Abnormal Uterine Bleeding in Adolescents: A Multidisciplinary Approach.

Abnormal uterine bleeding is the most common complaint that motivates female adolescents to seek medical advice. Abnormal uterine bleeding has a significant impact on quality of life, promoting school absenteeism and limitations in social life. Moreover, episodes can vary from mild to life threatening events if not recognized and treated promptly. Healthcare providers should be able to distinguish between a normal and abnormal menstrual pattern, as this may provide early diagnosis of a potential health concern. The PALM-COEIN classification system should be used in the evaluation. Anovulation is the most frequent cause, frequently due to immaturity of the hypothalamic-pituitary-ovarian axis. A careful history and physical examination are crucial in the differential diagnosis. Management is based on both the underlying cause and the severity of bleeding. Most patients improve with pharmacological treatment, frequently requiring a multidisciplinary approach. First line treatment consists of hormonal therapy. Surgery is rarely needed. Although the prevalence of abnormal uterine bleeding is higher in adolescents compared to adults, most recommendations are not specific for this age, which makes the diagnosis and management challenging. The literature reveals lack of standardized care for adolescents and regimens vary widely. Future studies on efficacy and safety of treatments specifically in adolescents are needed.

A hemorragia uterina anormal constitui a queixa que mais frequentemente leva as adolescentes a procurar cuidados de saúde. Esta situação tem um impacto significativo na qualidade de vida, levando a absentismo escolar e limitações na vida social. Os episódios podem variar de ligeiros a potencialmente fatais, se não reconhecidos e tratados rapidamente. Os prestadores de cuidados de saúde devem ser capazes de distinguir um padrão menstrual anormal, uma vez que isto poderá permitir o diagnóstico precoce de um grave problema de saúde. A classificação de PALM-COEIN deve ser usada na avaliação. A causa mais frequente é a anovulação, frequentemente associada a imaturidade do eixo hipotálamo-hipófise-ovário. A história clínica e um exame objetivo cuidado são cruciais no diagnóstico diferencial. A abordagem terapêutica deve ser baseada na etiologia subjacente e gravidade da hemorragia, sendo frequentemente necessária uma intervenção multidisciplinar. A maioria das doentes melhora com tratamento farmacológico, cuja primeira linha é constituída pela terapêutica hormonal. O tratamento cirúrgico é raramente necessário. Apesar da prevalência ser superior em adolescentes, a maioria das recomendações não são específicas desta idade, o que dificulta o diagnóstico e abordagem. A literatura revela falta de uniformização de condutas em adolescentes e os esquemas posológicos são muito variáveis. Por este motivo, é fundamental a realização de estudos sobre a eficácia e segurança dos tratamentos nesta faixa etária.

Arterial hypertension as an inaugural sign of myomatous uterus.

Uterine fibroids can be large enough to cause mechanical obstruction of pelvic ureters, which may result in hydroureters and hydronephrosis. Renal impairment frequently results in hypertension due to increased activity of the tubuloglomerular feedback system and renin-angiotensin-aldosterone axis. This process, however, seems reversible because normalisation of blood pressure is possible after the relief of renal obstruction. We report a rare case of a nulliparous woman with a myomatous uterus and an isolated initial complaint of high blood pressure. After proper diagnostic investigation, a uterine mass of 20 cm causing bilateral hydronephrosis was discovered. A successful myomectomy was conducted, which achieved an intact endometrium lining with posterior normalisation of blood pressure.

Surviving cancer or future motherhood? Both are possible: an Ewing sarcoma case in an 8-year-old girl.

Ewing's sarcoma is an aggressive tumour, common in paediatric age, in which treatment often implies a decrease in reproductive potential. We describe a case of a woman who had a lumbar Ewing's Sarcoma in 1991, at the age of 8. She was submitted to extended tumourectomy, chemotherapy and local radiotherapy without preservation techniques. In adult life, and after two in vitro fertilization (IVF) reproductive cycles without success, she spontaneously conceived at the age of 32. After an uneventful pregnancy, she delivered a healthy child by caesarean section. This is a rare successful case of a spontaneous and uneventful pregnancy without previous preservation techniques. In the last 30 years, there has been significant development in this area, and currently, there are solutions for these patients, including in prepubertal age.

