Category Archives: Women Disease Treatment

Breast Cancer Detection and Treatment

The first recorded case of an inflammatory breast cancer: Persian empress Atossa (550 BC to 475 BC), daughter of Cyrus the Great, wife of two Achamenian kings, Cambyses and Darius.

“Cancer may have started the fight, but I will finish it.” 

Introduction

Since cancer-prevention is not possible, the saying, “prevention is the cure” is amended to “early detection is the cure.”

Only about 10% of cancer deaths are because of primary tumour. Most of the deaths are because of metastasis – spreading of the cancer to other parts of the body. Once metastasis happens, it is difficult to treat the cancer. Early detection of cancer is therefore of utmost importance.

Early Detection

Several ways of early detection:

  1. Self-examination of Breasts

More than 80% cancers are detected by women doing self-examination of breasts. The examination should be done every month, 5-7 days after menorrhoea. Look for the following:

  • Lumps in breast (less than 20% are cancer) or in lymph nodes in armpits.
  • Thickening of breasts
  • One breast becoming larger than other
  • A nipple changing position or shape or becoming inverted
  • Discharge from nipple
  • Constant pain in part of breast or armpit
  • Swelling beneath the armpit or around the collarbone

‘Breast cancer self-check’ images and videos are available on internet. In case of palpated anomaly, consult your gynecologist.

The limitations of self-examination are:

  • Only 20% women do self-examination of breasts.
  • The tumour/changes are large by the time they are felt and this delay in detection can adversely affect the treatment outcome.
  1. Imaging Techniques

Early detection of cancer is required and is possible by using Imaging Techniques. Six Imaging Techniques are available:

  • X-rays examination. Small neoplasmatic tissue formations can be seen.
  • Sonography (Ultrasound)

Sonography is done in addition to Mammography to rule out possible cysts and to estimate the size of the tumour. However, tumours smaller than 5 mm cannot be detected.

  • MRI

MRI is used to detect if the breast has been affected by more than one tumour.

  • Computer Assisted Detection (CAD)

CAD is used to point out possibly diseased regions. It is used mainly as a second opinion to the report of the doctor.

  • CT-scan

CT-scan is most often used to see if breast cancer has spread to other organs.

  • PET

A PET scan is used to detect the cancer cells in the body. It is often combined with a CT scan (known as a PET/CT scan).

Limitations of Imaging

  • Imaging techniques magnify the tumour much as the magnifying glass magnifies the letters in a book. If the font size is very small, a letter cannot be identified even with the magnifying glass. In a similar way, the imaging techniques cannot identify tumours that are very small.
  • The QUALITY of cancer is more important than the QUANTITY. A small tumour can be more dangerous than a large tumour.  Imaging can tell the quantity of the tumour, that is, its size, but cannot tell the quality of the tumour.
  • Most of the time, Imaging cannot even tell whether a tumour is cancerous or not.

Confirming Cancer

The only absolute way to confirm cancer is by biopsy: a small tissue from the tumour is taken and microscopically examined to check for cancer.

Types of Biopsy

  • Punching Biopsy. Done in a locally sedated state.
  • Needle Biopsy. Done with a syringe and a special needle. As painful as venepuncture.
  • Advanced Breast Biopsy Instrumentation (ABBI). Done with X-ray to ensure localisation of target. Only a few doctors are experienced in this technique.

Microscopic examination of biopsy is sufficient; but in a few rare cases specialized lab tests are required.

Treatment

Even small localised tumours have the potential of metastasis and therefore need to be treated. The treatment is surgery, medications (hormonal therapy and chemotherapy), radiation and immunotherapy.

Surgery offers the single largest benefit. Used along with chemotherapy and radiation, the local relapse rate is reduced, and the overall survival rate may increase.

Surgery

  • Mastectomy:  remove whole breast.
  • Quadrantectomy: remove quarter breast.
  • Lumpectomy: remove small part of breast.
  • Endoscopy-assisted breast-conserving surgery (EBCS), which has the advantage of a less noticeable scar, was developed more than ten years ago.
  • Breast Reconstruction Surgery or breast prostheses: to simulate breast.

Neo-adjuvant, that is prior to surgery, and Adjuvant that is after and in addition to surgery, medication is used as part of treatment. For example, Neo-adjuvant use of aspirin may reduce the mortality from Breast Cancer.

