​ABNORMAL MENSTRUAL BLEEDING

 

Most women have, at least, a rough idea of when to expect their monthly visitors – the menses. But some are not so lucky. The visitor can just decide to barge in at any time. Irregular menses can be very embarrassing, frustrating and distressing. 
I have discussed normal menstrual cycle on this blog before, read it here… http://wp.me/p72X3S-1U

Let’s look at some of the definitions of abnormal menses. 
*Menorrhagia – heavy menstrual flow, which can be described subjectively as the need to change pads more frequently than before. 
*Metrorrhagia – prolonged menses lasting for more than 9 days. 
*Menometrorrhagia – combination of heavy and prolonged menses. 
*Hypermenorrhea – cycle length shorter than 24 days. 
*Hypomenorrhea – cycle length greater than 38 days. 
*Amenorrhoea – absence of menses for 3 or more consecutive months. 
*Inter-menstrual bleeding – bleeding or spotting in between the menstrual cycles. 
*Post-coital bleeding – bleeding or spotting after sexual intercourse. 
*Post menopausal bleeding – bleeding or spotting after menopause (after at least one year of confirmed menopause) 
*Irregular menstrual cycle – more than 7-9 days of disparity in lengths of cycles. 
What are the causes of irregular menses? 

Irregular menses are commoner in pubertal girls (11-14years) and older women who are approaching menopause. Other than these, irregular or abnormal menses can be due to any of the following – 
*Psychological stress, physical exertion, or sudden change in diet, environment, etc. 

*Problems with ovulation 

*Uterine fibroids

*Adenomyosis (a condition in which the uterine lining – endometrium – grows into the wall of the uterus) 

*Use of contraceptive pills and devices 

*Miscarriage 

*Ectopic pregnancy 

*Bleeding disorders

*Hormonal imbalance 

*Infections of the genital tract including the uterus 

*Cancers of the genital tract

*Co-morbid medical conditions such as diabetes, obesity, etc. 

*Some drugs, alcohol, tobacco smoking, etc. 
Management of abnormal menstrual bleeding depends on the cause. You need to visit a doctor who will take a detailed history and carry out some tests to determine the cause. 
Some of the tests you have to do are:

*Pregnancy test

*Ultrasound scan

*Endometrial biopsy 

*Hysteroscopy

*CT scan or MRI, if indicated 

*Full blood workup

*Hormonal profile 
Of course, treatment depends on the cause or definitive diagnosis. This can be medical or surgical. Certain general measures can be used to restore normal menses; such as weight loss and stress management. 
In conclusion, menstrual disorders and irregularities are quite common. It is important to understand the mechanism of normal menses, so as to be able to detect any anomaly and seek professional advice for prompt investigation and treatment. 

ECTOPIC PREGNANCY

a rebellious embryo may decide to implant itself outside the uterus!

After the fertilization of the egg by a viable sperm, the resultant embryo travels from the fallopian tube down into the cavity of the uterus. Implantation occurs when the embryo is attached to the uterine wall and continues to develop until full term gestation.

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However, for reasons that are not fully understood, a rebellious embryo may decide to implant itself outside the uterus!

Ectopic Pregnancies (EP) account for about 11:1000 pregnancies. More than 80% of such rebels implant in the fallopian tube, hence the name “Tubal Pregnancy”, often used interchangeably with EP.

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Other recognized locations of EP are the abdominal cavity, ovaries, cervix and cesarean section scar.

Because of the limited space for growth within the tube or other ectopic sites, rupture and severe internal bleeding could occur starting from 6-8weeks. Ruptured EP is a life-threatening condition and one of the major causes of maternal mortality.

What are the risk factors for EP?

  • Previous history of EP
  • Previous history of infertility and its treatment (assisted reproductive techniques)
  • Pelvic inflammatory disease (PID)
  • Intrauterine contraceptive device use at the time of conception
  • Endometriosis (presence of the uterine lining outside of the uterus)
  • Pelvic or tubal surgery
  • Smoking

The only way to ensure prompt diagnosis and treatment of EP is to have a high index of suspicion by recognizing the telltale signs.

