Metformin -Its dynamics on suppression of hyperandrgenaemia
Are we at SE
Asia , sub optimally utilizing the overall benefits of metformin in
hyperandrogenic PCO women ?? Tthe non-carbohydrate
actions of metformin in PCO women ? Several data suggest that metformin does counteract
on hyperandrogenism by interfering both
with direct and specific mechanisms on peripheral androgen-secreting organs and with free androgen fraction-regulating systems.
Metformin, acroding to them has
many beneficial effects in PCO women which are still unexplored. It (metformin)
is far from just an promoter of glucose entrance in cells.
In fact, many a researchers in
last two decades have claimed that metformin exerts followings in addition tomaking her euglycemic
:--
All such actions are independent
of beneficial effects of glucose entry !!All these
taken together make Metformin as an important adjunct drug if we believe that
PCOisprincipally a hyperandrogenic disorder of any etiology. There seem to be stillmany other mechanisms that is mediated by metformin in the face on hyperandrogenism .
The research on the misc effects of metformin whichis a relatively new concept is limited . I believe the reason is that
assay of insulin and bioactive androgens are usually non availableto clinicians. As such scanty studies have
been undertaken by clinicians
Chr Pelvic pain (CPP) where
all possible noninvasive tests have been done but no definite cause could be established
with certainly in such cases inabsence
of palpable pelvic pathology (T O Mass)
/ subfertility problem one can offer trail of medl tr of endometriosis before
invasive procedure is approved (diagnostic laparoscopy) .It also happens albeit
rarely that Opinions of Urologist, Orthopedic surgeon and Colorectal surgeon
have been taken but no definite cause
could be established.
Put under such circumstances can we prescribe
Dienogest or say other drugs specifically designed as medical managements of
endometriosis like B) Danazol B) Gn RH agonist C) Progesterone
Consensus statement for the management of chronic pelvic pain and
endometriosis: proceedings of an expert-panel consensus process.
.
For women in whom
endometriosis is the suspected cause of the pain, laparoscopic confirmation of the diagnosis is unnecessary, and a
trial of medical therapy, including second-line therapies such as danazol, GnRH
agonists, and progestins, is justified provided that there are no other
indications for surgery such as the presence of a suspicious adnexal mass.
Committee Opinion 1 : When
surgery is necessary, laparoscopic approaches seem to offer comparable clinical
outcomes to those performed via laparotomy, but with reduced morbidity.
Committee Opinion 2 :-The balance of evidence supports the use of adjuvant
postoperative medical therapy after conservative surgery for CPP.
Committee Opinion 3 :There is some evidence that adjuvant presacral neurectomy adds
benefit for midline pain, but currently, there is inadequate evidence to
support the use of uterosacral nerve ablation or uterine suspension.
Committee Opinion 4 : Hysterectomy alone has undocumented value in the surgical
management of women with endometriosis-associated CPP.
Rh factor -The discovery of Rh and its terminology
Rh:-Point
1:-There are total45blood group system (including ABO system) of which Rh is one. Rh system
.Therefore Rh isone of
forty-five known human blood group systems.
Point 2: The
Rh blood group system again consists of 49 defined subgroups group antigens. However for clinicians it is sufficient to
be familiar with common five
antigens D, C, c, E, and e . These antigens are the most important. We know that there is no d antigen. and Rh
negative refer to the Rh(D) antigen only.
Mistake 1:--The term "Rh" was originally an abbreviation of
"Rhesus factor." It was so named as such group first was discovered in 1937 by Karl Landsteiner and Alexander S. Wiener, who, at the time, believed it to be a similar antigen
found in rhesus monkey red blood cells only which was found later to be not true. .
Mistake 2: It was subsequently learned the human factor is not
identical to the rhesus monkey factor. Thus, notwithstanding it is a misnomer,
the term survives (e.g., rhesus blood group system and the
obsolete terms rhesus factor, rhesus positive,
and rhesus negative – all three of which actually refer
specifically and only to the Rh D factor and are thus
misleading when unmodified.
Mistake got corrected byPhilip Levine and Rufus Stetson:-à
The
first rhesus blood type as mentioned earlier was discovered in 1937 by Landsteiner and Wiener,
who named it after a similar factor found in rhesus
monkey blood. The significance of the
discovery was not immediately apparent and was only realized in 1940, after
subsequent findings by Philip Levine and Rufus Stetson.
