your pregnancy chances and also this minimal stimulation will take care of your subtle periovulatory defects, which are not predictable on the routine investigations. So by these two techniques, the minimal stimulation improves your chances a little better compared to doing a natural cycle IUI.

Center head: Okay, but this ovary stimulation must be requiring some drugs, some medications?

Dr. Garima: Of course, yes.

Center head: So, like do those medications have side effects?

Dr. Garima: So, when we talk about the medications that we use to stimulate the ovaries, the idea is it’s very minimal stimulation that is to be considered in cases of IUI, because you want to form maximum of two follicles, thereby maximizing your pregnancy chances and simultaneously you want to prevent the multiple pregnancies. So, the drugs can be either oral or injectables. The short-term side effects are seen when it’s an unsupervised stimulated cycle, so you can have side effects like multiple pregnancy or hyperstimulated ovaries. So, a proper care and supervision during the procedure of stimulation is mandatory. Otherwise, there are not many significant long-term side effects attached to these medications.

Center head: That’s great. During IUI, we just covered the ovary part. Coming towards semen part, so what are the factors that will influence on the IUI procedure, like the semen factors?

Dr. Garima: Okay, so that’s one, the cornerstone, which determines your success rate. They are not defined cut-off points, which I would say that you know, beyond this, you will have a success rate, and below this, IUI will not work. However, through various scientific evidences that we have, we have certain threshold limits whereby we say, “Okay, if the values are above these threshold limits, you definitely benefit with your IOI and if the values are little lower compared to, in comparison to these threshold limits, the success rate diminishes.” So, basically talking about these factors, we take into regard four factors, the first one is you want to check the total sperm count in the native sample that the husband or the male partner gives, and the cut-off we take is 10 million per ml. The next one you want to assess is the total motility in that native sample and the motility threshold is greater than equal to (=>) 30%. Another important factor is the inseminating motile count, that is having prepared your semen sample, how much fraction of the motile count do you get, and generally, it is regarded that greater than equal to ( =>) 1 million is the count which is required for an IUI to be successful. And last of all, we don’t have to forget about the morphology that is the make of these sperms, so that has to be more than equal to 4% when ascertained by the strict criteria, this is basically the international WHO Guidelines, which have laid down certain paranorms to see the sperm morphology. Over here, I want to emphasize on the role of an andrologist, what we forget about is how important andrologist is, who gives us the semen sample which is going to determine your IUI success rates. Only those andrologists who have been trained and certified to assess the semen sample as per the WHO criteria are the ones which should be working in the Certified Fertility Centers.

Center head: That’s really a difficult job, I guess. You just mentioned in earlier, your lines, that the semen sample which you will be collecting, I mean it needs a wash.

Dr. Garima: Yeah.

Center head: So, why that wash is needed?

Dr. Garima: See, when you are using a native sample, okay, the problem with the native sample is: one, it can sometimes induce pelvic infection when instilled directly into the uterine cavity, and secondly, because the seminal plasma is still there, this seminal plasma has certain substances like prostaglandins, which are going to irritate the uterus resulting into uterine contractions and therefore reduced success rates. So it’s always imperative that you have to use a washed, prepared semen sample for the process of intrauterine insemination.

Center head: And what is the time, best time rather, to go for IUI post hCG injections?

Dr. Garima: Generally speaking, 36 to 42 hours after your trigger injection is widely acceptable norm, and there is no specific time limit that you have to do it at this particular hour, so 36 to 42 hours window is acceptable.

Center head: And once the sample is collected, like how long one can wait?

Dr. Garima: It’s better that you inseminate it as soon as the sample is ready, but then we say that for any XYZ reasons, if there is some delay, the delay should not be more than 2 hours, and during this particular period, the ambient environment which is required for the semen sample, that is in terms of your temperature, CO2 and pH, everything should be maintained.

Center head: You mentioned about single IUI and double IUI, so what is it and whether like double IUI is more beneficial for the treatment?

Dr. Garima: Yeah, I purposefully brought this question over here because there is a notion, “yeh dil mange more,” so you know, double IUI means better but the answer to it is “No.” The role of double IUI is only and only in certain cases where there is a severe male factor and the couple is not ready to go ahead with the advanced ART Technologies. In this condition, the second sample is taken immediately like within first 1 to 3 hours after collecting the first sample, and the idea is you just want to pool the sample so that you can have the maximum yield of the motile sperms and also it has been seen in these men, the second sample gives you little bit of motile sperm count. However, for any other condition, it’s the single IUI which gives you the success rate as good as the double IUI. The double IUI would only add the cost without giving anything much to it.

Center head: So, I think you have more transparent doctor, as the treatment part is… that’s really great.

Dr. Garima: No, it is, I think that’s important.

Center head: Yeah, that is very important. Another question that comes into my mind like, how many times one should go for these IUI cycles and/or then then when can move towards further treatment part?

Dr. Garima: Yeah, so again very important and a very practical question that has been brought into the picture is usually we recommend good 3 to 4 consecutive, stimulated IUI cycles before recommending any other advanced fertility management for these couples.

Center head: Okay. Another very common question which comes to the females mind is like if I am working then how much time should I take leave, how much bed rest is required, and all those things.

Dr. Garima: So bed rest, again big “No.”

Center head: Oh!

Dr. Garima: So, any prolonged immobilization or bed rest is not advisable. You have to remember, uterine cavity is a potential space, it’s a closed cavity, once we have inseminated the sample, you jump, you walk, the sample is not going to come out; so you are very well fit to go back to your work and resume your activities. Yes, of course, we do tell the female, not to go ahead with the weight-bearing exercises but her life continues the way it was before coming on to the IUI table.

Center head: That is really awesome, I mean really great tool. You said multiple pregnancy…

Dr. Garima: Yeah.

Center head: So, how much is the risk of multiple pregnancy?

Dr. Garima: So, if I am doing a natural cycle IUI, the risk is negligible. The risk averages between 5-15% depending on what drugs are you using to stimulate the ovaries. So as I said earlier also, any stimulated cycle has to be very well supervised because you want to avoid multiple pregnancy rates and simultaneously you don’t want to compromise on your pregnancy success rates.

Center head: Okay. So, as we said, like there are chances of multiple pregnancy or whatever, the babies who are born after IUI, so do we expect any abnormalities or anything like that?

Dr. Garima: Right… yeah, so that’s a question which worries any couple…

Center head: Yes.

Dr. Garima: …because at the end of the day, you want to take the healthy baby back home. So fortunately, all the scientific evidences that have been done so far, have said that IUI per se as a procedure does not cause any kind of birth defect or developmental delays in the baby. However, whatever pregnancy complications we see are mainly because of the multiple pregnancies rather than because of procedure per se, so you monitor the cycle well and avoid multiple pregnancies.

Center head: Right. So, like after hearing all these things, can we say that IUI is 100% successful?

Dr. Garima: There is no 0 and there is no 100% when we talk about any fertility treatments, starting from the basic fertility treatments to as high as IVF policies. When I talk about the success rates per cycle in an IUI treatment, the success rate averages between 15-25% based on all the parameters that I have discussed. So on an average when I say that good 3 to 4 consecutive cycles are advisable, roughly by the end of the 4th cycle, we expect 55-60% of the females getting pregnant, it can be the 1st cycle, 2nd, 3rd, or the 4th, which I cannot predict. But by the 4th cycle, if the female does not get pregnant, it is high time to move to the next line of management or to look out for other roadblocks for your fertility success.

Center head: Okay. So, I think we broadly heard about IUI and we learned so many things. So, what is the take-home message?

Dr. Garima: So, IUI is a very simple technique.

Center head: Yeah.

Dr. Garima: It’s non-invasive, quite cost effective, very minimal stimulation is required and therefore minimal monitoring is required. And side effects related to ovarian hyperstimulation and multiple pregnancy are also low So as a result of all these modalities, it’s quite a couple of friendly and quite a couple compliant modality of infertility regimes that we have to date. So IUI when done properly does bring us good success rates.

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Common Abdominal Problems In Day-To-Day Life

Today we will talk about common abdominal problems which you face in day-to-day life, like gall stones, acidity, reflux, gerd problems – constipation, diarrhoea, which need to be taken care of, especially this rainy season, hence you have to be careful about what you are eating and what you are drinking.

