​PELVIC INFLAMMATORY DISEASE AND ITS SEQUELAE

The female genital system consists of the lower and upper genital tracts. Anatomically, the lower tract consists of the vulva, vagina and cervix while the upper part consists of the uterus, fallopian tubes, ovaries and the supporting tissues. Pelvic inflammatory disease (PID) is the infection of the upper genital tract, plus or minus the ovaries. 

PID is often referred to as an ascending infection because the upper tract is relatively free from microorganisms compared to the lower tract which contains several harmless bacteria called “the normal flora”. There is a barrier at the level of the cervix. If this barrier is breached for any reason, the bacteria would ascend to the upper tract, causing PID. 

Most PIDs are sexually transmitted, chiefly due to Neisseria gonorrhoea and Chlamydia trachomatis. Infection can also occur following instrumentation or surgical procedures whereby the cervix and uterus are accessed from below (eg. D&C, cervical/endometrial biopsy, hysteroscopy, intrauterine contraceptive device insertion, etc.) 


What are the common signs and symptoms of PID? 
*Lower abdominal/pelvic pain – usually starting after the menstrual period. 

*Low back pain 

*Fever

*Nausea and vomiting 

*Abnormal vaginal discharge – can be absent 

*Loss of appetite 

*Dysmenorrhoea (menstrual pain) 

*Dyspareunia (painful sexual intercourse) 

***Note that PID can be totally asymptomatic and the first sign could be an incidental finding of a complication in a chronic case. 
***Other diseases that mimic PID must be ruled out. These include acute appendicitis, acute gastritis, urinary tract infections and problems of early pregnancy. Of course, pregnancy must be excluded as most patients are sexually active. 

As noted above, most cases of PID go silently without symptoms. Some could resolve spontaneously and others progress chronically to complications. Once you notice any of the symptoms, it is important to see your doctor immediately. The doctor would take a detailed history, examine you and request that you do some tests. Some of the tests you should do include:

*high vaginal swab – for microscopy, culture and other advanced (DNA-based) tests

*full blood count – to check for elevated white cell count 

*pelvic ultrasound – to detect possible tubo-ovarian abscess (collection of pus around the ovaries) 

*renal and liver function tests – in complicated cases

*laparoscopy – the gold standard for diagnosis, but not always necessary 

*other tests to rule out differential diagnosis eg. Urine analysis and culture 


What are the long-term complications of untreated or poorly treated PID? 
*Infertility – due to adhesions in the tubes and ovaries (20% following one episode of PID, increasing with recurrent episodes) 

*Chronic pelvic pain

*Increased risk of ectopic pregnancy (implantation of embryo outside the uterus, mainly due to adhesions) 

*Transmission to sexual partner

*Septicaemia, septic shock and possibly, death. 


Treatment

Antibiotics should be started as soon as diagnosis is established. Usually, a combination regimen is used to cover a wide range of bacteria. Specific antibiotics must be used for specific bacteria isolated from the lab tests. Intravenous forms are preferred in severe cases, but can be switched to oral after 24-48hours. It is important to trace all recent sexual partners and let them get treated. Other STDs (such as HIV, Hepatitis B, etc) should also be tested for and managed as appropriate. 


How can PID be prevented? 
*General screening of “at risk” individuals, such as sexually active young women, those with multiple sexual partners, pregnant women, HIV positive persons, etc. 

*Promotion of abstinence from indiscriminate sexual activities 

*Use of condom

*Mutual faithfulness between sexual partners 

*Prompt treatment of acute disease to prevent chronic disease and it’s complications.

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​WEIGHT MANAGEMENT BEFORE, DURING AND AFTER PREGNANCY

A lot of women keep wondering if it is possible to control their weight during pregnancy and lose weight after childbirth. The answer is YES, it is possible. Before we proceed, let’s talk about the Body Mass Index (BMI). Your BMI is a measure of the appropriate weight for your height. You can calculate this by dividing your weight(in kg) by the square of your height(in meters). It is expressed as kg/m2 . 