It
was recognized that the Rh factor was just one in a system of
various antigens. Based on different models of genetic inheritance, two
different terminologies were developed; both of them are still in use.
Overall approximately 1% to 2%
of all newborns are CMV infected, about half due to primary infection during
pregnancy and the other half due to reactivation of a prior infection.Cx can
shed CMV virus !!! It is now known to virologists that intermittent CMV
shedding from the cervix and other body sites is quite possible if CMV remains
in host body as an dormant state and not cleared after primary infection
. In such situations as CMV being a herpes family virus
–Can Pap have some kind of reflection by exhibiting
some specific cytological changes due to CMV excretion via
endocervix?? ??
At the present
moment we don’t have any idea about abnormal cytology by HPV or else it is due
to other kind of Herpes family. Food for thought . Surprisingly, the great
majority of CMV infections are asymptomatic and we are aware of the fact that
presence of activation of dormant virus can be identified only by
prospective antibody testing.
After primary CMV
infection, virus replication may persist for many months and can be reactivated
months or years later, with intermittent CMV shedding from the saliva, tears,
urine, faeces, cervix and other sites. AS it is (CMV) is secreted via saliva /
tears therefore viral spread can occur by direct body contact amongst the
family members. The presence of IgM-specific CMV antibody correlates quite
well with infection. Immunoglobulin M antibody is detected with about 90% of
primary infections; however, it may also appear with recurrent infections. CMV
IgG avidity testing may be of value in assessing a patient's likelihood of
recent infection .
Matter of great
concern for obstetricians and Neonatologists too
. !!!
Surprise 1:- How
many of us believe that CMV (which is a virus of Herpes family like varicella,
E B Virus ) after causing an primary infection i the host , quite often remains
alive in the host in as an dormant state and can be an potential source of
reactivation and cause maternal illness and more importantly foetal harm ?
Surprise 2: Can
such state of reactivation occur in case of T Gondii also ?
Surprise 3 : What , according to will be best drug for
acute Cytomegalovirus infection if serologically confirmed after a brief
maternal illness in nonpregant state when CMV IgM is strongly
positive. .
Surprise 4 : Is
it true that maternal immunity against CMV does ensure guarantee against
prevention of vertical transmission of CMV in 70% only?
Surprise 5:
Avidity tests facility often unavailable in small towns.
Surprise 5 : Like
Covid we still dont have vaccination against CMV and also against Toxo
infections. .Members views and worry about these two organisms which attack
pregnant women often silently !!!
Overall approximately 1% to 2% of all newborns are CMV infected,
about half due to primary infection during pregnancy and the other half due to
reactivation of a prior infection.Cx can shed CMV virus !!! It is now known to
virologists that intermittent CMV shedding from the cervix and other body sites
is quite possible if CMV remains in host body as an dormant state and not
cleared after primary infection . In such situations as CMV being a herpes
family virus –Can Pap have some kind of reflection by exhibiting some specific
cytological changes due to CMV excretion via endocervix?? ?? At the present moment we don’t have any idea about abnormal
cytology by HPV or else it is due to other kind of Herpes family. Food for
thought . Surprisingly, the great majority of CMV infections are asymptomatic
and we are aware of the fact that presence of activation of dormant virus can
be identified only by prospective antibody testing.
After primary CMV infection, virus replication may persist for
many months and can be reactivated months or years later, with intermittent CMV
shedding from the saliva, tears, urine, faeces, cervix and other sites. AS it
is (CMV) is secreted via saliva / tears therefore viral spread can occur by
direct body contact amongst the family members. The presence of IgM-specific
CMV antibody correlates quite well with infection. Immunoglobulin M antibody is
detected with about 90% of primary infections; however, it may also appear with
recurrent infections. CMV IgG avidity testing may be of value in assessing a
patient's likelihood of recent infection.
Multicystic ovaries should be stimulated by HMG only ::: Selection of Ovulogen
(ovulation stimulation /Ovulation accelerating agent in cases of oligo ovulation ).
How to do that ??
An ultrasound assessment of ovarian volume and AFC in the early
follicular phase has been used as a predictor for ovarian response before IVF
treatment, even n letrozole tr if woman concerned ins elderly , because a low
AFC and with small-volume ovaries usually
indicate reduced ovarian reserve
With experience, one can recognise
in the ovary three distinct morphological appearances: A) normal, B) polycystic and C).. multicystic.
