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Barrier Methods of Contraception the Female Condom The female condom is a pouch made of polyurethane purchase kamagra chewable us, which lines the vagina order genuine kamagra chewable line. The integrity of the female condom is maintained with up to eight multiple uses with washing discount kamagra chewable 100 mg without prescription, drying, and relubri- cating. Kost K, Singh S, Vaughan B, Trussell contraception: a Cochrane review, Hum J, Bankole A, Estimates of contraceptive Reprod 17:867, 2002. Keith L, Berger G, Moss W, Prevalence ted diseases in women: a comparison of gonorrhea among women using vari- of female-dependent methods and con- ous methods of contraception, Br J Vene- doms, Am J Pub Health 82:669, 1992. Psychoyos A, Creatsas G, Hassan E, diaphragms among couples in the Do- Spermicidal and antiviral properties minican Republic, Contraception 78:418, of cholic acid: contraceptive efficacy 2008. Centers for Disease Control and randomized trial, Obstet Gynecol 93:896, Prevention, Nonoxynol-9 spermicide 1999. Van Damme L, Ramjee G, Alary M, ceptive effectiveness and safety of five Vuylsteke B, Chandeying V, Rees H, nonoxynol-9 spermicides: a randomized Sirivongrangson P, Mukenge-Tshibaka trial, Obstet Gynecol 103:430, 2004. The risk of gonor- Female condom (Femidom): a clinical rhea transmission from infected women study of its use-effectiveness and patient to men, Am J Epidemiol 108:136, 1978. This method must take into account the viability of sperm in the female reproductive tract (2 to 7 days) and the lifespan of the ovum (1 to 3 days). The variability in the timing of ovulation is the reason why the period of abstinence must be relatively lengthy unless barrier methods are used during the fertile days. The period of maximal fertility begins 5 days before the day of ovulation and ends on the day of ovulation. Unsuccessful use can be predicted in couples who are unable to part with sexual spontaneity, women with irregular menses, dis- organized people who cannot keep good records, and women with chronic problems of vaginitis or cervicitis. The advantage of periodic abstinence as a method of contraception is the availability of this method regardless of 315 A Clinical Guide for Contraception economic status or the accessibility of other methods. Methods of Periodic Abstinence Tere are several specifc methods, and most teachers of periodic absti- nence advocate the incorporation of features from more than one method. The sophistication of these methods was made possible by the tremendous increase in the scientifc knowledge of the events in the human menstrual cycle. The time of ovulation (the fertile period) was identifed in the 1930s, but it was not until the 1960s with the advent of the radioimmunoassay that relatively precise timing of the various events became possible. The Rhythm or Calendar Method This method of periodic abstinence was based on the assumption that men- strual cycles were relatively constant, and therefore, the fertile period of the subsequent month could be predicted by the timing of the past cycle. The general rule is to record the length of six cycles, then estimate the beginning of the fertile period by subtracting 18 days from the length of the shortest cycle, and to estimate the end of the fertile period by sub- tracting 11 days from the length of the longest cycle. Tus, a woman with cycles varying from 26 to 32 days will practice periodic abstinence from the eighth day until the 21st day, a formidable requirement of 14 days of abstinence per cycle. Indeed, because of the normal variation in menstrual cycles, the average couple would practice periodic abstinence 16 days each month. This method has a pregnancy rate of about 40 per 100 woman-years, and therefore, it is not advocated without com- bining it with other techniques. However, the utilization of programmed electronic devices to record temperatures, keep track of cycles, and provide a signal to the patient during the fertile period can reduce pregnancy rates to 5 to 10 per 100 woman-years. The cer- vical mucus method is also called the ovulation method, the Billings method, the Creighton Model Fertility Care System, or the TwoDay method. Some recommend the addition of cervical palpation: frm and closed when infer- tile, sof, open, and moist when fertile. Not on consecutive days during the postmenstrual preovulatory period so that seminal fuid will not obscure observation of cervical mucus changes, although assessment in the evening afer intercourse that morning or the previous night should be reliable. Most women (95%) will have 4 to 12 days of observable secretions; thus, the method requires a lengthy period of abstinence for many women. Intercourse resumes the night of either the third day of a temperature shif or the fourth day afer the last day of sticky, wet mucus, whichever is later. Although this method is more complicated, the efcacy is slightly better, about 2 to 3 failures per 100 woman-years when practiced by experienced couples who follow all the rules. A study that compared the cervical mucus method with and without this device found a 2% failure rate with the monitor compared with a 12% rate without the monitor. CycleBeads, also devel- oped by the Institute for Reproductive Health of Georgetown University, are a string of color-coded beads used with the Standard Days method to moni- tor cycle days and lengths. Users of this method are advised that efcacy will be reduced even if only one menstrual cycle is out of the 26- to 32-day range, and to abandon the method if two cycles are out of the range. Resources It is too much to expect the average clinician to provide the necessary instruction and support for these methods. The local afliate of the Planned Parenthood Federation of America can direct a