Adjuvant Therapies

Radiation (negative effect on normal cells) to kill cancer cells in tumour bed and regional lymph nodes that may have escaped surgery. It reduces the risk by 50 – 66 % (i.e., 1/2 to 2/3 reduction of risk). It is confined to region being treated. But only solid tumour can be treated.

Therapies using drugs/agents etc.

  • Chemotherapy (negative effect on normal cells). Uses drugs, usually two or more drugs in combination, to destroy cancer cells.
  • Targeted Therapy that became available in 1990s that uses drugs that inhibit enzymes.
  • Monoclonal Antibody Therapy in which the agent is an antibody
  • Immunotherapy that uses patient’s immune systems to fight cancer using drugs.
  • Hormone Blocking Therapy. Uses Estrogen Receptors (ER +) Tamoxifen and Progesterone Receptors (PR +) Anastrozole that block the receptors.

Experimental Cancer Treatment

  1. Gene Therapy
  2. Ultrasound Energy.

Complementary and Alternative Cancer Treatments

Alternative cancer treatments do not cure cancer. But they may lessen signs and symptoms – such as anxiety, fatigue, nausea and vomiting, pain, difficulty sleeping, and stress  – caused by cancer and cancer treatments. Hypnosis, massage, meditation, relaxation techniques, yoga, acupuncture, aromatherapy, music therapy, and Tai chi – alone or in combination may be beneficial.

But many alternative cancer treatments are unproved, and some may even be dangerous.

Type of Treatment Given

Patients with good prognosis are offered less invasive treatment – e.g. lumpectomy + radiation + hormone.

Patients with poor prognosis are offered more aggressive treatment – extensive mastectomy + radiation + chemotherapy + adjuvant medication.

Treatment Success Rate

If the cancer is detected early, that is at Stage 1, prognosis is excellent and usually chemotherapy is not required.

If detected in Stage 2 & 3 prognosis is progressively poorer with a greater risk of recurrence.  Surgery, chemotherapy, and radiation are required.

If detected in Stage 4, that is metastatic cancer (spread to distant sites), prognosis is poor.  Surgery, radiation, chemotherapy, and targeted therapies are used. But the 10-year survival rate is 5% without treatment and 10 % with optimal treatment.

In India, more than 60% of the BC’s are diagnosed at stage III or IV. Hence the low survival rate.

Psychological and Emotional Aspects

Cancer patients need psychological and emotional support. Besides the family, such support can be given by support groups who are trained and experienced in giving such support. ‘Cancer Sahyog’ is one such support group in India.

Conclusion

Cancer is a 3200-year-old disease. It is endogenous, a part of life-process. So, it can neither be eradicated, nor prevented, nor cured. As yet.

Late detection of cancer is fatal. The causes for late detection are many but lack of awareness is the principal cause. Other main causes are patient being shy, social stigma and doctors’ ignorance because of which the treatment is delayed. An awareness program will address all these issues.

Will some radical discovery in the future make cancer prevention and cure possible? We do not know. But we can always hope.

Because as Richard Causer, Director, NCI, USA, says about the future of cancer cure, “There are far more good historians than there are prophets.”

Breast Cancer Awareness

 

“The only person who can save you is you” – Sheryl Crow

Introduction

Breast cancer is the most common, and the biggest killer, cancer in women in India and worldwide. In India, one woman is diagnosed with breast cancer every three minutes, and one woman dies of breast cancer every six minutes. Out of one hundred breast cancer women, forty-fifty die within five years in India, but less than five die in the US. The difference in death rates is because in India women come for treatment late, when cancer has advanced to  Stage III or IV, and has low survival rate.

Rise in Breast Cancer

Breast cancer in India is rising at a rapid rate. And is affecting younger women, those in 30s and 40s. In 2018, breast cancer had 1,62,468 new registered cases and 87,090 reported deaths. By 2030, the number of cases will rise to about 200,000 a year and deaths to about 100,000 a year. Twenty-five years ago, about 30% patients were blow age fifty. Now, about 50% are.

Improving Survival Rate

Breast cancer survival rate in India is among the lowest in the world because it is detected late. Late detection is because of lack of awareness of breast cancer. Increasing awareness can reduce the death rate. Even if we start a cancer awareness program today, 20-30 years will pass before its effect becomes discernible.

Breast cancer cannot be prevented. But its incidence can be reduced by a few simple lifestyle changes; and the survival rate can be improved by early detection. But let us begin with what is cancer and what is breast cancer.

What is Cancer

Our body is composed of many different types of cells. These cells grow and divide in a controlled manner to produce more cells as required by the body. Also, the older cells and the damaged cells die.