So, commonly asked questions are like, “I was diagnosed with gall stones a few days back. Should I do it, should I wait, should I go in for gallbladder surgery or can the gallstones go on its own?” The simple answer to this question is that gallbladder is at fault and not the gall stones, it’s the gallbladder lining which has got broken up and therefore it is causing gall stones, so treatment is of not gall stones but treatment is of gallbladder. So, it’s no point removing the gall stone, gall stones cannot be removed like that, like a kidney stone. We have to remove the kidney stone, we cannot remove the kidney, it’s a vital organ, but the gallbladder is not functional in your body and therefore it is forming stones and therefore we need to remove the gallbladder. It’s a laparoscopic key-hole surgery, one-day stay, you get admitted, you get the operation done on the same day and go home the next day. So, it gives you relief from the constant pain/ache or like acidity, reflux associated to gallstones. And within a day’s time, you can go back, switch to your work in 7 to 8 days’ time. So, it’s a small surgery, and therefore, there is nothing to get worried about it because that will solve the problem once and for all.

Other things which are asked is how can I wait. The answer is you can wait till you start getting recurrent pain and you start landing up in the hospital with all these problems, so it’s not right to postpone things to the point that it becomes very serious. It is a small surgery, it has to be done quickly and/or you can get rid of the things as soon as possible. There is no medicine which can dissolve the gallstones life long, you have to take the medicines lifelong, otherwise, so instead of taking so many medicines lifelong, it is better that you get the surgery done and get rid of the gallbladder problem.

People ask how to keep a healthy, disease-free stomach. I want to say, if you eat properly, if you have a good balanced diet, if you don’t eat anything which is non-hygienic, if you keep less spice and oil in your diet, if you don’t keep your tummy fasting for long time, your stomach will automatically be healthy and disease-free; otherwise, you will start getting recurrent acidity, reflux symptoms, constipation, diarrhoea. So, the best thing is to have a good, healthy, balanced fat-free diet, otherwise, all the problems start popping up. Drink as less possible as milk, and don’t take besan or channa dal or what you call like vada pav, bhajia, deep fried stuff because that will create lot of acidity and that will grow as lot of reflux problems. So having a healthy, disease-free stomach means you are having good habits and drinking lot of water.

Benefits of Laparoscopic surgery: People ask me, what are the benefits of doing laparoscopic surgery over open surgery? See, open surgery was done with a big cut on the abdomen and you would have a big scar. So would healing and all, everything was a big issue, so we are having key-hole surgery, wherein you don’t put your hand into the stomach, but you make small holes, take small instruments, put in the abdomen, dissect the tissue with that instruments, see it on a video camera on a TV Monitor, and you had to remove the organs or do the surgery to be done laparoscopically. Open surgery requires bed rest for month’s time and that would be disaster for, if you are a young person, working person, you lose one month of you time.

Laparoscopic surgery, you can go for work in 4-5 days’ time, when your inner wounds heal. Therefore, there are lot of benefits, there are also cosmetic benefits of a laparoscopic surgery. There are also the hernia which happens after open surgeries that is not in case of laparoscopic surgeries.

People ask me, “Can we keep upwas? Is it harmful for us or is it helpful for us?” I say, “Don’t keep your stomach empty for 4 to 5 hours, more than 4 to 5 hours because by doing that, you are keeping acid under control and reflux under control. So, doing upwas or fasting is not a great idea, it will lead to more acidity, more gallstones because the gallbladder is getting distended while you are not using that by keeping fast, and therefore, you will start forming gallstones, so it’s a common problem. Gallstone is a common problem in fasting stage.

Alcohol, whether it should be taken or not taken, is it good for health, not good for health. Alcohol, if you are taking beer, once in a while is okay. But if you are taking heavy drinks, whiskey and all that, they contain 43-44% alcohol, as compared to beer which contains only 17% of alcohol, so taking heavy drinks regularly will put you into liver damage and liver cirrhosis and that can damage your liver over a long time. So anything in moderate or anything in less quantity is okay, especially beer is okay but heavy drinks every day will put your liver at risk.

The next question commonly asked is, “I have appendicitis, I am suffering from that. Doctors told me the pain subsides, I become better. Should we operate or should we not operate?” I tell them, “If the appendicitis worsens, it can lead to perforations in appendix and all the stool contents will come in the tummy and you can have serious health issues.  And you better go and remove the appendix, do an appendectomy by laparoscopic way because that will help you avoid complications. Appendix is a vestigial organ, you don’t have any need of appendix; at the same time, it will start creating trouble to you, it should be removed by laparoscopy.

“Does excessive tea and coffee intake effect the digestion,” people ask me, tea and coffee contains milk, so drinking milk for, I mean to say, if you consume lot of milk, it will cause acidity, constipation. So, tea and coffee moderation is okay, it boosts you, especially coffee, but anything in excess is not recommended.

So, even cancers, people ask me are cancers dangerous? Definitely, cancers are dangerous but if you treat them properly with good surgery and chemotherapy if required, all the things can be taken care of. Ones which are bad are pancreatic cancers, gallbladder cancers, sometimes liver cancers, they are bad cancers and those cancers should be diagnosed early, treated early, every cancer can be cured. It depends on the stage what you are approaching your doctor for cancer treatment. If it is advanced stage, no cancer can be cured, but if you diagnose any cancer at the early stage, all the cancers can be taken care of because of control of the cancer rather than cure. It is said that if you survive in the cancer with treatment for 5 years, you will survive lifelong, so 5 years survival will depend on what stage of cancer you are approaching the doctor. Therefore, you should have early diagnosis of anything. Therefore, you should not linger with the problem for long time because lingering with the problem will lead to problems, you will not be able to diagnose it early, the cancer will spread everywhere in the body and then you will have hard time fighting, it’s like a fire, you have to control the fire. If you control the fire, well, otherwise it will be too late, it will damage all your organs, and therefore, you should control the fire well in time. Ideally, you should not allow the fire to break, if it breaks, you have to control it early otherwise the fire will take control over you. So, any cancers in the body is like a fire, you have to be quick in accessing the problem and tackling the problem.

So how to prevent the cancer is first thing is to have good, healthy eating habits, which itself will lead to good body hygiene I am talking about. So, if you have good body hygiene, you maintain it with regular exercises, gyming, and if you eat properly every day then it automatically… cancer cells are our own cells which start growing in the rapid rate, so we have to get a hygienic diet. Also, some cancers are genetic, you have to know the family tree, who had what cancers in the family and do investigation accordingly. Especially after 40, you start doing the ultrasound of the abdomen, x-ray of the chest, routine blood test after the age of 40, so that you diagnose heart ailments as well as all the small, small problems like cancers or tuberculosis and treat them well in time. Once you treat any problem well in time, you should be fine.

Regarding the liver, I would like to discuss the topic about liver, healthy liver, lot of reports are saying that you have fatty liver or your liver functions are saying that SGPT, SGPT are high, if that is so, it means that you have fatty liver, it may damage your health, and so you should well control the fatty liver. How to control the fatty liver is simple it is, you have to have a healthy, fat-free diet, less of carbohydrates, and more of rich proteins like soya milk or egg whites, fish, which are rich in proteins so that your fat automatically gets destroyed and you will have a good, non-fatty liver. Fatty liver over a period of time can lead to lot of issues, it can lead to liver cirrhosis and if you are alcoholic on top of it, it can damage your liver more so and therefore you need to take care of the liver. So, fatty liver is a common problem which is seen nowadays on sonography, best you should have weight reduction and that will take care of your fatty liver.

Regarding balanced diet, you should have lot of fibre in your diet, which will help you in passing good amount of stools every day, fat-free diet, less of carbohydrates, more of proteins, and that’s what is called as balanced diet, where you have each component in adequate proportion. So, if you are non-vegetarian, you should have two egg whites every day and you should impinge on fried, deep fried, roasted, but more of boiled, steamed products so that you are eating healthy food and from that, and at the same time, you are getting all the micronutrients, vitamins, and everything in your body. You should always have a good routine about when to eat food, I mean you should have a good, healthy breakfast in the morning, which contains egg, soya, high proteins, and after 3-4 hours, you should have some fruit, you should have good, small lunch, and a small evening snack, and you should have your dinner which is wholesome, rich in proteins by 7 or 8 o’clock, so that you have 2 hours to move around, empty the stomach properly and then go to bed. You should not eat your dinner and go to bed immediately. So, timings as well as content of the food is very, very important. It is just that you eating food, you are having a healthy diet but you are not eating on time, also can damage your health.