Optimum BMI for women is defined as 18.5 to 24.9 kg/m2 . As a result of the developing fetus/placenta, expanding uterus, increasing blood volume and amniotic fluid, weight gain is inevitable. However, your rate and target of weight gain depends on your pre-pregnancy BMI. Therefore, a slim woman needs to gain more while an obese woman gains less, but strict weight loss should be postponed until after delivery. 

The best approach to maintaining healthy weight throughout pregnancy and beyond is to start BEFORE pregnancy. If you get pregnant with an healthy weight, chances are high that you will maintain a steady weight gain and then, lose all the weight thereafter. Overweight and obese women with increase weight gain, are more likely to have adverse pregnancy outcomes – gestational diabetes and hypertension, big babies and difficult delivery. Underweight women also stand a high chance of developing complications like miscarriages and small-for-age babies. 

Women can achieve and maintain a healthy weight by:

*Eating simple starchy foods and whole grains, such as brown rice, whole wheat bread, potatoes, yam and pasta

*Eating fibre-rich diet such as fruits and vegetables, oats, beans, peas and lentils. 

*Eating at least 5 portions of fruits and vegetables as daily snacks, instead of sweets and pastry junks. 

*Minimising high calorie foods (like cakes and fizzy drinks) and choosing low-fat foods instead. 

*Eating breakfast because when you skip breakfast, you’re more likely to overeat during the rest of the day. 

*Eating small portions of meals and snacks. Small portions every 3 hours is more preferred to 3 binges 3 times daily. 

*Exercising daily – walking, swimming and gardening, taking the stairs instead of the elevator, etc. Working women should take short walks every now and then, especially at lunchtime. 

*Minimising sedentary activities such as watching television, using the computer and playing video games. 

*Attending antenatal clinics regularly and keeping track of your weight at each visit – you can also buy a bathroom weighing scale to check at home. 

*Attending post natal clinic after delivery and enrolling in weight loss programmes designed for new mums. 

*Breastfeeding your baby exclusively, as this helps you to lose the baby weight quickly (among other benefits)

*Liaising with a dietician to help calculate your calorie needs, especially if you’re diabetic. 

Furthermore, we need to dispell common myths concerning nutrition and weight in pregnancy. There is no such thing as “eating for two”. You eat when you feel hungry and whatever you feel like eating (of course, with the exception of the unhealthy eating habits highlighted above). Conversely, you don’t have to starve yourself for the fear of gaining too much weight or having a big baby. If you’re ever in doubt, ask your midwife or obstetrician. 

Reference: National Institute for Health and Care Guidance, UK (PH27, July 2010) 

Depression

You can’t love others if you don’t love yourself and you are selfish if you love yourself too much because few would embrace you. If you don’t love yourself at all, you need help, not death.

“Since the robbery, I have cried all day and night, I can’t believe I have lost it all, ahh! I am so sad, in fact, I am depressed, she said”

DEPRESSION IS NOT SADNESS

Sadness, like excitement, is a normal reaction to an unpleasant situation or life difficulties. Often times, however, ‘I am depressed as used in the story above is used synonymously with I am sad. By extension reducing the reality of the illness to just a mood- sadness. This misconception is what birth statements like “snap out of it”, “man up”, “you are just making a big deal out of it”.

Depression is a mental illness, associated with low mood, decreased energy, low self-esteem, loss of interest in previously exciting activities, appetite disorder (loss or excessive), a feeling of guilt, thoughts of death and disturbed sleep. Depression is way beyond sadness.

Signs and Symptoms of Depression

“It started with my being unable to sleep, but it soon got worse. I lost weight drastically and started experiencing somatization- chronic physical pains in various parts of my body, making me very weak and low-spirited, but no one at the time understood what I was talking about”.  