However, sometimes, the genetic material of one cell gets damaged or changed [mutation] and the cell becomes immortal: that is, it will not die. When this ancestor cell dividesits descendant cells are also immortal. This gives rise to a limitless number of immortal descendant cells. The number of cells is far more than what the body needs. The extra cells then form a mass that is called a tumour.

These immortal cells are called cancer cells. The cancer cells are immortal; capable of limitless division, and thus of limitless growth in the number of cells; and capable of spreading [Metises] to other parts of the body through blood and lymph system.

There are more than 100 types of cancers. Not all cancers form tumours. Cancers of the blood and the bone-marrow [leukaemia], for example, do not form tumours.

Most cancers are named for the body part in which they begin: colon cancer, prostate cancer, ovarian cancer, breast cancer and so on.

What is Breast Cancer

Breast consists of lobules (milk producing glands), ducts (tiny tubes that carry the milk from lobules to the nipple) and blood and lymphatic vessels. Breast cancer is a malignant tumour that starts in the cells of the breast. It begins in the ducts; sometimes in the lobules:  and rarely, in other cells of the breast. It then spreads through the breast lymph vessels to lymph nodes under the arms and thence to other parts of the body

Who is at risk of Breast Cancer

Every woman is at risk of breast cancer. In India, one in 28 women will get breast cancer. Certain factors increase the risk of BC.

  • Cancer is a disease of old age: most cancers begin to strike at age 60 and above. But now cancer is also striking, though only rarely yet the teenagers. Risk of breast cancer, for example, is about 0.25% for a 30-year-old woman but increases to about 11% in a seventy-year old. In different countries, breast cancer risk in a 70-year-old is 54% to 154% higher than in a 30-year-old. Thus, as longevity has increased, so has the cancer incidence.
  • Heredity. If first degree relatives [mother/father/brother/sister] had cancer, the risk of cancer is increased.
  • Genetics. A person can be genetically predisposed to get cancer. A woman who has a family history of breast cancer is statistically more likely to get breast cancer. However, only a small percentage, less than 0.3% of population, is genetically disposed to get cancer. And less than 3-10% of all cancers are because of genetic predisposition. In women with BRCA 1 and BRCA 2, the probability of getting breast and ovarian cancer is more than 75%. Mutations in a few other genes [PTEN, CDH 1, TP 53 etc.] also increase the risk though not as much.

Angelina Jolie, Producer | Director | Actress had both her breasts removed in 2013 to reduce the risk of breast cancer because of a gene mutation (BRCA1) she has.

  • Obesity.  In obese postmenopausal women breast cancer risk is twice that of the non-obese women.
  • Diet.Diet contributes to up-to 80% of cancers of colon, prostate and breast; and contributes to cancers of pancreas, lung, stomach and esophagus. Alcohol, red meat, sugar increase the risk of cancer.
  • Smoking, night work, no children or child born after age 30, recent use of oral contraceptives (reverts to normal on stopping), HRT, and Chemicals in environment – increase the cancer risk.
  • Menopause. Late menopause increases the risk.

Reducing the Risk

Healthy weight, physical activity – brisk walking, cycling, swimming – 45-60 minutes five or more days a week, breast feeding, no red meat, less sugar, and less alcohol lowers the risk.

Controversy about whether diet rich in whole grains, fruits, vegetables and legumes and low in total fat (butter, oil), more vitamins, Marine Omega 3 fatty acids (found in seafood (e.g. fish oils) and in walnut, seeds, flaxseed oil etc.), and antiperspirants and bras reduce the risk.  Abortion and Breast Implants have no effect.

Selective Estrogen Receptor Modulators such as tamofoxien reduce breast cancer risk but increase the risk of thromboembolism and endometrial cancer.

So, eat well and exercise and you would have done your bit to reduce your cancer risk.

Depression in Pregnancy

Depression, suffering and anger are all part of being human. – Janet Fitch

Depression is the inability to construct a future. – Rollo May

SYNOPSIS

Depression is a mood disorder, a biological illness, which affects 14-23% of women during pregnancy. Depression makes a woman feel sad, bleak, helpless, anxious, irritable, fatigued and lacking in energy.

Depression can be treated. Left untreated, it can lead the woman to poor nutrition, drinking and smoking causing the babies to be born premature, less active, and have developmental problems. Antenatal depression is a strong precursor to Postpartum Depression.