[Medically Assisted Reproduction in Natural Cycle: Outcome Evaluation of a Reproductive Medicine Department]. / Procriação Medicamente Assistida em Ciclo Natural: Avaliação dos Resultados de um Departamento de Medicina da Reprodução.

INTRODUCTION: Medically assisted reproduction in natural cycle has been investigated, especially in women with poor response to conventional ovarian stimulation, with endometrial receptivity improvement, lower cost and possibility of successive cycles. The disadvantages are: lower profitability per treatment cycle and higher cancellation rate. The aim of this study was to determine the rate of clinical pregnancy in infertile women subjected to medically assisted reproduction in natural cycle. MATERIAL AND METHODS: Retrospective study of 149 medically assisted reproduction without ovarian stimulation of 50 infertile women, between January/2011 and October/2014. RESULTS: The mean age of women undergoing medically assisted reproduction in natural cycle was 36.1 years. Approximately half (46.0%) of the cycles were performed in poor responders. On the day of ovulation trigger, the mean diameter of the follicle was 17.5 mm. Twenty-three cycles (15.4%) were canceled prior to ovulation trigger. In 8 cycles (5.3%), ovulation occurred between ovulation trigger and oocyte retrieval. In the majority of cycles (n = 118; 79.2%) oocyte retrieval was executed, a medically assisted reproduction technique was performed in 71 (47.6%), mostly intracytoplasmic injection. The overall fertilization rate was 77.5%. In 40 cycles (26.8%) there was embryo transfer. The implantation rate and the clinical pregnancy rate by embryo transfer was 35.0% and 25.0%, respectively. Most pregnancies occurred in poor responders, according to Bologna criteria. DISCUSSION: Although the pregnancy rate per cycle started was 6.7%, the rate of clinical pregnancy per embryo transfer is quite satisfactory, being a group of women with unfavorable responses in previous treatments. The relatively high rates of cycle cancellation are mitigated by the greater simplicity and lower cost of these cycles. CONCLUSION: The results obtained in this study demonstrate that Medically Assisted Reproduction in natural cycle may be an alternative treatment for ovarian stimulation in patients with poor prognosis, whose only alternative would be oocyte donation.

Introdução: As técnicas de procriação medicamente assistida em ciclo natural têm sido investigadas, sobretudo em mulheres com má resposta à estimulação ovárica convencional, observando-se melhor recetividade endometrial, custo inferior e possibilidade de realização de ciclos sucessivos. Como desvantagens salientam-se: menor eficácia por ciclo de tratamento e maior taxa de cancelamento. O objetivo definido para este trabalho foi determinar a taxa de gravidez evolutiva em mulheres inférteis, submetidas a procriação medicamente assistida em ciclo natural. Material e Métodos: Estudo retrospetivo de 149 ciclos de procriação medicamente assistida sem estimulação ovárica de 50 mulheres inférteis, entre janeiro de 2011 e outubro de 2014. Resultados: As mulheres submetidas a procriação medicamente assistida em ciclo natural tinham, em média, 36,1 anos. Aproximadamente metade (46,0%) dos ciclos realizaram-se em más respondedoras. No dia do desencadeamento da ovulação o diâmetro médio do folículo foi 17,5 mm. Cancelaram-se 23 ciclos (15,4%) previamente ao desencadeamento. Em 8 ciclos (5,3%) ocorreu ovulação entre o desencadeamento e a punção folicular. Na maioria dos ciclos (n = 118; 79,2%) efetuou-se punção folicular, realizando-se técnica de procriação medicamente assistida em 71 (47,6%), maioritariamente injeção intracitoplasmática. A taxa de fecundação global foi 63,8%. Em 40 ciclos (26,8%) houve transferência embrionária. A taxa de implantação e de gravidez evolutiva por transferência embrionária foram de 35,0% e 25,0%, respetivamente. A maioria das gestações ocorreu em más respondedoras, conforme critérios de Bolonha. Discussão: Apesar de a taxa de gravidez por ciclo iniciado ser de 6,7%, a taxa de gravidez evolutiva por transferência embrionária é bastante satisfatória, sendo mulheres com respostas desfavoráveis em tratamentos prévios. As taxas relativamente elevadas de cancelamento do ciclo são atenuadas pela simplicidade e menor custo destes ciclos. Conclusão: Os resultados obtidos neste trabalho demonstram que as técnicas de procriação medicamente assistida em ciclo natural podem ser uma alternativa de tratamento à estimulação ovárica em doentes com mau prognóstico, cuja alternativa seria o recurso à doação de ovócitos.