 

The symptoms are variable and non-specific but there is a classical triad reported by many patients:

  1. Missed period (6-8weeks)
  2. Lower abdominal pain
  3. Mild vaginal bleeding or brownish discharge. 

 Other symptoms include:Shoulder tip pain (sign of internal bleeding-ruptured EP),  Sudden collapse (due to severe blood loss)

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    A diagnosis is usually confirmed by identification via ultrasound scan, supported by the level of an early pregnancy hormone known as Human Chorionic Gonadotropin B (BHCG). The modality of treatment depends on the clinical status.

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    *Surgical management – in ruptured EP, with acute severe blood loss, emergency surgical intervention must be done, together with blood transfusion to save the patient. 

    *Medical management – using methotrexate, in clinically stable patients who are compliant 

    *Expectant/Conservative management – in small sized EP and falling BHCG where the body is expected to get rid of the “rebel” by itself. This is reserved for a select few cases.

    Below is a summary of events in a woman with ectopic pregnancy and how the doctor chooses how best to help her.

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    Cervical Cancer

    Cervical Cancer has been attributed to infection with HUMAN PAPILLOMA VIRUS (HPV). HPV infection is usually transmitted sexually.

    …..to her, she was doing this to help her only child whom she gave birth to while in the penultimate year of secondary school.  Regrettably, she said, ‘ i had aborted a couple of pregnancies and had sex with several men while in secondary school and by then i was seventeen because i had to fend for myself as an orphan who had no one to help me, but this child just could not be aborted’.     … that is the result the doctor said. She has stage III cervical cancer at age forty-five…

    Overview

    Womanhood is a world on its own and it takes patience, knowledge, and pity sometimes for one to dabble into such world. They have their own peculiarities in every sphere of life. In the medical world, as cancer remains one monster to deal with, peculiar to women are some cancers like breast, cervical cancer. In this article, I would focus on cervical cancer which from my own little experience most women don’t know about until they come down with it.

    Cervical Cancer

    The cervix ( pronounced: saviks) is the neck or narrow portion of the uterus(womb) where it joins with the vagina. Cancer is simply when cells of a particular tissue undergo uncontrolled (and often rapid) growth. Thus cervical cancer is the cancer of the cervix.

    Cervical cancer is the second commonest malignancy after cancer of the breast in women in developing countries ( Nigeria inclusive) and it remains the leading cause of death in these countries but the third commonest cancer in women in the world. Peak age when women present in Nigeria is 45 to 55 years. However, it is diagnosed in any woman of reproductive age group.

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    The causes have been attributed to

    • Genital infection with human papilloma virus
    • Sex at a young age
    • Multiple sexual partners
    • Promiscus male partners
    • One who had or has a sexually transmitted infections. It is important to point out that HIV infection is associated with a very high increase in risk of cervical cancer.
    • Also, a patient with cervical intra-epithelial neoplasia can progress to cervical cancer

    What makes the Doctor think A patient has it

    *Though, there are some that may not have any symptom but will come to the hospital with abnormal Papanicolaou (Pap smear) result. This is in those that do screening

    * abnormal bleeding from the vagina, majorly after sex

    * bleeding from the vagina between menstrual period or after menopause

    *offensive vaginal discharge which is characteristic

    *pain on pelvic side

    For those women that present late, they may have in addition

    • Backache
    • Leg pain/ swelling
    • Blood in the urine or bloody urine

    Or the doctor investigates by looking at the cervix called colposcopy

    How does the Gynaecologist treat

    The treatment modality depends on the stage of cancer the patient presents with.

    • It may be surgery if it is at the early stage or
    • The use of radiation and chemotherapy for the more advanced cases
    • Or the use of chemotherapy or radiation for palliation for cases that have developed other things from it

    Survival

    There is a similar 5-year survival rates for radiotherapy or surgery for someone with the cancer. This survival also depends on the stage of the cancer. If stage I there is 70-80% survival rate but stage IV has 18% survival rate.

    What is in this for YOU! 