Again, sadness is not depression, sadness could for some is only a small part of depression and some others may not feel sadness at all. Depression has many other symptoms, including physical ones. If you have been experiencing any of the following signs and symptoms for at least 2 weeks, you may be suffering from depression:

  • Decreased energy, fatigue, being “slowed down”
  • Difficulty concentrating, remembering, making decisions
  • Persistent sad, anxious, or “empty” mood
  • Feelings of hopelessness, pessimism
  • Feelings of guilt, worthlessness, hopelessness
  • Loss of interest or pleasure in hobbies and activities
  • Difficulty sleeping, early-morning awakening, or oversleeping
  • Appetite and/or weight changes
  • Thoughts of death or suicide, suicide attempts
  • Restlessness, irritability
  • Persistent physical symptoms, e.g. diarrhea

Types

There are different types of depressive disorders and based on symptom severity, depression can range from mild to severe to very severe condition

Major depression

Major depression is sometimes referred to as clinical depression, unipolar depression or major depressive disorder. It involves low mood and/or loss of interest and pleasure in usual activities, as well as other symptoms for at least two weeks. Symptoms of depression interfere with individual’s daily life and normal functioning. Depression can be described as mild, moderate or severe; melancholic or psychotic (see below).

Melancholia

This is the term used to describe a severe form of depression where many of the physical symptoms of depression are present particularly slow movement. It is also characterized by complete loss of pleasure in everything or almost everything.

Psychotic depression

Sometimes a depressive disorder can be accompanied by loss \of touch with reality and experience psychosis. This can involve hallucinations (seeing or hearing things that aren’t there) or delusions (false beliefs that aren’t shared by others), such as believing they are divinities, prophets or evil, or that they’re being watched or followed. They can also be paranoid, feeling as though everyone is against them or that they are bad omens.

Antenatal and postnatal depression

In the days or weeks following birth, many women experience ‘baby blues’ which is a common condition related to hormonal changes and affects up to 80 percent of women. The ‘baby blues’, are common experiences, but are different from depression and tend to decrease within a week or two. Depression is longer lasting and can affect not only the mother but her relationship with her child, the child’s care and development, the mother’s relationship with her partner and other members of the family. Almost 10 percent of women will experience depression during pregnancy. This increases to 16 percent in the first three months after having a baby.

Bipolar disorder

In bipolar disorder, the person experiences periods of depression and periods of mania, with periods of normal mood in between. Mania is the opposite of depression, characterized by extremely “high” moods, energized behavior, having racing thoughts, little need for sleep, difficulty concentrating and feeling frustrated and irritable. It may sometimes affect the person’s touch with reality and has episodes hallucinations (seeing or hearing something that is not there) or having delusions (e.g. the person believing he or she has divine powers).

Bipolar disorder tends to run in families. Stress and conflict can trigger episodes for people with this condition and it is common for bipolar disorder to be misdiagnosed as depression, alcohol or drug abuse, attention deficit hyperactivity disorder (ADHD) or schizophrenia. A mild form of bipolar disorder is cyclothymic disorder

Seasonal affective disorder (SAD)

SAD is a mood disorder that has a seasonal pattern. The cause of the disorder is unclear, but it’s thought to be related to the variation in light exposure (Sunlight) in different seasons. Depression which starts in winter and subsides when the season ends is the most common.

Causes

“Mopelola was noticed in September in the year 2014 to be unduly withdrawn from people including keeping away from her friends on the ground that nobody loves her; almost at the same time, she has also been seen not to be participating in some of the church activities that were known to be pleasurable to her. Within a month of the onset of the condition, she has been observed to have reduced appetite for food as she claims that she has a need to engage in fasting and prayers to combat some negative thoughts that were running through her mind, such thoughts according to her include but not limited to thoughts of not “good enough, being worthless and useless and that there was nothing good about her future”. Consequently, she felt unhappy all the times and sometimes got angry at others around him. This condition has affected her ability to concentrate on her JAMB coaching class and her level of concentration has dropped significantly. Her parents in their state of being bewildered to have made many spiritual attempts to ameliorate the problem, only minimal improvement was noticed”

The thought that depression is mood-sadness, and sufferers being individuals “who can’t just get over it” consequently make the misconstrued cause of depression to be Weakness. Religious affirmations that link spiritual weakness to depression further make appropriate treatment less sought.