[Reproductive outcomes after hysteroscopic septoplasty: a retrospective study]. / Desfecho reprodutivo após septoplastia histeroscópica: estudo retrospectivo.

PURPOSE: To assess the reproductive outcomes after hysteroscopic septoplasty. METHODS: A retrospective observational study was performed with analysis of the medical records of 28 women with infertility or recurrent abortions undergoing hysteroscopic septoplasty. To evaluate reproductive outcomes we consulted the medical records of our hospital and of primary health care units between septoplasty and the present or first pregnancy. Primary outcomes were pregnancy rate, newborns, and abortions after septoplasty. Uterine septum was diagnosed by 2D or 3D ultrasound and classified according to the American Fertility Society. All procedures were performed in the follicular phase of the menstrual cycle using monopolar or bipolar energy and/or microscissors. To compare the reproductive outcomes before and after septoplasty we used Microsoft Excel and SPSS version 17. Fisher's exact test was considered statistically significant if p<0.05. RESULTS: Hysteroscopic septoplasty was performed in 20 patients (72%) with secondary infertility and in 8 patients (28%) with primary infertility. The septum was incompletely removed during the first hysteroscopy in 5 cases (18%), which required a second surgery. One case was complicated with minor uterine perforation. After hysteroscopic septoplasty, 64% of women became pregnant and 48% live neonates were delivered; 4% of the patients had a tubal pregnancy; and 19% had miscarriages. CONCLUSIONS: The results of this study are consistent with those described in the literature. Patients obtained a significant improvement of reproductive outcomes with a fivefold reduction in miscarriage rate after hysteroscopic septoplasty.

Desfecho reprodutivo após septoplastia histeroscópica: estudo retrospectivo / Reproductive outcomes after hysteroscopic septoplasty: a retrospective study

OBJETIVO: Avaliar os resultados reprodutivos após septoplastia histeroscópica. MÉTODOS: Estudo retrospetivo observacional por meio de análise dos registos clínicos de 28 mulheres com antecedentes de infertilidade ou de abortos recorrentes, submetidas à septoplastia histeroscópica. Para a avaliação do desfecho reprodutivo foram consultados os registos informáticos dos Cuidados de Saúde Primários e do nosso Centro Hospitalar, no período compreendido entre a septoplastia e a primeira gravidez ou o presente. Os outcomes primários foram a taxa de gravidez, de recém-nascidos e de abortos após septoplastia. O septo uterino foi diagnosticado por ecografia 2D ou 3D e classificado de acordo com a classificação da American Fertility Society. A septoplastia foi realizada na fase folicular do ciclo menstrual, com recurso da energia monopolar, bipolar e/ou microtesoura. Os programas Microsoft Excel e SPSS versão 17 foram utilizados para comparação do desfecho reprodutivo prévio e posterior à septoplastia. Foi utilizado o teste exato de Fisher, considerando significado estatístico quando p<0,05. RESULTADOS: Foi realizada septoplastia histeroscópica em 20 doentes (72%) com infertilidade secundária e 8 (28%) com infertilidade primária, tendo sido necessária segunda intervenção para remoção completa do septo em 5 casos (18%). Ocorreu um caso perfuração uterina minor. Após septoplastia histeroscópica, 64% das mulheres engravidaram, obtendo-se uma taxa de nados vivos de 48%; gravidez tubária de 4%; e 19% das doentes tiveram abortos espontâneos. CONCLUSÕES: Os resultados do presente estudo estão de acordo com o descrito na literatura, tendo-se obtido uma melhoria significativa dos desfechos reprodutivos, com uma redução da taxa de aborto espontâneo de cinco vezes após a septoplastia histeroscópica. .