Is there a relation between diet and cancer? Yes, there is a big relation between diet and cancer. If you are taking lot of deep fried, roasted, non-healthy food, all your proteins are replaced by fats and it leads to fatty liver, it can lead to blockage in your heart, at the same time, it can give rise to cancer. Cancer, there is no single reason which causes cancer. Cancer is our own cells growing at a faster pace and forming lumps or tumours in the body. So to avoid cancer, you should have a healthy, balanced diet, not eat too much rich carbohydrate or heavy fat-laden food. And also tobacco, alcohol should be not consumed. Alcohol in moderation is okay but tobacco is absolute no because it can lead to any cancer, starting from mouth to the anal canal – food pipe cancer, stomach cancer, small intestine cancer, large intestine cancer, it can lead to any cancer. So you should avoid having the tobacco product at least.

Also smoking, alcohol, and cancer, do they go hand in hand? I told that they do go hand-in-hand, so best thing is not to consume them, have a good fat-free diet and no tobacco and also alcohol, I told you, in moderation is okay. Anything in moderation is okay, anything in excess is dangerous.

Micronutrients are required, vitamins are required. If they are deficient, you need to correct them by food or by tablets if required but something which helps you in building that, that’s fine.

People ask me about weight reduction surgeries, cosmetic surgery, liposuction, bariatric surgery, obesity surgery, whatever you call that. Best is to not reach to a stage where you require surgery for obesity. I told you, you should have balanced diet at right time, get all the things which should be added in your diet. If required, consult a dietician and get a proper diet plan meant for you, because once you get obesity, it is related to many problems in the body like you may have osteoarthritis because of spine issues, you may have heart ailments where you can start having troubles, you can have joint pains, you can have fatty liver, liver cirrhosis, so fat is dangerous to your body in short.

So tummy-tuck liposuction, see removing the tummy fat or doing a tummy tuck or liposuction is okay if you are reducing weight. If you are not reducing weight and if you are just doing liposuction, you will remove the fat temporarily, again in a month’s time, all the fat will be re-deposited, all the money is wasted and goes down the drain. So normally, cosmetic surgeries like liposuction and tummy-tuck are advised only when you have done some weight reduction either by medical means or by surgical means like a bariatric or a metabolic surgery, what you call. When you cut down the size of the stomach by sleeve gastrectomy, reduce the size of the stomach and then and then only you can progress on to the further weight reduction. So tummy-tuck by itself, on itself is not a good idea, best is to reduce weight, get you BMI checked either by medical means or by surgery and then tummy-tuck or cosmetic surgeries are advisable.

This is all about gastro. All these problems surface during rainy season when you start eating outside food and when you start consuming more of fried, deep fried stuff, so best is to avoid them, have a healthy nutritious diet, lot of fibre in your diet, which can avoid constipation. And problems related to constipation like piles, fissure, hard stools, fistula, so these are all problems related to constipation. Avoid constipation and you will not have all these problems. So this is in short whole situation about the tummy problems or abdominal problems.

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Abnormal Uterine Bleeding – Currae Hospitals

Today, We are going to talk about a very common topic, for which we see the patients in the OPD, that is abnormal uterine bleeding. Now, what is abnormal uterine bleeding? Abnormal uterine bleeding is when there is an abnormality in the duration of the cycle, the menstrual cycle, amount of flow and the cycle length.

To know what is abnormal, you should know what is normal first. So, what is a normal menstrual cycle? There’s a lot of doubts in the people like, you know, when they start, what is the normal menstrual cycle has to be? A normal menstrual cycle lasts somewhere between 4 to 6 days, the cycle length that is the duration of the cycle should be between 21 days to 35 days, and the blood loss should not be more than 30 to 35 cc. Now, when it is abnormal is when the cycle length, the length of the cycle is less than 21 days or above 35 days, if the bleeding is above 80 cc, i.e. more than 80 cc of blood loss, and the duration is more than 7 days. So, this is basically what we call as an abnormal uterine bleeding.

Now, there are a few terms which you must be noticing it when you come to an OPD or when the doctors discuss your case, i.e. dysmenorrhoea. In the day-to-day life, you know, you must be listening to terms like dysmenorrhoea. What is dysmenorrhoea? Dysmenorrhoea is painful menses or painful menstrual cycle, same way, polymenorrhea is when the cycle length is short, i.e., it is you get menses in less than 3 weeks. Menorrhagia is other term which usually we hear is when the flow is more, i.e. more than 80 cc of blood loss or more than 7 days of bleeding. Amenorrhea that means there is no periods at all. And metrorrhagia, i.e. in between periods when you get bleeding, that is these are the common terms which I used.

Now, what are the causes of abnormal uterine bleeding? We always think that now, according to the age, the causes of bleeding have been divided. A young girl, i.e., she is in her puberty can come with menorrhagia. Menorrhagia means heavy flow or abnormal uterine bleeding. Puberty menorrhagia what we call as… so, these girls basically have got a history of early menarche that means they start their periods less than 10 years of age or they have got precocious puberty that is early puberty, so their management is accordingly. The second thing is when it is in the adolescence that means they get their periods at the normal age, mean when they menarche that is around 12 to 14 years of age, but they have heavy periods. Now, why, what are the causes? What we suspect is that either they are anovulatory cycles, i.e., because the hormonal axis is not yet developed, so these girls deal a lot, or the other causes are any coagulation defect. Some girls have got or some families have got genetic history of, you know, bleeding dyscrasias, so these patients have to be treated accordingly.

The other age group is again the reproductive age group. So, in reproductive age group, they can be abnormal uterine bleeding as a cause of complication of pregnancy, like either abortions or ectopic or other conditions like either fibroids or adenomyosis, polyp, and dysfunctional uterine bleeding, i.e., an abnormal hormonal cycle.

In perimenopausal age group that means around 40 to 60 years of age, again, the patient presents to us with abnormal uterine bleeding. So, in these patients, what we suspect is, first of all, a dysfunctional uterine bleeding, i.e., hormonal imbalance or endometrial hyperplasia that means the endometrium formation is more. Other conditions like either fibroid or adenomyosis, polyps, and even carcinoma to that matter.

In postmenopausal ladies, again once the menses are stopped, we are not supposed to bleed. At least when we label the patient as menopause that means 1 year there is no period and then again she starts bleeding that is a matter to be worried about. These patients have to be definitely assessed with regards to their endometrial hyperplasia, carcinoma, polyp, so and dysfunctional uterine bleeding.

And last but not the least, is iatrogenic that means some factor which is causing problem introduced by yourself. For example, if you have Copper T or an intrauterine device which can cause an abnormal uterine bleeding. For example, now the festive season is coming up, so most of the ladies come to our OPD, we want to postpone our periods, so some medicines that is oral and injectable steroids; or inbuilt medications like psychotropic drugs or patients who are already on medications, they also can present with abnormal uterine bleeding.

Now, what is the commonest cause of abnormal uterine bleeding, that is DUB, dysfunctional uterine bleeding. Now, what is the DUB? DUB is a bleeding condition when there is no organic pathology involved. Organic pathology, as in there is no fibroid, polyp, or any other inbuilt cause which is involved. There is just a hormonal imbalance. There is no iatrogenic factors like any Copper T or any medicines, which are on, or any other, other hormonal problems like thyroid, you know pituitary causes and all that. So, commonest causes are hormonal imbalance that is DUB. Now, in DUB, in 90% of the patients, it is either anovulatory cycle that is where the oestrogen which is the hormone, which supports the whole menstrual cycle, is produced in excess and there is no progesterone support to it. In such patients what happens, the patient starts bleeding and she continues to bleed because there is no support of progesterone which is there. And the other 10% have got ovulatory cycles, where they have excess of progesterone, where the progesterone is irregularly supplied in their body and that causes irregular bleeding or excessive bleeding because of irregular shedding of the endometrium.