Depression treatment is psychotherapy, medication, and self-care. Cognitive behavioural therapy (CBT) is the often used psychotherapy. A woman can do it herself after suitable instructions. Medication is antidepressants. These pose a very small risk to fetus. A few supplements are also claimed to help. But these should not be taken without doctor’s advice. Self-care involves proper diet, adequate sleep, exercise, and pregnancy-yoga.

Several women have depression during pregnancy. So, you are not alone. Do not therefore hesitate to speak to your doctor at the first appearance of the symptoms of depression.

INTRODUCTION

Pregnancy is a joyous period for women. But for a few the joy is clouded by mood swings. We all have transitory mood swings. But if these last a few weeks or a few months, then these signal depression.

DEPRESSION

Depressions are biological illnesses caused by changes in brain chemistry. Such changes may be triggered by the hormonal changes during pregnancy. This is called antenatal depression. But except in name, it is similar to clinical depression.

SYMPTONS

Symptoms of depression vary from person to person. But if you have one or more (usually five) of the following symptoms for most of the day, nearly every day, for two weeks or more, it signals depression:
• feelings of sadness, bleakness, hopelessness, and anxiety;
• lack of interest or pleasure in doing anything;
• feeling tired or having little energy;
• difficulty concentrating;
• difficulty remembering.
• feeling emotionally numb.
• extreme irritability.
• sense of dread about everything, including the pregnancy.
• feelings of failure, or guilt.
• trouble getting to sleep, waking up in the night or sleeping too much;
• overeating or decreased appetite.
• weight loss/gain unrelated to pregnancy
• low self-esteem, or feelings of guilt or failure
• fidgeting a lot, or moving and speaking very slowly
• loss of interest in sex.
• thoughts of suicide or self-harm may occur.
• inability to get excited about the pregnancy, and/or baby
• feeling of disconnection with the baby, and an inability to form/feel a bond with the developing baby.

RISK

Anyone can have depression. But the following factors, or a combination of these, increases the risk of getting depression:

• Family history of depression. Risk of suicide also goes up.
• Personal history of depression or anxiety in the past – like during an earlier pregnancy or after the birth of a previous child. Also the risk of postpartum psychosis, a rare but very serious condition that involves hallucinations, increases.
• Life stress events, such as financial problems, the end of a relationship, the death of a close friend or family member, or a job loss.
• Lack of support like having relationship problems or an unsupportive partner or having your baby on your own, or if you feel isolated from friends or family
• Unplanned pregnancy finding out you’re pregnant when you didn’t plan to be.
• Domestic violence and emotional abuse that tend to get worse when you’re pregnant.
• Infertility treatments
• Complications in pregnancy

TREATMENT

Antenatal depression is treatable with psychotherapy, medication and self-care.

Psychotherapy

• Cognitive behavioural therapy (CBT) is the often used psychotherapy. It helps the mother recognise her emotions and counter her negative thoughts. She is encouraged to do CBT herself after step by step instructions in CBT through books and talks; or she may be advised do it in sessions with a therapist.

Medication

• She may also need antidepressants. Not enough evidence is available that these are completely safe to take in pregnancy. A few of these pose a very small risk of birth defects that include fetal heart and skull abnormalities. Doctor weighs the risks and benefits to the mother and to the baby to decide on antidepressants. If the mother was on mental health medication before pregnancy, she should not stop these without asking the doctor. Also, she should not start any medication, including herbal medication, without asking the doctor.
• Supplements. Several supplements such as St. John’s wort, SAMe, Saffron extract, 5-HTP and DHEA are being marketed as being helpful in depression. These seem to help some people but sufficient evidence is not available for their efficacy. A few of these can interfere with prescription medications or cause dangerous interactions and may be unsafe. Consult your doctor before taking any supplements or herbal medication.

Acupuncture

Acupuncture is claimed to help relieve depression. But the evidence for its effectiveness is ambiguous or outright contradictory. The World Health Organization has recognized acupuncture as effective in treating mild to moderate depression. – Dr Andrew Weil in ‘Depression, Health, World, Organization.’

Self-care

Diet, sleep, and physical activity are just as important as medication and therapy — sometimes more so.

Diet and nutrition.

Diet is so important to mental health that a new field of medicine called nutritional psychiatry has grown around it. Many foods have been linked to mood changes, the ability to handle stress and mental clarity.

• Foods to avoid are:

o Alcohol: it depletes serotonin, which makes people prone to anxiety, depression and panic attack.
o Caffeine: It lowers serotonin and increases the risk for anxiety, depression, and poor sleep. Reduce intake of coffee, tea, and hot cocoa.