    The major cause of this disease has been attributed to infection with HUMAN PAPILLOMA VIRUS (HPV). HPV infection is usually transmitted sexually. Condom use may not prevent the transmission. The HPV 16 and 18 are the major serotypes of the cause. Thus, a lady or woman who has been introduced to sex life should get screened two years into sex life and every 3-5 years. In essence, those who should have PAP SMEAR done are

    • Ladies who have started having sex
    • Or above age 21

    The American Cancer Society, American College of Obstetricians and Gynaecologist recommend that

    • 21-29 years should have pap smear alone every 3 years
    • 30- 65 years pap smear every 3 years or HPV and cytology testing every 5 years
    • Greater than 65 years no screening recommended
    • Less than 25 no screening recommended because women aged 21-24 are at low risk for invasive cervical cancer but they are at high risk for HPV exposure and associated lesions.

    Any Vaccine.

    The joy here is that, one could be vaccinated against the Human Papilloma Virus (which is not only for girls but also available for boys) but for girls majorly. The vaccine is useful in those who have not had the disease and no usefulness in one who already had it. The two HPV vaccines approved in the United States of America are Gardasil and Cervarix.

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    THE GIST HERE is, please go and get PAP SMEAR done today and tell others about it. It is for your future, in other to live a meaningful life insha Allaah. So please present YOURSELF at any Government health care facility for details.

    …. her sex partners were no longer patronizing her since they got to know about her disease as she even was no longer interested in that. She was no more lively, seems no hope for her. Her Chemotherapy drug has made her loose her hair, no beauty to display any longer. The radiotherapy also played it own part on the pelvis. At last, she gave up the ghost with a repentant soul. Don’t ask me if God would accept such repentance.  I leave YOU TO JUDGE…. this woman, this cervical cancer.

    I.O Dada (Haniif ibn Toyin)

    ABORTIONS

    Abortion is defined as the termination of pregnancy before the age of viability (varies from country to country; 20 weeks in the US, 28weeks in Nigeria) or loss of a foetus weighing 500 grams or less. Abortion can be spontaneous or induced. Some gynecologists often prefer to use the word “miscarriage” for a spontaneous abortion. 

    It is estimated that up to 50% of all confirmed and unconfirmed human pregnancies will result in an abortion. However, by the 8th week of a viable gestation, the chances of a spontaneous abortion occurring drops to only 2-3%.

    Bleeding from the vagina is the commonest symptom of abortion. 30% of pregnant women experience some form of bleeding in the first trimester. About 50% of them will end up with a spontaneous miscarriage. Therefore, it is important to understand that, apart from impending abortion, bleeding during pregnancy could be due to other causes such as:
    *lower genital tract infections 

    *unprovoked or post-coital bleeding due to increased friability of the cervix

    *ectopic pregnancy (implantation of the embryo in any location outside the uterus) 

    *implantation bleeding

    What are the causes of miscarriage? 
    *Genetic causes – foetal genetic anomalies account for 70% of 1st trimester miscarriages 

    *Uterine causes – abnormal anatomy, growths or adhesions

    *Cervical causes – incompetent cervix

    *Infections of the genital tract and other systemic infections 

    *Endocrine causes – such as diabetes

    *Immunologic causes – such as antiphospholipid syndrome 

    *Toxins – such as alcohol, caffeine, high energy radiations, some drugs, etc

    What are the symptoms of abortion? 
    *Vaginal bleeding – from mild spotting to heavy bleeding, can be life-threatening if not treated promptly. 

    *Lower abdominal pain – can be mild to moderate to severe, sometimes no pain 

    *Passage of fetal tissues – clotted blood, fleshy materials, (take note of “vesicles” in case of molar pregnancy) 

    *Gush of fluid from the vagina – ie. amniotic fluid, in second trimester miscarriages 

    *Reduced or NO fetal movement – if the fetal movement has been perceived earlier 

    *Cessation of the usual early pregnancy symptoms 

    *Fever, malaise, vomiting etc – in septic abortion

    Clinical investigations

    -Full history and thorough examination 

    -Complete blood count

    -Blood group – especially Rhesus

    -BHCG levels – to rule out ectopic pregnancy 

    -Pelvic ultrasound 

    -Other investigations to determine the cause, especially in recurrent (>/= 3) pregnancy losses 

    Types of Abortion and their management. 
    *COMPLETE ABORTION – spontaneous expulsion of the foetus and placenta, bleeding stopped and cervix closed. No further management is required except ultrasound to confirm completeness.