The other causes are thyroid disorders, which is again one of the causes for abnormal uterine bleeding where the patient does not even realize whether the patient has thyroid or not, unless a blood test is done. When the patient comes to our OPD that is the first time when a thyroid has been sent and it comes to a very high level. Only correcting the thyroid can make her periods normal. So, that is thyroid or pituitary conditions.

Secondly, the most most most common is PCOD. Nowadays, 20% of our OPD patients come with complaints of PCOD. They usually present with complaints of amenorrhea that is no periods at all for 3 to 4 months, but once they start bleeding, they bleed a lot. They bleed for 15 days, 20 days continuously at stretch, which is not good. Now, PCOD that is polycystic ovarian disease is a condition where there is a hormonal imbalance in the patient and these patients have anovulatory cycles. So, these patients usually present with the symptoms of obesity that is excessive weight, more than the BMI. They have features of acne, hirsutism, and irregular cycles. Obesity, one more major factor for periods becoming irregular and with heavy bleeding in between, like they have amenorrhea of 3 to 4 months and then they again present with… when they start bleeding, they bleed, profusely they bleed. So, obesity also has to be controlled. I will be talking about the management later.

Now, when the patient comes to the OPD, first of all, we have to do an examination, a general examination, which includes weight, as I said, obesity is one of the factors for heavy periods. We have to check her BMI. What is her BMI? If she is in the high BMI then accordingly lifestyle modification has to be advised. Similarly patients with PCOD, when they come, they have to be counselled about weight loss, about lifestyle modifications, about maintaining a healthy lifestyle, losing weight. Acne, hirsutism is for cosmetic reasons, but for the Gynaec point of view, we have to monitor their weight.

Other features like thyroid problem or any other blood tests, blood tests have to be sent, of the patient. Haemogram , to know their basic CBC that is the basic haemoglobin of the patient. A proper history is the most important thing. When the patient comes to our OPD, they have got a very vague complaint, that I bleed every month but I bleed for a longer period of time. Now, the history what the patient presents is very subjective. For a patient, bleeding for 2 days, maybe she is bleeding for 2 days but maybe she is using maybe 8 to 10 pads in a day. When I take the history of the patient, I just don’t go by the days of bleeding because we Indians have usually take it for granted that it’s good to bleed. No, it is not good to bleed. We don’t have to have a heavy flow or passage of clots because that invariably makes us anaemic. So, when a patient comes in the OPD with saying 2 days of bleeding, I have to definitely ask her about the amount of pad she is using every day, how much is the bleeding, how many pads does she use, does she pass clots or not, how many days does she bleed. So that gives me a basic idea about how much is the blood loss of the patient. The external feature of the patient, she might be looking pale, she might be white as, you know, she must be just pale, too pale, but she says that no, that much, that is a regular menstrual cycle. So, a Haemogram that is a CBC tells me about how much is the blood loss that she is having.

Similarly, with the sonography, sonography usually tells me… after examination, history, investigations; after the CBC, a thyroid profile; in young girls of PCOD, maybe a hormonal profile, and a prolactin level, and a sonography. A sonography tells me about her inbuilt pathology, if any, like a fibroid or a polyp or any other adenomyosis, which is the cause of bleeding. See, if the cause is known, the treatment of the cause is most important.

Similarly, after sonography, there are other procedures like hysteroscopy. Once the cause is detected like a polyp or a fibroid. A hysteroscopy can be both, it can be either a diagnostic hysteroscopy where a scope is introduced through the vagina into the uterine cavity and we have a generalized look, whether there is a polyp involved or any adenomyosis and a submucous fibroid which is causing a bleeding. Similarly, if the cause is ruled out that is there is no clinical cause then we can treat her only with hormonal medicines. At the same time, hysteroscopy also helps us to treat the cause. For example, when we do a hysteroscopy, there is a polyp which is there, we can immediately remove it. If there is a fibroid, we can immediately remove it and send it for testing.

Other things are endometrial biopsy. Whenever we take a patient for hysteroscopy, it is always associated with a hysteroscopy-guided endometrial biopsy because in patients who are perimenopausal or who are postmenopausal, a biopsy always is sent for histopathological examination and it gives us the result whether there is a carcinoma or just a hyperplasia. So our line of management changes accordingly.

Now, if there is some other pathology which is involved, the treatment options I will be going ahead with, first of all, just general haematinic which are given to increase the haemoglobin of the patient because a pale patient or a patient who has bled a lot generally has complains of weakness or you know loss of interest in doing daily activities. So, these patients definitely have to be prescribed with haematinics. A patient with PCOD has to be explained about lifestyle management. Whatever the patient comes, we have to treat what is bothering her more. Most of the patients, when they come, they are not worried about their period, how much is the flow of the period, they are just wanting that it just becomes regular [ki bus regular ho jaye]. They have to be treated according to what is their requirement at that time. If she is a young girl, she is in her puberty and she is bleeding a lot, so right now, the concern for the parents is to control the bleeding. Once all the tests are done and there is no problem, we have to treat her. If she has a coagulating disorder then we have to treat her accordingly. Same thing is with adolescent girls, if she is bleeding continuously, we just can’t leave her like that, we will have to support her with progesterone. So, the hormonal management comes into play where we put her on hormones and we have to control, at the same time, give her something to build up her haemoglobin, so that because these are young girls, they are growing girls.

Same way, in a patient who are in the reproductive age group, if she has complaints of bleeding, first of all, rule out the cause like any iatrogenic cause like a Copper T or a medicine what she has taken, for example, an I-Pill or any other hormonal medicines to postpone the periods, so that has to be removed, regularize her cycle. If she is in the reproductive age group, not wanting for a pregnancy but wanting regular cycles, we can even put her on hormonal medicines that is oestrogen-progesterone combination all birth control pills. Same way, if the patient is bleeding continuously that is an anovulatory cycle where there is a constant oestrogen supply which is there, we have to support it with progesterones. Now, progesterones can either be given in a continuous manner or in a cyclical manner.

If a patient in a postmenopausal age group comes with complaints, we do an endometrial biopsy, there is only hyperplasia, we can wait or advice for a hysterectomy. Same way, we rule out any carcinoma because if there is any carcinoma then the line of management is an extensive surgery. If a patient comes with complaints of fibroid or polyp or adenomyosis on a sonography then the fibroid has to be removed, now that we can do it either laparoscopically or hysteroscopically, which has got a very good patient compliance and much faster recovery.

If the patient is a young girl, family complete, but still she is bleeding, we cannot do a hysterectomy for this patient. So, in such patients, we advise them for progesterone intrauterine device that is Mirena or levonorgestrel IUCD, which gives continuous release of progesterone and that regularizes your cycle. So just an intrauterine device, a progesterone supportive intrauterine device which can be inserted and the bleeding can be controlled, that will give a dual protection, she will have contraceptive help also as well as her uterus is conserved.

If she is in the elderly age group, if the patient is about 45-50 and the family is complete, she is bleeding. On the endometrial biopsy, there is only hyperplasia and she is not wanting to keep her uterus then in such patients, we advise them for a hysterectomy, which can be done again either laparoscopically or an open hysterectomy.

So, whenever we treat a patient, it has to be what the patient wants, it has to be depending upon what is the cause which is causing the abnormal uterine bleeding. If there is just hormonal imbalance, just supporting her in that time or just regularizing her cycles with maybe 1 or 2 cycles of hormones can make her bleeding regular. If there is a thyroid problem, treat her with the thyroid medicines; she does not need any hormones, only correcting the thyroid can make her periods regular. At the same time, if the cause is removed, like a fibroid, polyp or adenomyosis. So, you always treat a patient what she wants, whether it all depends upon what is her lifestyle, what is her reproductive… whether she is in the reproductive age group, what is her family, what does she want.

[curraehospitals]

All You Need To Know About Dysmenorrhoea In Women

Today, We are going to talk about a very common problem which most of the girls, young girls, ladies who face is painful periods. Mahine ke time pe, MC ke time pe pain hona, and about endometriosis. Endometriosis is one of the reasons.