Depression like all illness have factors that play a role or make an individual vulnerable. They include;

  • Traumatic events
  • Other mental health problems
  • Physical health problems e.g. chronic or life-threatening health problems
  • Genetic inheritance
  • Childhood experiences such as neglect, loss of parent(s)
  • Medication, substance and alcohol abuse.
  • Sleep, poor nutrition, and exercise

Treatment

Depression – even the supposed worse cases – can be treated and individuals can recover and live a productive life. Like all illness, early detection and treatment greatly affect treatment outcome. The earlier the better.

While many may still argue that depression is caused by spiritual weakness or attack, I advise that while deliverance and other spiritual approach are being sorted, kindly visit a doctor. The goal is to be better, isn’t it? The first step to recovery is seeking help, speak to a doctor, your doctor may then refer you to a specialist after physical problems have been ruled out.

Depression depending on the diagnosis made can be treated with medications or psychotherapy or both. Treatment is often times individualized.

Depression can occur to anyone and at ages

According to the World Health Organization (WHO), depression is the leading cause of disability worldwide, and at least 350 million people are affected worldwide, this could be higher considering denial and treatment abstinence based on misconceptions or ignorance could hinder diagnosis in some sufferers. Although a common illness, it affects individuals differently

Depression in Women.

Women with depression do not all experience same symptoms, however, symptoms of sadness, worthlessness, and guilt are typical symptoms women have.

Depression is twice as common among women as among men. Hormonal fluctuations during puberty, menstruation, pregnancy, childbirth and menopause are probable causes amongst other factors such as genetics and abuse.

Depression in Men

Men although less likely than women also suffer depression and manifestations in men differ from those in women. Men are more likely to react to life difficulties with denial, anger, violence or substance and alcohol abuse. Some men may throw themselves into their work to avoid talking about their feelings or behave recklessly. Although more women attempt suicide, many more men die by suicide.

Depression in Children

Children are particularly thought to be free-spirited and do not “think”, hence can’t suffer depression.

“Most studies concur that about 1% to 2% of pre-pubertal children and about 5% of adolescents suffer from clinically significant depression at any one time and by the age of 16 years 12% of girls and 7% of boys would have had a depressive disorder at some time in their lives”.

The implication of the above is that in a primary school of about 300 children at least 3-6 of them will be depressed at any one time. Children with depression may pretend to be sick, refuse to go to school, cling to a parent or become excessively anxious. The normalcy of children makes recognition a bit difficult, however, a change in the initial behavioral or academic pattern are major red flags to watch out for.

Depression in Teens

As children grow into teenagers and adolescent, parental acceptance is second to peer acceptance, coupled with hormonal changes, teenage years can be tough and irritable moods are expected.

However, depression in teenagers often presents with persistence in irritability (hostile, easily frustrated, angry outbursts), hypersomnia, increased appetite or loss of it, extreme sensitivity to rejection (criticism). Depression if left untreated may manifest fully in reckless behavior, substance abuse or school desertion.

Unlike in adults, children and teenagers rely on adults (parents, teachers, and caregivers) in recognizing and helping them get help as ignorance of their feelings or their natural dependence may prevent them from getting help.

Takeaway

Prevention is better than cure, early detection and treatment will prevent disease progression

Self-care tips and general lifestyle modifications can help manage the symptoms of many mental health problems, and may also help to prevent some problems from developing or getting worse.

Reference

Depression in children and adolescents, 2015 edition by; Joseph M Rey, Tolulope T Bella-Awusah & Jing Liu pg. 2

Shadows in the Mirror by; Dr. Vivian Ikem

 

 

 

Rukayat Ogunbiyi is a Pharmacist and Public mental health advocate, inclined towards child and adolescent psychiatry. She was trained as an intern at the Federal Neuropsychiatric Hospital, Yaba. She is currently set to resume post graduate studies in Child and Adolescent Mental health at the Center for Child and adolescent mental health in University of Ibadan.

Anxiety and co…

Anxiety disorders are the most commonly encountered psychological disorders among adults

If you have never felt anxious, something is wrong with you. It is okay to worry temporarily especially when we have to make important decisions when we are faced with a challenge or a test/exam. However, it is a different case entirely when this is blown out of proportion. Anxiety disorders are the most commonly encountered psychological disorders among adults and they interfere with performance, relationships and other healthy daily activities.  Have you read about Stress?