• Foods to take are those rich in:

o B12 and folate. These prevent mood disorders and dementias. Sources: beetroot, lentils, almonds, spinach, liver (folate); liver, chicken, fish (B12)
o Vitamin D. Its deficiency is associated with different mood disorders. Sources: sun exposure; breakfast cereals, breads, juices, milk; high-quality supplements.
o Selenium. It decreases depression. Sources: cod, Brazil nuts, walnuts, poultry.
o Omega-3 fatty acids. These improve cognitive and behavioral function. Low levels of omega-3 fats leads to mood swings and depression. Sources: cod, haddock, salmon, halibut, nut oils, seeds, walnuts, and algae; high-quality supplements
o Endorphins. These enhance mood and promote a sense of well-being. Source: dark chocolate

Sleep

Lack of sleep (insomnia), or disturbed/obstructive sleep (apnea) are linked to depression. People with insomnia are 10 times more likely to have clinical depression and 17 times more likely to have clinical anxiety, and people with apnea are five times more likely to have clinical depression, than people who sleep normally. To help get sleep, lower room temperature, follow a schedule, avoid naps during the day, listen to relaxing music, try a low carb/high fat diet and eat 3-4 hours before sleep time, exercise, and practice yoga and meditation.

Exercise

Exercise releases endorphins, natural cannabis-like brain chemicals, and other natural brain chemicals, that enhance your sense of well-being. Depression causes tiredness and lack of energy. It may therefore be difficult to begin exercising. So begin with a walk for five or ten minutes and gradually increase to 30-45 minutes a day for three to five days a week. Results will appear after a few weeks because exercise is a long term treatment. Therefore pick up an exercise – walking, cycling, swimming – that you enjoy.so you will continue to do it

YOGA

Yoga focuses on the balance between your mind, body and breath. This balance is created through:

• physical exercises and postures (asanas)
• breathing exercises (pranayama)
• relaxation
• meditation

Yoga improves your physical, mental and emotional wellbeing. It helps you to:

• Improve your circulation, muscle tone and flexibility; to keep the body supple and relieve tension around the cervix by opening up the pelvic region. This prepares to-be-mothers for labor and delivery.
• Alleviate the effect of common symptoms such as morning sickness, painful leg cramps, swollen ankles, lower-back pain and constipation.
• Stay mentally agile through relaxation, breathing and meditation.
• Train you to breathe deeply and relax consciously, helping you to face the demands of labor and childbirth.
• Feel calm, and ease muscle tension.
• Recover faster post-delivery.

If you are already doing Yoga, you may continue to do pregnancy yoga during pregnancy. Since most miscarriages happen during the first trimester, you may, as a precaution, decide not to do Yoga during that period. Although there is no evidence that doing yoga, or any other exercise, during the first trimester will harm your pregnancy.

If you have never before done Yoga, then do not begin it in the first trimester. Begin in the second trimester, after 14 weeks of pregnancy. Join a pregnancy Yoga class. Your instructor will start you gently and slowly and modify the posture to suit the stage of your pregnancy.

Avoid these:

• Lying on your back after 16 weeks.
• Breathing exercises that involve holding your breath or taking short, forceful breaths.
• Strong stretches or difficult positions that put you under strain.
• Lying on your tummy (prone).
• Upside-down postures (inversions).
• Back bends.
• Strong twists.

A study published in Obstetrics & Gynecology in December 2015 found no evidence of fetal distress in any of the 26 postures attempted. These included downward facing dog and savasana. But avoid any poses that feel uncomfortable.

The Art of Living recommends only nine asanas (postures) for pregnancy Yoga. These include Shavasana (Corpse Pose) and Yoga Nidra (Yogic sleep).

You may restart postpartum yoga six weeks after a vaginal delivery; and a longer period after a Caesarean section as advised by your doctor. The postpartum asanas help combat back and neck aches and also help breastfeeding mothers.

ADDITIONAL

To help yourself handle depression:

• Talk about your concerns with your partner, family and friends. They may offer you a proper perspective or practical help. And simply talking about your problems makes these seem more manageable.
• Take time to relax. Give yourself some “me time.” Read, take a calming bath, lunch out with friends, watch an entertaining movie or play. In short do anything that takes your mind away from your concerns and gives you physical and mental relaxation.