First, let me begin with what is painful periods, jisko hum log dysmenorrhoea bolte hai. Dysmenorrhoea matlab mahine ke time pe pain hona. Now, this can be either primary dysmenorrhoea or secondary dysmenorrhoea. Primary dysmenorrhoea jab hota hai to cramping hota hai, normally when there is no organic cause of pain, and it lasts… begins basically first 12 to 24 hours of period matlab jaisa hi humko mahina shuru hota hai, pahale 12 se 24 ghante tak rahata hai. Yahan koi organic cause nahi hai, matlab there is no reason for the pain to happen, okay. It’s basically because of the prostaglandins, jiske release hone pe pain hota hai. Secondary dysmenorrhoea hum usko bolte hai jab koi cause hai, koi reason hai pain ka, abhi yeh reason bohot cheezon ke wajah se ho sakta hai, where it can be endometriosis jiske bare me mai baat karungi, it can be adenomyosis, fibroids, yah agar kisine Copper T bidhaya ho, uske wajah se ho sakta hai, yah cervical stenosis, matlab jo hamara opening hai uterus ka, uska passage agar thoda sa tight ho to, to yeh reason hai.

Abhi normally, patient jo humko present karte hai, those patients present with severe pain in the abdomen, jo lower abdomen me jyada karke hota hai or when the pain radiates from the back radiating to the thighs yah agar secondary dysmenorrhoea hai to heavy menstrual flow, backache, bohot se logon ko iske dauran, menses ke dauran nausea hona yah vomiting hona yah chakkar ana, dhakan lagna, yeh sab symptoms hote hai. Abhi history jab hum lete hai, to jo primary dysmenorrhoea hai, uska history normally aise hota hai ki mereko jaise hi period ka date ane wala hai tab mujko ek 12 se 24 ghante pahale se pain shuru hota hai. Jabki secondary dysmenorrhoea jo hai unme jinko problem hai andar, unme yeh hota hai ki pain is usually continuous, pure 5 din rahana, pure 5 din rahata hai, heavy flow hona, jinme goliyon ka asar nai karna yah goli khane ke baujudh bhi pain hona yah when there is a cause like infection, to foul smell hona yah lower abdomen may bohot tez hona, urinary complaints hona, yah motion ke time pe problem hona, yeh sab symptoms secondary dysmenorrhoea me dikhte hai.

Abhi iska diagnosis hum kaise karte hai, pahali cheez to jab aap doctor ke pass jaoge to aapko ek sonography karne ka salah diya jayenga, just to rule out ki koi cause hai andar yah examination pe. Mainly, when the patient comes, hum examine karte hai. Abhi agar young girl hai, unmarried hai, not sexually active hai to hum unme internal examination nahi kar sakte but agar sexually active hai yah jinke hue hai, shadi hui hai, unme hum internal examination karke bhi humko pata chal jata hai. Uske baad sonography advise ki jati hai. Agar koi other reason hai jaise Copper T hua yah koi urinary infection hua to urine test honga, apka ek Pap smear honga. Yeh sab karke hum ek reason find out karte hai. Abhi is reason ke… on the basis of this investigation, hum treatment decide karte hai. Agar primary dysmenorrhoea hai yane sonography ka report normal hai, koi bhi pathology nahi hai, un cases me a mild painkiller or an antispasmodic should be more than enough, matlab jaisa jaisa age badenga larki ka yah jaise unki shaadi hongi, bacche honge, passage open honga to woh apne aap se yeh jo spasm ke wajah se jo pain hota hai, primary dysmenorrhoea me, woh release ho jata hai. Magar agar secondary dysmenorrhoea hai, jaise koi cause hai jaise endometriosis hai yah fibroid hai yah agar adenomyosis hai, to uske hisaab se fir treatment decide hota hai.

So now, I am going to discuss about endometriosis to begin with. Endometriosis basically kya hai? It is endometriotic tissue outside the uterus, matlab jo hamara menses ke time pe jo normally shed hota hai endometrium, woh uterus ke alawa kisi aur jagah pe uska maujudh hona. To abhi ye, humlog isko divide karte hai, into pelvic endometriosis yah extrapelvic endometriosis. Pelvis matlab jahan hamara uterus hai, to endometriosis aga tubes me hai, fallopian tubes me hai yah ovaries me hai yah uterus me hai, adenomyosis hai yah fir uterus ke side ki jo jagah hai, peritoneum jisko bolte hai wahan hai, usko yah bladder ke idhar hai, udhar usko pelvic endometriosis bolte hai. Abhi jo extrapelvic matlab endometriosis ka hona, yeh bahar ke taraf bhi ho sakta matlab uterus ke alawa bhi, to woh bohot se logon me bowel, that is intestines me uske components paye jate hai yah phir bladder me, matlab urinary jo hamara bag hai, wahan paya ja sakta hai, yah phir rectum me jahan se motion  hamara nikalta hai, wahan se ho sakta hai. Bohot se logon ko agar koi scar hai matlab agar pahale ki normal delivery hai to episiotomy jo lagta, piche takah lagta udhar kabhi kabhi endometriosis paya jata hai, yah caesarean ka jo scar hai uspe ho sakta hai. In rare cases, it is also seen in the lungs, matlab lungs ke yahan paya ja sakta hai, to uske basis pe symptoms hote hai, jaise endometriosis ke main symptom kya hai, ki painful periods hona that is the most common symptom, patient go mahine ke time pe yah period ke time pe continuous pain rahana, agar pain bohot severe hai to we suspect deep infiltration, matlab bohot andar tak dhasa hua endometriosis hum suspect karte hai. Dusra complain hai, agar married hai to dyspareunia. Dyspareunia ka matlab kya, ki intercourse karte samay yah sex karte samay bohot pain hona. Now, this can be a component of endometriosis again, where the endometriosis is in depth in the subperitoneal tissue, means andar dhasa hua, in the vagina ke jagah pe, to that causes dyspareunia, yah phir chronic pelvic pain matlab mahina nahi hote hue bhi ek dull aching pain rahana, hamesha ek lower abdomen me ek pain sa rahana, this is chronic pelvic pain.

The last but not the least is subfertility. Bohot se logon ko kuch symptom nahi hota hai but they have complaints of subfertility, matlab conceive hone me problem hona. Conception me problem hona, endometriosis ke wajah se ho sakta hai because endometriosis does not allow pregnancy to happen, so yeh aur ek bohot important reason hai. Yeh kyo hota hai, endometriosis kyo hota hai? This is a very common doubt which we have ki uterus ke bahar endometriotic tissue ko kyo jana chahiye. Abhi uske bohot theories hai, bohot reasons hai. The more specific ones are ki ek to hai ki backflow, jaise kabhi kabhi MC, menses ke time pe agar bleeding jo hai woh uterus ke, cervix ke, vagina ke jagah se nah ate hue uska backflow hona, matlab tubes ke taraf se abdomen me uska jana, that is one of the reasons which is seen. Second reason is it is an oestrogen dependent disease, matlab jin aurton me oestrogen ka hormone ho hai, wo agar bohot matra me paya jata hai to unke yeh hone ke chances zyada and third one is genetic. Agan appke mummy ko hai yah apke family me woh run karta hai to bhi uska hona is very natural to have that.

Abhi, how do we differentiate it? Yah why does it call subfertility? Endometriosis me main hota hai ovulation bara bar se nahi hona yah anovulatory cycles hona yah jo quality of the eggs hai jab release hota uska accha na hona, fibrosis hona, because endometriosis ke wajah se kya hota hai ki hamare tubes jo hai, fallopian tubes, woh kharab ho jate hai, unki function kum ho jata hai, plus bohot sara scarring yah fibrosis hota hai. Peritoneum me agar hai to pura chipak jata hai under ka, jo tubes hai, ovaries hai, yah phir cyst hona. Bohot young girls ate hai with big cyst, big endometriotic cyst, to cyst agar bohot zyada hai, yah aap logon ne bohot commonly suna honga, chocolate cyst. Chocolate cyst is nothing but an endometriotic cyst, to yeh sab hone ke wajah se hamara jo under ka virgin peritoneum hai woh kharab ho jata hai, uske karan fertility meh problems hote hai.