Anxiety disorders are the most commonly encountered psychological disorders among adults and they interfere with performance, relationships and other healthy daily activities.

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Nobody wants to be labeled as crazy, especially in an African society where stigmatization thrives like wild-fire. For this reasons, critical issues pertinent to assessing anxiety disorders are bordered on;

  • Sensitivity to making the diagnosis
  • Anxiety in a mask of productivity
  • Other psychiatric diagnoses associated with it
  • Medical conditions and medications that can cause or exacerbate anxiety disorders.

Risk Factors

  • Shyness, or behavioral inhibition, in childhood
  • Being female
  • Having poor economic resources
  • Being divorced or widowed
  • Exposure to stressful life events in childhood and adulthood
  • Anxiety disorders in close biological relatives
  • Parental history of mental disorders

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The anxiety disorders that will be examined in this write-up will include:

  1. Panic disorder
  2. Generalized anxiety disorder
  3. Obsessive compulsive disorder
  4. Post-traumatic stress disorder
  5. Social phobia and specific phobia.

As each disorder is explored, emphasis will be placed on assessment of commonly encountered psychiatric and medical conditions that contribute to anxiety symptoms. However, before considering the specific anxiety disorders to be presented in this program, it is useful to highlight the following issues:

Psychiatric Disorders associated with Anxiety Disorders

  • Major depressive disorder
  • Substance abuse disorders – alcohol, marijuana
  • Somatization disorders (fatigue, chest pain, headache, insomnia, non-specific GI complaints)
  • Complex anxiety disorders – ( Post-traumatic stress disorder with Panic disorder)

Medical Conditions associated with Exacerbating Anxiety

  • Hyperthyroidism
  • Adrenal Dysfunction
  • Angina
  • Hypoglycemia

Medications and Substances associated with Exacerbating Anxiety

  • Stimulants (Amphetamines, caffeine, cocaine, and other over the counter “natural stimulants”)
  • Withdrawal from drugs, including alcohol
  • Heavy metals and toxins
  • Steroids
  • Rapid withdrawal from some antidepressants

General Action plan in dealing with anxiety and associated disorders

  1. Assessment for suicide risk, particularly in patients with depression and panic disorder, substance abuse or high levels of agitation.
  2. Identification of severity of anxiety disorder (chronic or episodic)
  3. Identification of substance abuse
  4. Assessment of key symptoms of panic disorder, fear of dying and/or fear of going crazy
  5. Assessment for depression or other mood disorder
  6. Inquiry as to the presence of anti-social behavior
  7. Exploration of presence of precipitating event or trauma
  8. Being alert to people with anxiety disorders who have insomnia, headache, non-specific GI complaints, cognitive complaints

We will be talking extensively about mental health and major associative conditions in the comings weeks. Stay tuned. Read about Stress here.

Harmattan Blues: Medical conditions that come or worsen with this harsh weather

The Harmattan is a dry and dusty wind which blows from the Sahara Desert over the West African subcontinent between the end of November and the middle of March. It is cold in some places and hot in others, according to differing circumstances.

The Harmattan brings desert-like weather conditions:

  • it lowers the humidity
  • dissipates cloud cover
  • prevents rainfall formation
  • creates big clouds of dust

Effect on our Health

Skin Conditions

Dry skin: (because of obvious loss of moisture) you may have cracked lips, cracks in the sole of the feet and even the skin itself. Some cracks even become ulcerated. Those with have a natural dry skin tends to have scales and blisters on their skin during this period

Also, when the weather is cold, Infants, children and the elderly are more vulnerable to a low body temperature (hypothermia; below 35 degrees centigrade) due to a sub-optimal temperature regulating mechanism.

Remedy

  • Keep lips and skin well lubricated: Shea butter does a great job.

ENT

Nose problems

Spontaneous nosebleeds are common for some people because the nose is at the forefront, takes in the dry dusty air that we breathe. So the nose tries to warm the air, acting like a conditioner, before it’s transported to the lungs where the air is utilized optimally.