DOWNSIDE

Untreated depression can lead to poor nutrition, drinking and smoking. These can cause premature birth, low birth weight, and developmental problems. Babies of ‘depressed’ mothers may be less active, have lower attention span, be more agitated, have behavioral problems and delayed cognitive and language development as compared to babies born to normal mothers.

Antenatal depression is a strong precursor to Postpartum Depression: a major depression in the weeks and months after childbirth. It affects mother’s health and quality of life and also the well-being of the baby. It can cause bonding issues with the baby and can contribute to sleeping and feeding problems for the baby.

CONCLUSION

If you have symptoms of depression, remember, you are not alone. Between 14-23% of women struggle with some symptoms of depression during pregnancy. Antenatal depression can be treated and managed. Most women recover with a few weeks, or a few months, of treatment.

So do not feel shy. Speak to your doctor at the first appearance of the symptoms of depression.

REFERENCES

1. Depression During pregnancy
https://www.babycenter.com/0_depression-during-pregnancy_9179.bc#articlesection1
2. Depression In pregnancy

Depression in Pregnancy


3. Facing Depression During Pregnancy
https://www.webmd.com/baby/features/facing-depression-during-pregnancy#1
4. Depression during pregnancy: You’re not alone
https://www.mayoclinic.org/healthy-lifestyle/pregnancy-week-by- Antenatal depression
5. Antenatal depression
https://en.wikipedia.org/wiki/Antenatal_depression
6. Prenatal Yoga for women to do during pregnancy | The Art of Living …https://www.artofliving.org/in-en/yoga/yoga-for-women/yoga-and-pregnancy
7. Introduction to Pregnancy Yoga – Verywell Fit
https://www.verywellfit.com › Fitness › Yoga › Yoga and Your Health
8. Pregnancy yoga for beginners – BabyCentre UK
https://www.babycentre.co.uk/a1033238/pregnancy-yoga-for-beginners
9. The Complex Relationship Between Sleep, Depression & Anxiety …
https://sleepfoundation.org/excessivesleepiness/…/the-complex-relationship-between-sl…
10. Depression & Sleep – National Sleep Foundation
https://sleepfoundation.org/sleep-disorders-problems/depression-and-sleep
11. Can Acupuncture Treat Depression? – Scientific American
https://www.scientificamerican.com/article/can-acupuncture-treat-depression/
12. Natural remedies for depression: Are they effective? – Mayo Clinic
https://www.mayoclinic.org/…/depression/…/natural-remedies-for-depression/faq-200.
13. Depression and anxiety: Exercise eases symptoms – Mayo Clinic
https://www.mayoclinic.org/diseases…/depression/in…/depression…exercise/art-20046.
14. Exercise is an all-natural treatment to fight depression – Harvard Health
https://www.health.harvard.edu/…/exercise-is-an-all-natural-treatment-to-fight-depress..
15. 20 Simple Ways to Fall Asleep as Fast as Possible – Healthline
https://www.healthline.com/nutrition/ways-to-fall-asleep

Pelvic Inflamatory Disease (PID)

Every human being is the author of his own health or disease.
– Gautama Buddha

SYNOPSIS

Pelvic Inflammatory Disease (PID) is an infection of the female reproductive organs. It is caused by many types of bacteria. If not treated, it can cause complications such as ectopic pregnancy and infertility.

PID affects women in reproductive age. Peak incidence is in women of 15 to 24 years age. India is estimated to have at least one million episodes of PID each year.
Risk of PID increases with risky sexual practices: multiple sexual partners, sex with a person having PID, starting sex at a very young age and having sex without a condom.
PID often has no signs or symptoms. But a few of the symptoms that may appear are: pain in lower abdomen or pelvic pain, heavy or foul periods, bowl discomfort and pain in urination.

There is no single test to diagnose PID. It is diagnosed from symptoms and from gynaecological examination. Urine and blood tests, ultrasound, and laparoscopy may also be used. Because of absence of symptoms, and because the symptoms are similar to those of other diseases, PID diagnosis is often delayed. Woman’s recent sexual partners also need to be tested and treated.

A mixture of antibiotics is used for treatment and is successful in most cases. But a few cases may need laparoscopic or surgical intervention. Removal of intrauterine devices (IUDs) is not necessary.

Because of difficulty of diagnosis, and serious consequences of delayed treatment, empirical treatment may be initiated in at-risk women if symptoms of PID appear. Having regular medical care throughout lifetime maximizes the chances of early diagnosis and treatment of PID.