Abhi jo extrapelvic endometriosis hai, jo jaise maine bataya ki alag jagah pe hona, agar bowel involvement hai jaise intestines ke yahan pe hona. So, patients will present with severe pain in the abdomen yah phir bar bar motion ke time pe takleef hona, constipation hona, excessive vomiting during your periods, yah phir pulmonary agar hum log pagadte hai to, to periods ke time pe saans lene me dikat hona, yah hemothorax hona, yeh bohot severe form me dikhta hai. Scar endometriosis aisa hai, where during periods ke time pe hi aapko episiotomy ka jo scar hai, jo normal delivery ka scar hai, udhar pain hona yah udar se bleeding hona yah caesarean ka jo scar hai woh scar sirf period ke time pe dukhna, yeh sab scar endometriosis ke features hai.

Abhi hum isko kaise diagnose karte hai, first of all, is a history jaise maine bataya. Yeh sab history janne pe hum ek conclusion meh ate hai ke there is a possibility of endometriosis, and examination. Examination pe jab period ke time pe when the patient comes, we examine their vulva, vagina, cervix, agar koi component dikh raha hai to, external examination pe. Uske alawa scar endometriosis hai to phir scar tissue pe endometriotic yeh hona, woh dikhna, humko pata chalta yah cyclical bleeding hona, yah cyclical pain in the abdomen, matlab sirf period ke time pe umbilicus ke yahan pe pain hona. Yeh sab features dikhte hai.

Abhi iska diagnosis hum kaise karte hai – pahali cheez hai, sonography as I said, aap doctor ke pass jayenge, doctor aapko ek sonography likh ke de denge. Sonography pe normally jo humko dikhta hai, is the endometriotic cyst, matlab ovaries ke idhar cyst hona. Abhi ek complex cyst hota hai, jo uska size upar depend hai. Agar less than 3 centimetre hai yah chota sa cyst hai to usko normally hum log medical line of management se treat karte hai, jisme hormonal therapy involved hai. Magar agar size bohot bada hai jaise more than 4 to 5 centimetres ke upar hai, to uska operation hi treatment hai because bohot bada cyst does not normally respond to a medical line of treatment aur uska usse bhi zyada bade hone chances bohot zyada hai.

Second is a CA-125, yeh ek prakar blood test hai jo hum normally endometriosis patients meh recommend karte hai because CA-125 helps us to differentiate with the other tumour markers, matlab koi aur prakar ka tumour to nahi hai, yeh dekhne ka humko pata chalta hai. Abhi iske hisaab se last but not the least is a laparoscopy. Laparoscopy is the gold standard to diagnose as well as treat endometriosis. Laparoscopy iske liye bhi better mana jata hai because laparoscopy meh hamara stay kum hai hospital meh, mobility better hai matlab operation ke baad yah procedure ke baad aap immediately mobile hote hai. Post-operative, less chances of adhesions, adhesions ka matlab operation ke baad jab hum cyst nikalte yah uska ka jo fluid bahar nikalta hai uske wajah se bhi bohot sara undar organs chipak sakte hai jo hum laparoscopy se avoid kar sakte hai. And as well as cost, if you compare the cost with the hormonal line of treatment, which is a long course of treatment for endometriosis, that it also less.

Laparotomy matlab cut karke operation unn patients may hum log recommend karte bohot severe endometriosis hai, matlab it is on the… hum log staging karte hai, laparoscopy ke hisaab se we can even stage the endometriosis. Staging ke hisaab se humko pata chalta hai ki kitna involvement hai endometriosis ka andar, jaise agar uterus involved hai, sirf uterus hai aur tubes, ovaries involved hai ki bahar ka intestines involved hai yah bladder that is the urinary bag involved hai, to uske hisaab se hum staging karte hai, kitna spread hua hai endometriosis. Laparotomy unn patients meh karte hai jahan bohot severe form me humko dikhayi de raha hai, jin me operation jaise laparoscopy not advisable, koi other medical condition ke wajah se, to unn patients meh hum laparotomy karte hai yah jinme fertility is not an issue, matlab unke bacche ho juke hai, unme hum log open surgery karte hai. Laparoscopy ka aur ek advantage yeh hai ki hum log isme jo operation karte hai woh normally reproductive age group, matlab jo hamare paas pregnancy ke liye ate hai unme laparoscopy zyada recommended karte hai because fertility rates are much better after laparoscopy, plus the treatment matlab hum log jo postoperatively medical line of treatment dete hai uspe bhi patients respond much better after laparoscopy, to in cases meh laparoscopy is the gold standard.

Now, after the patient has undergone a laparoscopy, bohot bada cyst hai usko nikala gaya hai, uske baad taki recurrence nah ho, see recurrence, yeh endometriosis me ho sakta hai because hamara menses to band nahi hota hai, to recurrence bhi ho sakta hai, usko prevent karne ke liye hum medical line of treatment bhi rakhte hai. Medical line of treatment abhi kiss hisaab se karenge? First of all, hum pahale low-dose oral contraceptive pills deke dekhte hai, we give them low-dose pills first, matlab hormonal cyclical pills jo hote hai woh leke dekhte hai. Kyo dete hai? Because endometriosis has been shown to have oestrogen dependent, to oestrogen ko hum thoda control karenge yah hormones ko control karenge. We put them on a low-dose pill and we see how they respond. If the pain is less, if the bleeding is less, then yes, she is responding to the medical line of treatment. Yeh bhi nahi hota, then we go one-one step ahead, then we go one step ahead with progesterones. Abhi progesterones meh kya karte hai ki yeh oestrogen to oppose karte hai, to progesterones meh we either give injectable progesterone like medroxyprogesterone acetate, intramuscular injections. Yah phir hum log agar samhjo family complete hai yah bacche ho juke hai to hum ek loop bhi bidha sakte hai jo hormonal loop hai jisse bleeding, pain, aur continuous release of progesterone andar rahata hai, to usse bhi pain kum hota hai. Yah phir anti- progesterone, jiske wajah se, jaise Mifepristone hai, uska ek low dose hum continuous rakhte hai taki endometriosis bade nahi. Previously, pahale ke zamane meh Danazol use kiya jata tha magar filhal Danazol hum bohot kum use karte hai because Danazol ka side effect bohot zyada hai.

Recently, in severe endometriosis, what we have seen is GnRH, that is gonadotropin hormone which is an agonist which we use, jo injectable form meh monthly diya jata hai. Yeh dose meh dene se endometriosis jo hai uska recurrence nahi hota hai aur uska jo andar jo adhesions hai woh bhi kum ho jate hai. Now, the only side effects with this GnRH Agonist are that it causes severe menopausal symptoms, isko hum log pseudo menopause bolte hai, matlab aapko injection dene ke baad ek menopause ke jaisa picture create ho jata hai, jahan hormones nahi hai hamare body meh. To yeh hum recommend karte hai only in severe endometriosis, jahan peh fertility is not an issue, matlab hum log bacche ke bare me planning nahi kar rahe hai, family complete hai, but sirf pain is a criteria, unn cases me hum yeh patients ko recommend karte hai.

So, overall, if you see endometriosis, it’s basically a chronic treatment, chronic disease, yeh puri tarah se hum cure kar sakte hai magar iska recurrence bhi utna hi severe ho sakta hai, if it is not treated properly. To agar chota sa cyst hai, it is better to start with the improvement. If there is a cyst which is causing you pain, at least remove the focus, laparoscopy say hum usko at least nikalte hai, uska major component jo hai, nikalte hai. Agar scar endometriosis hai to jo scar tissue hai usme se endometriosis ko excise karke nikalte taki yeh bade nahi yah pain kum ho jaye. So this is… we depend upon the patient’s reproductive age. Abhi patient agar fertility ke liye aya hai, pain is not an issue, to uss hisaab se hum usko medications dete hai. Once the endometriosis is cured of, then we suggest the line of treatment, jaise agar natural conception hua yah if agar bohot age is a criteria, phir IVF, IUI, iske hisaab hum log medical line of treatment decide karte hai.

So, overall, endometriosis is a dreaded disease. Sirf pain hona is not endometriosis. Jaise maine bataya, agar primary dysmenorrhoea hai aur sirf pain hai periods pe, baki aapke investigations normal hai to koi chinta ki baat nahi hai, it will just respond to the medical line of treatment. Magar yes, agar endometriosis ata hai yah koi other organic cause ata hai to uska treatment time pe lena bohot zaruri hai.