    *INCOMPLETE ABORTION – passage of some fetal tissues but not all, cervix is open and bleeding continues. Management – group and prepare blood, IV fluids, medical or surgical evacuation of the remaining uterine contents, +/- blood replacement 

    *THREATENED ABORTION – bleeding but closed cervix. Management – rest and avoid intercourse 

    *INEVITABLE ABORTION – bleeding/rupture of membranes with cervical dilatation but no expulsion of foetus or placenta. Management – expectant, medical or surgical

    *MISSED ABORTION – foetal demise without expulsion, +/- bleeding, cervix closed. Management – medical or surgical. 

    *SEPTIC ABORTION – any abortion associated with uterine infection. Management – IV fluids, antibiotics, followed by surgical evacuation. 


    What are the complications of unsafe abortion or uterine evacuation? 
    If the evacuation is handled by a qualified personnel, using aseptic techniques, the complications are infinitesimally low. 

    Short term complications of unsafe abortion include: 

    *severe blood loss –  which can require blood transfusion and may lead to death if not treated promptly. 

    *infection – septic abortion 

    *uterine perforation 

    *damage to adjacent internal organs such as the bladder and bowels 

    Long term complications include:

    *uterine adhesions

    *menstrual dysfunction 

    *infertility

    IN CONCLUSION 

    -Pregnancy losses more than 3 consecutive times should be thoroughly investigated. A cause can be identified in 50-60% of cases and measures can be taken to prevent subsequent losses. 

    -Patients should be reassured that conception can be achieved within one cycle after complete abortion. The chances of a live birth after 2 or more consecutive miscarriages is up to 50 – 70%

    -A miscarriage can be physically and mentally traumatic. Women should be supported and reassured throughout this trying period.

    Childhood Cancers

    To nurse one child in Nigeria with cancer, you need about N2 million on the average in a period of about two years

    By Drs. Azeezah Shopeyin and Ajayi Abass 

    Childhood cancers occur in children less than 15 years. They are devastating not only to the children but their entire family. In Nigeria, it creates a huge financial burden on the family as there is no supportive treatment plan for children and the cost of treatment is very high.

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    Cancer leads to abandonment of treatment and consequently death of children. Hence, prevention of childhood cancers cannot be over emphasized. It’s important to note that in most fields of medicine, pediatrics have been found to be of significant challenge, because of communication challenges, and caregiver support.

    Burden to public health

    The international agency for research on cancer stated in 2004 that worldwide 160,000 children under 15 years get childhood cancers and 90,000 will die from it every year. In 2007, 71.2 of every 1 million Nigerian children below 15 years had childhood cancers.

    Due to the lack of data in Nigeria, and the paucity of studies on childhood cancers, it is not easy to appreciate the burden of childhood cancers, this might be due to the preoccupation with infectious diseases which are said to cause about 25% of childhood deaths.

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    In an 11year retrospective study conducted in northern Nigeria, by A. Mohammed and A.U Aliyu, it was noticed that childhood cancers were 8.44% of cancers diagnosed within that period. A male: female ratio of 1.5:1.

    In 2014, Consultant Paediatrician, Oncology/Haematology Unit of the Lagos University Teaching Hospital, LUTH, Dr. Adebola Akinsulirie, said about four or five cases of childhood cancer are seen monthly at the LUTH. That will give you about 50 children in a year. That is big as far as cancer in children is concerned in Nigeria. To nurse one child with cancer, you need about N2 million on the average in a period of about two years.

    Types of childhood cancers

    The most common childhood cancers accounting for childhood deaths in Lagos  include kidney cancer (nephroblastoma) and blood cancer (Acute lymphoblastic leukemia and Acute myeloid leukemia)

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    Lymphomas (solid cancer of white blood cells) are also quite common childhood malignancies and neuroblastoma (cancer of nerve cells), others include leukemias, bone and muscle tumors.

    Causal or pre-disposing factors

    The cause of most childhood cancers are unknown in about 75-90% of cases, 5-15% are due to familial and genetic factors( intrauterine viral infections, parental occupational/ radiation exposures, war-torn regions and disasters, elderly maternal age above 35, parental especially maternal smoking and alcohol consumption.