Improved education, routine screening, diagnosis, and empirical treatment of PID will reduce the incidence and prevalence of PID and its long-term sequelae.

INTRODUCTION

PID, if not treated, can cause ectopic pregnancy, infertility, chronic pelvic pain, cancer, peritonitis and tubo-ovarian abscess – the latter two can become life threatening.

In the US, more than one million women have PID, and more than 100,000 become infertile each year because of PID. In industrialized countries PID-incidence is 10 to 13 per 1,000 in women in 15 to 39 years age-group, with a peak incidence of about 20 per 1,000 women in 20 to 24 years age group. India is estimated to have more than one million PID episodes each year.

CAUSE

PID is an infection of the female reproductive organs – vagina, uterus, fallopian tubes, ovaries, and of womb lining (endometrium) and lining of the inside of the abdomen (peritoneum).

It is a bacterial infection. Many types of bacteria can cause it but in about one in four cases it is caused by sexually transmitted infection (STI) such as chlamydia or gonorrhoea. Sometimes normal, harmless, bacteria in the vagina get past the cervix and into the reproductive organs and cause PID. This can happen when the cervix is damaged after childbirth, miscarriage, abortion and inspection of the womb; or by an earlier PID.

In many cases, the cause of PID is unknown.

RISK FACTORS

Any woman can get PID. But the risk of getting it is increased by:
• Being sexually active and younger than 25 years age
• Having multiple sexual partners
• Having a new sexual partner
• Being in a sexual relationship with a person who has more than one sex partner
• Having a history of PID or STI
• Having sex without a condom
• Douching regularly, which upsets the balance of good versus harmful bacteria in the vagina and might mask symptoms

Having an intrauterine device (IUD) does not increase the risk of PID. Potential risk, if any, is within the first three weeks after insertion.

SYMPTOMS

PID often has no signs or symptoms. But one or more of these symptoms may occur:

• Pain in lower abdomen
• Pelvic pain — especially during a pelvic exam
• Heavy or foul or painful periods with an unpleasant odor
• Unusual vaginal discharge, especially if it’s yellow or green
• Abnormal uterine bleeding, especially during or after intercourse, or between menstrual cycles
• Pain or bleeding during intercourse
• Fever, sometimes with chills
• Painful or difficult urination
• Bowel discomfort
• Nausea and vomiting

See your doctor if you experience any of the above symptoms.

Vaginal discharge with an odor, painful urination or bleeding between menstrual cycles can be associated with STI. If these signs and symptoms occur, stop having sex and see your doctor soon. Prompt treatment of an STI can help prevent PID.

DIAGNOSIS

There is no single test to diagnose PID. It is diagnosed from symptoms and from gynecological examination.

Gynecologist in Delhi will talk about your medical and sexual history and do a pelvic examination to check for any tenderness and abnormal vaginal discharge. This examination may be discomforting, especially if you have PID.

Swabs may be taken from the inside of your vagina and cervix to look for bacterial infection and identify the bacteria responsible. A positive test for chlamydia or gonorrhoea supports the diagnosis of PID. Most women test negative but this does not rule out PID.
Other tests may, therefore, be required to look for signs of infection or inflammation, or to rule out other possible causes of your symptoms. These tests may include:

• a urine or blood test
• a pregnancy test
• an ultrasound scan, which is usually carried out using a probe passed through the vagina (transvaginal ultrasound)

In a few cases, especially the more severe cases, and where there may be other possible causes of the symptoms, such as appendicitis, laparoscopy may be used to look at the internal organs and, if necessary, take tissue samples to diagnose PID. Laparoscopy can also be useful in disproving cases wrongly labelled as chronic pelvic disease.
Recent sexual partners also need to be tested and treated to stop the infection recurring or being spread to others.

Diagnosis of PID can be missed or delayed because of absence of symptoms in the earliest, most curable stage. When symptoms do occur, they can be similar to symptoms of certain other diseases, such as appendicitis, food poisoning or food borne illness, ruptured ovarian cyst, diverticulitis, and ovarian torsion. Therefore have regular medical care throughout lifetime to maximize the chances of early diagnosis and treatment of PID.

TREATMENT

If diagnosed early, PID is treated with antibiotics for 10-14 days. A mixture of antibiotics to cover the most likely infections is given as tablets and injections. Complete the antibiotic course and avoid sexual intercourse during the treatment period to ensure the infection clears completely.