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Diagnosis & Risk Factors About Prostate Cancer

Today, We are here to speak a little about prostate cancer. Prostate, to start with, is a gland which is found only in males. So if you think of the urinary system, the kidneys lie in two sides of our abdomen here, towards the back. Prostate gland is a gland which sits between the bladder and the urethra. Its main function is to produce nourishment for the sperm. So, as long as the person is desirous of fertility, desirous of parenthood, the gland is important. After that, the function of the gland is not at all important to our body. But why this gland is important is because, in terms of today’s discussion, the prostate is a commonest cancer in males in our country and worldwide. The commonest cancer that involves the male is prostate cancer.

Now, if you ask me how common it is, we don’t have a good data in India, to say how common the prostate cancer is. But a recent article published in the India Journal of Urology, has stated that the incidence varies from 1 in per lakh population in Manipur to 10 per lakh population in Delhi. It is not that Delhi has more prostate cancer and Manipur has less prostate cancer, it is because Delhi has a better cancer registry, so they have a better way of keeping a record of the cancer diagnosed. So, we do not know the exact incidence in our country, but yes, it will vary from maybe 10 in a lakh, but it is in fact the commonest cancer, effecting males in our country, so it is an important cancer to be discussed.

Now as I said, the prostate is a gland which basically serves the function for nourishment of the sperms during fertility. So after the incidence, now what are the risks of having a prostate cancer, means what are the things, you ask that what can I do to avoid prostate cancer risk. Now, the most important risk of prostate cancer is age and it is not modifiable. So, 65% of prostate cancer occurs in men greater than 65 years of age. men age less than 40, the risk is less than 10%. It is the most unknown and there is also a foreign literature which says so. So, for all working terms and condition, we say that prostate cancer is unknown in men less than 45, and it is more common, more than 65% occurs in men more than 65. So, age is the most important risk factor, it is non-modifiable risk factor.

Other important risk factors are genetics, so there comes family history. If you ask me, it is familial or not, only if your first-degree relative like your father or your brother had prostate cancer, then you are also at high risk of developing prostate cancer. Other than these two factors, the age and genetics, other risk factors which are said for prostate cancer is like having a possibility for, again comes under genetics, BRCA. So if your sisters and mother has a family history of breast cancer or ovarian cancer, which comes under the genetic of BRCA genes, you are in fact having a higher risk for developing prostate cancer. Other than that, a diet rich in red meat, an obese person, somebody who takes lot of fat in his diet, somebody who has a history of recurrent prostatitis, they have a higher risk. Good intake of fruits, vegetables decreases the risk. So obesity, red meat intake, increase in intake of saturated fats, oil and fat will increase the risk of prostate cancer, then vice versa, a good intake of vegetables and fruits, that will reduce the risk of prostate cancer. So there is nothing much you can do to modify risks of prostate cancer, it is all in your genetics and age and you cannot do much about it.

So now, since we are not able to do much about it, we should know that how we can best find it out and how we can treat it. Now, when we are talking about this diagnosis like to find it out, we think about there is two way of diagnosis, one is screening and another is diagnosis of symptomatic patients. Now, when I said screening, I mean that we screen the population with blood sugar to detect diabetes, we screen the population with BP monitoring to detect hypertension, we screen females that Pap smear to detect cervical cancer, and they have been found to reduce the mortality and morbidity drastically. By morbidity, I mean the pain which the disease gives. By mortality, I mean the risk of death of the disease.

But for prostate cancer, is screening good? It is a big question. As of today, it is said that prostate cancer screening is not beneficial, there is a lot of data in it. To summarize, prostate cancer screening is not beneficial in men more than 75 and in men less than 50 years of age. So, more than 75 and less than 50, there is no point in screening asymptomatic patients; I’ll tell you what are the symptoms. Asymptomatic patients, there is no point in doing a random PSA check for everybody to find out… Why? Once you detect this with screening then somebody has a possibility of developing prostate cancer, we will do a lot of unnecessary tests, we will do a lot of unnecessary treatment. Why I say unnecessary? Because many of these cancers would be in indolent, indolent means their likelihood of killing you is very less over a period of 10 years. To say something more in detail, for example, if somebody has a prostate cancer, which is confined to the prostate, it has not gone out of the prostate, his risk of dying in 10 years of prostate cancer is only 10%. So 10% is the risk, so only 10 out of 100 will die of prostate cancer, 90 out of 100 will not die of the prostate cancer. So, why to detect prostate cancer in asymptomatic patient when you know that the disease is more likely after 60, 60 or 65, anyway he will live more than 10 years without any problem. His risks of dying, say at the end of 15 years will increase from 10% to something 20%, so the risk of dying is not high. So, as of today, without going through this lot of confusion, there is no guidelines today, we say that you screen patients who is more than 75, who is less than 50. Between 50 and 75, we are supposed to screen patients. Screen means, again I repeat, patient is not symptomatic. We are supposed to screen patients who are at high risk of developing prostate cancer. High risk means somebody who is above 65, somebody whose family history of prostate cancer was there, they are the candidates on which you can screen to detect prostate cancer.

So, one part of the diagnosis is to screening. Another part of diagnosis is to find out people with symptoms. So what are the symptoms of prostate cancer? The symptoms of prostate cancer are the same as the symptoms of a normal prostatic disease which is known as benign prostatic hyperplasia or BPH. The patient will present… because the prostate gland lies between the bladder and the urethra, once it enlarges, cancer cells also enlarges. Symptoms are same, like the stream will be poor, the patient will have intermittent flow, patient has to strain while trying to pass urine, he may have to go again and again, he will have urgency like when he thinks of passing urine, he has to run to the bathroom, he cannot on for a long time. So these are the symptoms of prostate cancer: poor stream, intermittency, sense of incomplete evacuation, lot of time to start, he is on hesitancy, urgency, these are the symptoms. And when the cancer has spread, it will lead to pain in the bones, it will lead to difficulty in walking because of neurological spread, spread in the vertebrae is the common site of prostate cancer, so these are the symptoms.

When you have prostate cancer symptoms, we are supposed to do some investigation to find out whether that person has prostate cancer or not. So, the investigation includes screening and diagnosis, both are the same. The first investigation is a clinical examination in which the prostate is palpated by putting a finger in the rectum because the prostate likes just in front of the rectum, so we can put a finger in your rectum to palpate the prostate and see whether it is hard or not, this is known as digital rectal examination. Digital rectal examination and the second thing is serum PSA test.Test your Blood, do a PSA and DRE, which is digital rectal examination, to see that whether the patient can have prostate cancer or not.

PSA is something which is a very double-edged sword. So many times, we will find patients may have a very high PSA and he may not necessarily have prostate cancer, there are other diseases which can lead to prostate cancer, so we have to find out what value of PSA is significant. Now, it is said that when the PSA is more than 10, I have to tell this in two parts, first part, when the PSA is more than 10, the risk of having prostate cancer or harbouring prostate cancer is around 50%. So, 1 in 2 patients with PSA more than 10 will have prostate cancer that means another 1 in 2 will not have prostate cancer. Second, when the PSA is less than 4, the chances of having prostate cancer will be around 10% that means only 10 out of 100, but when the PSA is between 4 and 10, it is 25% that is 1 out of 4. So, when the PSA is more than 10, it is 1 out of 2; when it is 4 to 10, it is 1 out of 4; and when it is less than 4, it is 1 out of 10. So simple logic which can be derived out of it is when the PSA is more than 10, it is indeed significant, and when it is between 4 and 10, we have to perform other tests, important test is free PSA, when it is more than 25%, chances of cancer is very less. But when it is more than 10, what are the things you can do? Now, once you are screened, find out rectal examination showing hard, you always do a biopsy. You see the PSA is more than 10, now there are two things, the PSA is very high, say 100, 200, then we have to do a biopsy to find out, rule out prostate cancer. But if PSA is more than 10, the rectal examination shows a soft prostate or a firm prostate then there is no harm in giving antibiotics for some time, maybe the period of 2 weeks or 3 weeks, repeat the PSA after 4 weeks before going for biopsy. So somebody with the PSA of 15, with antibiotic, it comes down to 10, there is no harm in waiting for some more time to see if it comes further low because by that way, we can avoid unnecessary biopsies.