     

    and <5-10 % are due to known environmental exposures and exogenous factors (food, radiation, dyes, infections like intrauterine viral infection Epstein-Barr virus and leukemias/ lymphomas etc). It’s important though to note that cancers generally are caused by a variety of factors and are not limited to a single causative agent.

    How to recognize childhood cancers early

    Complaints about any of the following that does not go away in a child:

    • Feeling of an unusual lump or swelling
    • Unexpected paleness and loss of energy
    • Easy Bruising
    • An ongoing pain in one area of the body
    • Limping
    • Unexplained fever or illness that doesn’t go away
    • Frequent headaches, often with vomiting
    • Sudden eye or vision changes
    • Sudden unexplained weight loss

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    Prevention of childhood cancers

    1. Avoidance of chewing or smoking tobacco.
    2. Protection from sunlight.
    3. Limiting fats in diet
    4. A healthy diet with at least 5 portions of fruits and vegetables per day.

    Management of childhood cancers

    Childhood cancers are managed by a team of specialized pediatric cancer care specialists, including pediatric oncologists, pathologists, radiologists, surgeons, radiotherapists, nurses and support staff include the nutritionist, social workers, pharmacists and other medical specialists. First, a correct diagnosis is made; depending on the stage of the disease from Investigations carried out, the child is given drugs,  and surgical intervention or radiation therapy may be necessary.

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    The challenges in pediatric cancer are numerous but surmountable if there is the will. These are

    1. Recognition of symptoms by parents
    2. Time of presentation/ late presentation
    3. Lack of funds by caregivers
    4. Limited diagnostic equipment/ facilities
    5. High cost of diagnostic investigations
    6. High cost of treatment
    7. Effects of cytotoxic drugs/radiation therapy
    8. Lack of political standing of their own as such children are forgotten in most policies.

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    The above challenges can be solved if

    1. Adequate awareness is provided about childhood cancers
    2. Children are exclusively included in the NHIS
    3. Funding is provided for research into childhood cancers
    4. Facilities for diagnosis and treatment are provided.
    5. Provision of psychological support and social welfare services.

    In summary

    Childhood cancers are a source of significant burden to the child, parents, and caregivers; as such a lot of support is needed; financial, psychological, and spiritual. The distress from the disease, the financial implications, and stress of accessing treatment including the toxicity of the cytotoxic agents is of significant concern, however, children are more likely to recover from cancers when they are detected early and commenced on therapy as quick as possible.

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    Dr. Azeezah Shopeyin graduated from the University of Lagos, college of medicine.With several years experience, she also has a master degree in public health. She’s interested in health education and promotion. She’s a wife and mother of two kids and she enjoys making people happy,

    Dr. Ajayi Abass Oluwaseyi graduated from Ahmadu Bello University in Zaria. Also known as Juggernaut bn Yusuf, he is also a writer, an aspiring Neurosurgeon, and a Farmer. He currently works at the federal teaching hospital in Gombe.

    ENGAGING CANCER

    Cancer starts from errors in coding as a result of mutations which could occur naturally by heredity when cells are multiplying or induced by an external agent

    Cancer is a group of diseases involving abnormal cell growth with the potential to invade or spread to other parts of the body. Not all tumors are cancerous and benign tumors do not spread to other parts of the body.

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    Today, millions of people will march all over the world to commemorate the world cancer day. Irrespective of our religion, tribe, nation and political views, this is the day we highlight to fight this menace that has claimed the lives of millions and shattered the hope of many families.

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    To explain cancer in simpler terms, biology has taught us all living things are made up of cells, be it unicellular (one) as the case of some microorganisms and multicellular (plenty) as the case of humans. The cell is the basic unit of life. Our cells contain the genetic material “genes” located in the DNA. These genes are made up of simple coding which defines the function of the cell.

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     The interactions of these gene replaces cells when they are damaged or need to grow. These lead to the formation and functionality of tissues, organs and different systems in our body. Just like a computer, made up with various coding and algorithms which help different softwares to work and at the long run function in tandem as a computer.