I am right my dear members ? Your opinion pl?
Type C: What is
Multicystic ovaries? Ans: Multicystic ovaries are characteristically observed in pubertal girls and women recovering
from weight-loss-related amenorrhoea. These multicystic (or multifollicular)
ovaries are A) normal in size or slightly
enlarged and
B) contain six or more cysts that are 4-10 mm in diameter
; in contrast to women with polycystic ovaries (PCOs),
C) the stroma
is not increased.
Etilogy & pathogensis of
multicystic ovaries?? The multicystic
ovary appears to develop as a consequence of reduced hypothalamic secretion of GnRH, resulting in subnormal stimulation of
the ovaries by the gonadotropins.
Treatment of multicystic
ovaries?? Ans: The multicystic ovary has a normal response to exogenous stimulation, by either pulsatile GnRH or gonadotropins, and the ultrasound
appearance of the ovary usually reverts to normal. As such t will not be wise
to go ahead with letrozole straightway without such basal scan .In this case of
multicystic ovaries Letrozole nor CC will work. Only HMG will work or else one
can add HMG on day3, day 5,& day 8 HMG 75 IU in addition to CC/Letrozole.
TVS -- The relevance of Transvagianl sonography ?? Like to have some informations on Ultrasound : Any non-emergentpelvic scan (elective scan ) à with the idea to diagnose any pelvic
tumour, small ovarian endometriomata, TO mass should be done following principle which may be of help : Please
correct me if I am wrong because I too have no training in sonology :Here we go : How to do Basal
Scan-& what to record the findings at Basal scan. Then taken together along
with endocrine evaluations in subfertility problem one can plan the treatment
of subfertility: - Here we go on ABC of Pelvic Ultrasound.
Point 1: Abdomen first : When
first scanning the pelvis, many radiologists suggest performing a transabdominal scan firstto obtain an overview of the pelvic organs,
and second to assess the
kidneys and renal tract if indicated.
Point 2: She is requested to void urine and then , a transvaginal
ultrasound examination of the pelvic is systemically done.To visualize
the pelvic organs TVS is preferred to
the transabdominal approach as it not only
obviates the need for a full bladder with its associated discomfort but also allows high-frequency probes
(5-7.5 MHz) to be used so that higher resolution and greater precision
in measurements or measurements of the
pelvic structures, follicular diameters(AFC in particular) and endometrial thickness be achieved. It is
especially advantageous in patients who are
undergoing assisted conception as they commonly have lower abdominal scars that impair the penetration of
ultrasound.
Furthermore, periadnexal adhesions may tether the ovaries deep in the pelvis and
limit the elevation of these structures that
normally occurs when the bladder is filled for a transabdominal scan. If only TAS done then such adhesive lesions May be missed so aso
difficult to visualize ovaries.
Ina recent study it was observed that the follicles were more sharply defined in 90%
of cases when the transvaginal approach was used compared with only 41% with a
transabdominal approach . The same study
found that the numbers and sizes of the dominant follicles correlated better with the serum oestradiol concentrations when
transvaginal scanning was used.
. Foetal neurosonoembryology What is
meant by HDlive USG?? Ans: This is an extraordinary
sonological imaging by which photographs
received of the imaged foetus . It appears and looks like that foetus is just
standing or lying in front of maternal abd
and there is no barrier of mat abd ,liquor amnii or placenta between the observer and foetal
image. That is the term coined is HDlive USG. Gone are the days when USG meant only
sonographic metrics and
different diameters and volumes of organs be it maternal or foetal.
HDlive USG is an extraordinary imaging methodology
which receives and processes quality photographs of foetus. This however, has
of late is a most debated topic among clinicians and
academics.
Sonogentics and diagnosing of Foetal Neurological
Development is possible to assess now intranatally :- Foetal
neurosonoembryology can pick up by HDlive silhouetteUSG & Sonoangiogram bysilhouette / HD live flow technology for
ventricular imaging of brain are also just possible.
Even the cognitive function of
foetalbrain can be assessed by advanced
(not traditional) - 4-D- USG Magnetic ResonanceSpectroscopy for detection of metabolic changes infoetal brain in FGR fetusesand due to all these detailed informations
and that is why this methodology is gaining importance!!!