To summarize, when the PSA is more than 10, if it is not a very high like 70, 80, or 100, there is a point in giving antibiotic for 2 weeks, repeat the PSA after 4 weeks and then do a biopsy, especially in rectal examination, the prostate is not hard. So, this is a prudent way of avoiding a biopsy which is associated with a little discomfort, it is not totally painless, it has some discomfort.

So now, we have talked about the prostate, incidence of prostate cancer.  We have talked about the diagnosis, screening part and the diagnosis by the symptomatic part. Diagnosis entails rectal examination, PSA, and biopsy is required. Once this has been done, we have done a biopsy and we have found out prostate cancer, still there is a question, whether to treat or not to treat the prostate cancer which we have diagnosed. Why? Because once the biopsy is done, biopsy will give us whether the tumour is low-grade, medium-grade or high-grade. The thing is that for a low-grade tumour, the risk of dying is again just around 10% over a period of 10 years. So out of 100, only 10 will develop more aggressive disease, 10 will spread, 10 will die of prostate cancer. Why we are talking of all these things? Because the treatment of prostate cancer is associated with some morbidity, if not mortality, as of 2019, we have almost zero mortality today, but it is associated with some risks, the risk of impotence that is sexual dysfunction and the risk of incontinence of urine. Some incontinence is always there, if not total incontinence, some months, patient will have incontinence, so it is not a very easy treatment, unlike a simple surgery for appendix or gallbladder, or whatever. The treatment we do for prostate is not without any mortality or morbidity, so we have to decide whether to treat or not. So, very low-grade tumour, if the patient is old, as I said, somebody is 70 for example, he will anyway live till 80 without any problem, we can always keep him under follow up. But somebody is 50 with a low-grade, maybe he will require treatment because he is going to live for another 30 years, 80. Today, in the metro city, the life expectancy is around 80.

So, when we have decided a biopsy and get a low-grade tumour, we have an option of not doing anything and waiting, keeping the patient under follow-up and treat when required, especially if elderly, when the age is more than 70. More than 70, it is always prudent to wait for a low-grade cancer and not to treat, not to give him the trouble of treatment, the cost of treatment, wait for some time. But for high-grade, we will always treat. For a medium grade, again this is a decision to be made whether to wait to treat and follow up regularly, the disadvantage is you need to require a regular biopsy, or not to treat.

Now, once that point is finished, we discuss what is the treatment. A very simple way of devising treatment is to see the stage, like many cancers, we will have I, II, III and IV. So I is the stage where the cancer is within the prostate, small cancer within the prostate, II is also within the prospect, so I and II, cancer has not grown out of the prostate. Stage III, the cancer has grown out of the prostate into the seminal vesicles, which is another organ surrounding, or to the lymph nodes. Stage IV cancer, when it has grown far into the bones, into the liver or many other organs, maybe. So treatment involves staging, staging involves further tests. Important tests are MRI, doing a bone scan, these are the important tests today. MRI is very important. Most important is perhaps a bone scan, bone scan detects spread of the tumour to the bones. There are two groups, a class which will ask for CT Thorax and the CT of the upper abdomen to see for the thorax and the liver. There are some groups today who does PSMA scan, who does FDG-PET. FDG-PET is perhaps not a good test for prostate cancer because prostate cancer is not a very metabolically active cancer, especially when it is a low-grade or a medium-grade, so it will not show much in a PET scan. So FDG-PET scan, if the FDG is not so good but a PET scan… PSMA scan is also PET scan, maybe perhaps better. As of now, today the guidelines are varied and most people will do CT of the chest, CT of the thorax and the upper abdomen with a bone scan to see whether the prostate cancer has not spread. And if they spread, it becomes a metastatic disease. The treatment will entail medical treatment, and when it is not spared, the option is between surgery and radiotherapy.

Stage III, it is always radiation, never surgery. So, when prostate cancer has spread to the seminal vesicles, spread to the lymph node, please don’t go for surgery, it is always radiation, surgery is not to be done, radiation has been shown to be much, much, much better than surgery. But for the stage I and II disease, we can choose between surgery and radiation, literature says both are equally good. People who are doing radiotherapy says that the chances of incontinence maybe far less. People who are doing surgery say that radiation is a longer treatment, better treatment can be done with surgery, for last moment mortality and mobility with the advent of laparoscopy and robotics. So, still literature is right, so both is good, radiotherapy and surgery in the way I think for stage I and II disease. For stage III, treatment is only radiation.

For stage IV disease, it is today a combination of chemotherapy and hormone therapy. Now, what is hormone therapy? Now, prostate cancer is dependent on testosterone. Testosterone is a hormone produced by our testicles and adrenal gland, 99% is produced from the testicles, only 5% is produced from the adrenal gland. Testosterone is like fuel, like petrol for the prostate cancer cells, they cannot live without testosterone. So, if we can do something to take out the testosterone from the body, it means the source and this you can do by orchidectomy or remove the testicles in one way or if you can give drugs to block the action of testosterone, something which is known as LHRH agonist. So, both ways are equally good, we can prevent the prostate cancer cells to get the testosterone, so they will lie low for some time. Today, in the latest edition of the Urology Clinics, they have said that if you add chemotherapy Taxol, Docetaxel with it, the overall survival is better than giving hormone alone. So hormone therapy entails either removal of the testicles or giving something to block the testicles with drugs. Removal of the testicle is basically a onetime procedure with far lesser cost when you compare it to a hormonal therapy with medicines, which involves 3 monthly or 6 monthly injection, which will be lifelong, but both are equally good. If cost is the issue, somebody can choose orchidectomy. If somebody doesn’t want to get rid of his testicles and retain his testicles, he can choose hormone therapy. Both are equally effective, both are equally good, and to add on this, chemotherapy, so this is the stage IV at the beginning.

But one day as the stage comes when prostate cancer is not responding on hormone. The patient may have bone pain, patient may have issue with the neurology. So, then things like vertebroplasty which can be done surgically today by injecting things under radiology guidance, by pain care physicians, or by Nuclear Medicine comes in the role when radioactive Francium is given for severe bone pain in the body.

With all this today, we can make the life of prostate cancer patients very easy, but overall, this cancer is not a dangerous cancer. If somebody has prostate cancer, it is perhaps one of the best cancers after thyroid cancer, so the risk of dying with prostate cancer is less, most of the patient will die of age than that of prostate cancer. In a gist, I tried to say whatever I could on the treatment and on the diagnosis and what a common man or a primary care physician should know about prostate cancer. I did not go into the details of treatment, which is the urologist domain. My talk was intended for audience who are the patients themselves or the relatives or primary care physicians who comes in contact with prostate cancer, and then decide what to do.

So to summarize, PSA is not to be done for everybody, more than 75 years and less than 50, it is useless. Between 50 and 75, only for patients who are at high risk, it is good. Now, once PSA is done, if the PSA value is more than 10, not necessarily a biopsy will be required. Only if antibiotics has not resolved the PSA, has not brought the PSA down, only when rectal examination is very hard then only we ask for a biopsy. Next, once the biopsy is done, low-grade tumour in higher age, we can prefer not to treat, this is the third point. For young patients, less than 70, it is better to treat, this is the third. So first is about going to screen, second is what to use to screen, that is PSA and rectal examination. Third is about but what to do after the biopsy is done and fourth is about the treatment. As I said, stage I and II, radiation and surgery are equally good; stage III, should be only radiation and not surgery. Stage III means the tumour has spread beyond the prostate into the seminal vesicles. Stage IV means it has gone to the bones, it has gone to the liver, in this then again surgery is not required, it is only medical treatment , hormone treatment basically, it maybe surgical orchidectomy or medical orchidectomy with hormones. And when the disease has spread further, there is bone pain. Today, radioactive materials are available, chemotherapy is available, which can make the life of the patient very easy.

Thank you very much for this patient hearing. Today, in this hospital, Currae Hospital, we are treating a lot of patients with prostate cancer. Most of them we are treating, especially who come for surgical treatment of prostate cancer, with laparoscopic radical prostatectomy or open radical prostatectomy and many times with orchidectomy. And many of our patients are doing good. But more important is to diagnose the disease properly and guide the patient properly of what further treatment is required.

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