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    Cancer starts from errors in these coding as a result of mutations which could occur naturally by heredity when cells are multiplying or induced by an external agent. Basically, these mutations could occur in genes that control the way cells grow; tumour suppressor genes (TSG) and oncogenes (ONC).

    Tumour suppressor genes function like a break system in a car, it halts the growing of cells while oncogenes function like the accelerator of a car, maintaining the speed or rate at which cells multiply. When either of TSG and ONC is affected, what will happen is either cells multiplying at an abnormal speed leading to the formation of tumour in an organ. This occur due to the inability of TSG ‘brakes’ to reduce the speed or cells multiplying excessively due to much pressure on the accelerator, the ONC.

    Causes of cancer

    Some cancers develop when an individual inherits a bad gene with mutations, an oncogene or a tumour suppressor gene from parents. As the person grows, the mutations increase and finally cancer develops at a particular stage in life. It is like buying a bad computer which eventually develops fault during use.

    Some viruses induce mutations in the coding in these genes leading to cancer. Similar to the way viruses attack our computers leading to the deletion of some important files on the desktop leading to software malfunction and sometimes might affect the hardware.

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    Carcinogens, chemical agents like benzene that can cause cancer when inhaled or consumed can also induce mutations. It is like using a computer to visit bad websites with malwares, installing fake applications or software that is incompatible with your computer. Also, some environmental factors like exposure to radiation can lead to cancer.

    Life style, practices such as smoking can contribute to the induction most cancers. This is similar to personal choices you make with your computer at your own risk, removing a flash drive inappropriately, shutting down your computer unexpectedly or using your computer in an environment where liquids could spill on it. These practices can crash your computer just as a smoker is liable to die young either by lung cancer or other respiratory disorders.

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    Another key risk factor that could initiate cancer is aging. The processes that control cell reproduction malfunctions. This lead to accumulation of toxic reactive oxygen species that damage mitochondria (cell engine). For example, reactive oxygen species above normal levels can oxidize our DNA.

    The cure, Our Hope

    Although we have been blessed with an immune system that could detect and destroy cancer cells, many cancer cells are well equipped to survive and evade these cells. Scientists are left with the option of finding cures for cancer, however, every cancer seems to be different, making it difficult to cure all cancers with one drug. Also, cancers can be well-managed and prevented, telling us cancer is not a death sentence.

    Early detection, you can revive a computer which is dragging or slow as a result of malware or viruses. Install an antivirus as quick as possible, there you go. Taking your car to a mechanic when it flashes check engine, when you notice the grip of the brake has reduced or when the clutch smells will definitely prevent a sudden disaster when driving.

    As well, early detection of cancers will significantly increase the chances of survival. Doctors would administer different form of therapies just like an antivirus in a computer. Cancerous cells would die and in many cases total remission could occur. However, successfully scanning and deleting the virus on your computer does not assure you your computer can not be infected again, hence, Cancer patients who are in remission can also have reoccurrence.

    Some cancers are gender specific, some are age specific, like prostrate cancer and there are recommendations for when to start detecting them.

    Positive lifestyle, practices such as eating fruits and vegetables, exercising, quitting smoking, maintaining a clean environment and avoiding junks can reduce the risk of cancer. Recent studies have discovered that processed meats, canned foods, over cooking food such as brown bread could cause cancer.

    The Future, Cancer will one day be treated like any other disease with significantly reduced mortality rate. The approach to getting a cure is like traffic rules, using camera speed checkers on the road to prevent excessive speeding of cars and arrest those who over-sped by giving them a surprise ticket when they get home. We would one day detect and arrest rouge cells before the progression of cancers. The use of bumps on roads to prevent over-speeding and also slow down drivers, we are already slowing down the rate at which ONC drive our cells to induce cancer. In the nearest future, our immune system will boosted and trained to apprehend bad drivers of our genes.

    Mahmud Abdullah Opekitan attended Obafemi Awolowo University, Ile-Ife, Osun state, Nigeria between 2008 and 2011 bagging a B.Sc Hons Microbiology with a Second Class, Upper Division. He Also has a Master of Biomedical Science degree in Biomolecular Science- With Distinction. He’s currently wrapping up his Phd in Cancer Biology from Strathclyde Institute Of Pharmacy And Biomedical Sciences. 

    ​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.