The humidifying effect of the nose on the air leads to a dry mucous lining of the nose and induces a lot of nose picking. Excessive nose pickings or violent sneezing against a blocked nostril can damage blood vessels within the nose. The bleeding is usually from just one nostril and would need urgent medical attention

Remedy

  • When the air is really harsh, even breathing can become painful, thus, steam inhalation comes in handy. Thi will have a moisturizing effect that will soothe the nose.
  • Use a face mask when traveling through very dusty regions
  • Always have your antihistamine if you are prone to excessive sneezing from allergic rhinitis

Eye disorders (Acute red eyes)

Apollo (Viral Conjunctivitis) is very common from the mid-November month and is caused by a virus that the wind sweeps along its path. Although the virus is self-limiting, it can be a nuisance as it infects all family members if care is not taken. Also, there is a risk of secondary bacterial infection.

Allergic Conjunctivitis: when the eyes are exposed to the dust particles, mites, and pollen carried by the dry, cold and dusty wind, they can also irritate the conjunctiva leading to itching, redness, and a feeling of having foreign bodies in the eyes. Also, excessive dust particles and other infections may irritate the cornea, leading to acute keratitis which also presents with red eyes, eye discharge and other symptoms similar to conjunctivitis.

Remedy

  • Have nasal and plain/anti-allergic eye drops
  • General covering of the head is beneficial
  • maintain good personal hygiene

Ears

Due to the connection between the nose and the throat and the ears, some people who are prone to having ear infections finds this period a nightmare. They have blocked ears which may also have a purulent discharge as infection passes through the eustachian tube. Also, dust may get trapped in the ear and lead to infection of the middle ear, called otitis media.

Remedy

  • Use mildly wet wool to clean the ears
  • See a doctor if you have serious pain and discharge from the ear, you may need antibiotics

Other Infections

It is important to remember that meningitis caused by a meningococcal infection is usually experienced between February to May in the ‘meningitis belt’ and some parts of Nigeria. Thus, routine immunizations should be a top priority.

Blood

The harmattan also triggers sickle cell crisis in those with sickle cell anemia. Oxygen in blood is usually reduced in extremes of temperatures, like the cold or heat this weather serves. This extremity can induce the blood cells to coagulate under this external stress, and combined with the dehydration,  Thus, it is important that people with Sickle cell disorder take extra precautions, keep warm, and increase their water intake.

Remedy

  • They should just communicate properly with those around them to achieve a stable, healthy environment
  • They should seek medical help immediately when symptoms of a crises ensue.

Respiratory system

Asthma: After the air leaves the nose, some unfiltered allergens (pollens, dust, mites) can still reach the lungs thus leading to aggravation of asthma. A special precaution to reduce exposure to the dusty atmosphere is imperative for asthmatics and in addition, having their inhaler with them all the times is advisable.

Respiratory infections

  • Pneumonia: The dust particles may overwhelm the system and predispose it to infection. It is common place to experience excessive sneezing, cough and catarrh.
  • Flu is a contagious respiratory illness caused by influenza viruses and can cause mild to severe illness
  • Superimposing bacterial infection can take advantage of any imbalance and must be aggressively treated with appropriate antibiotics.

Remedy

  • Prompt treatment of respiratory symptoms like a cough, catarrh, and others is important.

Other recommendations

  • Air-conditioners should also be serviced to avoid harmattan induced symptoms. Wipe windows, fans with wet rags.
  • Wearing weather friendly dressing is advised. Citizens at this time should seek means of keeping warm especially by putting on warm clothing.
  • Proper eye hygiene and care in form of washing with clean water reduce exposure to dust and use of protective spectacles is encouraged during this period.
  • Take more liquid, especially water, during harmattan to prevent dehydration and heatstroke.
  • Observe a high level of personal hygiene to prevent the spread of the virus.
  • Drive carefully due to reduced visibility; try not to have an allergic attack while driving as well
  • Stay alerted; not only are fire outbreaks common observe your surroundings and not fall a victim to other’s carelessness or misfortune.