PURPOSE: To assess the reproductive outcomes after hysteroscopic septoplasty. METHODS: A retrospective observational study was performed with analysis of the medical records of 28 women with infertility or recurrent abortions undergoing hysteroscopic septoplasty. To evaluate reproductive outcomes we consulted the medical records of our hospital and of primary health care units between septoplasty and the present or first pregnancy. Primary outcomes were pregnancy rate, newborns, and abortions after septoplasty. Uterine septum was diagnosed by 2D or 3D ultrasound and classified according to the American Fertility Society. All procedures were performed in the follicular phase of the menstrual cycle using monopolar or bipolar energy and/or microscissors. To compare the reproductive outcomes before and after septoplasty we used Microsoft Excel and SPSS version 17. Fisher's exact test was considered statistically significant if p<0.05. RESULTS: Hysteroscopic septoplasty was performed in 20 patients (72%) with secondary infertility and in 8 patients (28%) with primary infertility. The septum was incompletely removed during the first hysteroscopy in 5 cases (18%), which required a second surgery. One case was complicated with minor uterine perforation. After hysteroscopic septoplasty, 64% of women became pregnant and 48% live neonates were delivered; 4% of the patients had a tubal pregnancy; and 19% had miscarriages. CONCLUSIONS: The results of this study are consistent with those described in the literature. Patients obtained a significant improvement of reproductive outcomes with a fivefold reduction in miscarriage rate after hysteroscopic septoplasty. .

Juvenile cystic adenomyoma.

The purpose of this paper is to describe a case of juvenile cystic adenomyoma in a 17 year-old female patient with severe dysmenorrhoea unresponsive to non-steroidal anti-inflammatory drugs. The patient presents progressively worsening dysmenorrhoea that started 2 years after menarche and a cystic uterine lesion in MRI. The cyclic nature of symptoms, the similarity of the lesion and endometrium in MRI signal intensity and response to hormone suppression are consistent with juvenile cystic adenomyoma. The treatment depends on the age of the patient, severity of her symptoms and size and localisation of the cyst. This is a rare condition in young nulliparous women with a challenging differential diagnosis. This case highlights the relevance of MRI in the patient's study, featuring important characteristics of the lesion that disclosed the final diagnosis.

In vitro release and characterization of chitosan films as dexamethasone carrier.

Chitosan, a biodegradable and biocompatible polysaccharide, is a potentially useful material in various fields. We produced mono and bilayer chitosan films containing dexamethasone as a drug carrier for controlled release. The chitosan drug-loaded films were produced by a casting/solvent evaporation technique using 2 wt% acetic acid solution and distilled water and they were dried at room temperature. These films were characterized by release and swelling studies, DSC and ATR-FTIR. The total profile for water absorption was similar for the types of films developed. ATR-FTIR analysis showed little change in the band position of the O--H and N--H stretching from dexamethasone and chitosan, respectively. DSC analysis from bilayer film indicates that the dexamethasone peak was shifted from 256 to 240 degrees C. These results suggested an interaction between hydroxyl and amino groups of chitosan and hydroxyl groups of dexamethasone. In the drug release studies it was observed 89.6% release from the monolayer film in 8h and 84% from the bilayer film in 4 weeks. These results suggested that the chitosan sheet prepared in this study is a promising delivery carrier for dexamethasone.

Maltrato intrafamiliar, medicina social II

Encuadernado con Planificacion familiar de otros autores MFN 826

[Pelvic floor muscle training with Plevnik's cones in women with urinary incontinence]. / Reeducação do pavimento pélvico com cones de Plevnik em mulheres com incontinência urinária.

The aim of this study was to evaluate the effectiveness of the pelvic floor muscle training in the stress urinary incontinence. The standard protocol include forty eight treatment sessions all together, for sixteen weeks, three times a week with the using of Plevnik weighted vaginal cones and Kegel exercises. The effectiveness of this method in reducing urine loss was assessed through the "Pad-test" before and after exercises. A cohort of 75 women entered the study, aged between 28 and 66 years old, with mean aged 46 and light to moderate urinary incontinence. The results showed significant improvement with reduction in urine loss and increase in pelvic muscle tone in women that completed the whole treatment course.