Antibiotics alone are successful in 34-75% of cases. Patients who do not improve in 72 hours are re-evaluated for laparoscopic or surgical intervention and for other possible diagnoses. Laparoscopy should be used if the diagnosis is in doubt. Laparoscopic pelvic lavage, abscess drainage, and adhesiolysis may be necessary. Laparoscopy gives direct visualization of internal organs and of the pelvis and obtaining of cultures for more accurate bacteriologic diagnosis. However, laparoscopy is not always available in acute PID; moreover, it is costly and requires general anesthesia.

If surgical treatment is required, attempt is to conserve reproductive potential with simple drainage, adhesiolysis, and copious irrigation or unilateral adnexectomy, if possible. Further surgical therapy is needed in 15-20% of cases so managed.

Most tubo-ovarian abscess (60-80%) resolve with antibiotic administration. Laparoscopy may be used to identify the loculations of pus requiring drainage. Unresolved abscesses may be drained by colpotomy, laparoscopy, or laparotomy. In patients with recurrent PID, dense pelvic adhesions may render surgery difficult.

Removal of intrauterine devices (IUDs) in acute PID cases is not necessary. But close clinical follow-up is mandatory if the IUD is left in place.

More research is needed to optimize PID diagnosis and treatment; and to improve patient and doctor’s compliance to guidelines.

COMPLICATIONS

Untreated PID may cause scar tissue, and collections of infected fluid (abscesses) in the fallopian tubes, which can damage the reproductive organs.

Other possible complications are:

• Ectopic pregnancy. The scar tissue prevents the fertilized egg from moving through the fallopian tube to implant in the uterus thus causing a tubal (ectopic) pregnancy that can cause massive, life-threatening bleeding and that may require emergency medical attention. PID is a major cause of ectopic pregnancy
• Infertility. PID may damage the reproductive organs and cause infertility. Delaying the treatment, or frequent PID, dramatically increases the risk of infertility. In the US, 1 in 8 women with a history of PID has difficulty getting pregnant; and 15% of infertility cases are because of PID.
• Chronic pelvic pain. Pelvic inflammatory disease can cause pelvic pain that may last for months or years. Scarring in fallopian tubes and other pelvic organs can cause pain during intercourse and ovulation.
• Tubo-ovarian abscess. PID might cause an abscess — a collection of pus — to form in uterine tube and ovaries. If left untreated, this could develop into a life-threatening infection.

PREVENTION

To reduce the risk of PID:

• Practice safe sex. Use condoms every time you have sex, limit your number of partners, and ask about a potential partner’s sexual history.
• Talk to your doctor about contraception. Many forms of contraception do not protect against the development of PID. Using barrier methods, such as a condom, might help to reduce your risk. Even if you take birth control pills, it’s still important to use a condom every time you have sex to protect against STIs.
• Get tested. If you’re at risk of an STI, such as chlamydia, make an appointment with your doctor for testing. Set up a regular screening schedule with your doctor if needed. Early treatment of an STI gives you the best chance of avoiding PID.
• Request that your partner be tested. If you have PID or an STI, advise your partner to be tested and, if necessary, treated. This can prevent the spread of STIs and possible recurrence of PID.
• Don’t douche. Douching upsets the balance of bacteria in your vagina.

INCIDENCE

In a 1995 U.S. study, 8 percent of all women in their reproductive years were being treated for PID. The numbers have steadily reduced. In 2015, the annual visits for PID were down to about 90,000 a year.

Enough data on incidence of PID in India is not available. In one study about 11.55% of the study subjects were diagnosed with PID. In the industrialised world, the incidence is 1 to 2 per cent per year among sexually active women. On that basis, India will have about one million PID cases per year.

REDUCING THE INCIDENCE

Because of difficulty of diagnosis, and serious consequences of delayed treatment, it is recommended that empirical treatment should be initiated in at-risk women who have lower abdominal pain, adnexal tenderness, and cervical motion tenderness. That overtreatment be preferred to no or delayed treatment.

Women with PID should be counselled to abstain from sexual activity or use barrier protection strictly and appropriately until their symptoms and those of their partner have fully abated and they have completed their entire treatment regimen.

Improved education, routine screening, diagnosis, and empirical treatment of PID will reduce the incidence and prevalence of PID and its long-term sequelae. Education should concentrate on strategies to prevent PID and STIs, including reducing the number of sexual partners, avoiding unsafe sexual practices, and routinely using appropriate barrier protection. Adolescents, being at an increased risk for PID, should be advised to delay the onset of sexual intercourse until age 16 years or older.