clinician to a community program. The following resources can be contacted for advice, charts, and teaching plans: The Couple to Couple League Foundation http://www. Periodic abstinence is associated with good efcacy when used correctly and consistently, but the method is very unforgiving of imperfect use. A multicenter trial in the 1970s of the cervical mucus method in the United States documented over a 2-year period of time, a method failure rate of 1. Better rates have been reported with newer methods that emphasize patient teaching and provide techniques to assess and record the window of fertility. Concerns A lingering concern is that because of periodic abstinence, inadvertent fertilization could occur with aged gametes. Is pregnancy from aged gametes more likely to result in birth defects, spontaneous miscarriages, and chromosomal abnormalities? No diferences have been noted in the frequency of monosomic or trisomic abnormalities in relation to the timing of conception; however, conceptions A Clinical Guide for Contraception with postovulatory aged ova appear to be at increased risk of polyploidy. Evidence supports the idea that the further away from the time of highest fertility fertilization occurs, the more likely a male child will be conceived. Use of periodic absti- nence is possible during lactation, but scrupulous attention is required to detect impending ovulation. With typical practice of the method, the preg- nancy rate is about the same as with diaphragm and spermicides. The problem of a long period of abstinence can be overcome by using a barrier method and/or spermicides during the fertile period. If withdrawal before ejaculation occurs with every instance of intercourse, a failure rate over a year of only 4% can be achieved. A lack of respect for withdrawal as a contraceptive method can be attrib- uted to two factors: an understandable preference for modern methods and a belief that preejaculate fuid contains sperm. The latter concern is under- standable given the difculty inherent in separating preejaculate fuid from the ejaculate in order to study the question. Tere is one small study of fve men with a history of premature ejaculation and three men with excessive fuid during foreplay. In two other studies, no sperm was found in preejaculatory fuid from 16 men, and in 15 men, a few clumps of sperm were present in 5 men. National Survey of Family Growth) is difcult to accurately measure because individuals very ofen combine withdrawal with another method, and the other method is the one reported in family planning surveys. Indeed, many individuals do not classify withdrawal as a contraceptive method, saving that designation for modern methods.

In patients with a possible drug-induced thrombocytopenia quality kamagra chewable 100 mg, the primary therapy is to stop the suspect drug cheap kamagra chewable 100 mg fast delivery. Patients with severe thrombocytopenia should receive platelet transfusions because of the risk of fatal bleeding [81] buy generic kamagra chewable from india. However, with vancomycin-induced thrombocytopenia, the patient may be refractory to platelet transfusion [80]. If there are multiple risk medications, the best approach is to stop any drug that is strongly associated with thrombocytopenia (Table 91. Patients with hemophagocytosis appear to have higher rates of multiple organ system failure and higher mortality rates. Inflammatory cytokines, especially monocyte-colony stimulating factor, are thought responsible for inducing the hemophagocytosis. Three members of the Ehrlichia/anaplasma family have been reported to cause infections in humans [85]. Patients may have central nervous system signs and marked elevation of the serum levels of liver enzymes. In many patients, the buffy coat reveals the organisms bundled in a 2 to 5 µm morula in the cytoplasm of the granulocytes or monocytes. Consideration of ehrlichiosis is important because highly specific therapy is doxycycline, which is a drug not routinely used for therapy of sepsis syndrome. Patients suffer a flu-like prodrome and then rapidly develop a noncardiac pulmonary edema resulting in profound respiratory failure [89]. Marked hemoconcentration is also present because of capillary leak syndrome with the hematocrit reaching in some patients as high as 68%. In the southern United States, dengue is becoming an increasing problem, and fatal cases of arenavirus have been reported in California [93]. A key sign is that patients will experience profuse bleeding from the gastrointestinal tract and mucosal bleeding often out of proportion to the observed coagulation defects. Given the propensity of many of these infections to spread to health care workers, precautions should be taken to prevent nosocomial spread [95]. In the patient who is totally refractory to platelet transfusion, it is important to consider whether a drug has resulted in antiplatelet antibodies (especially vancomycin) [97]. Use of antifibrinolytic agents such as epsilon aminocaproic acid or tranexamic acid may decrease the incidence of minor bleeding but are ineffective for major bleeding [98]. These patients develop renal failure, encephalopathy, adult respiratory distress syndrome (often with pulmonary hemorrhage), cardiac failure, dramatic livedo reticularis, and worsening thrombocytopenia. Many of these patients have preexisting autoimmune disorders and high titer anticardiolipin antibodies. Early recognition of this syndrome can lead to quick therapy and resolution of the multiorgan system failure. Posttransfusion Purpura Patients with this rare disorder develop severe thrombocytopenia (<10 × 9 10 per L), and often severe bleeding, 1 to 2 weeks after receiving blood products [101]. For unknown reasons, exposure to the antigens from the transfusion leads to rapid destruction of the patient’s own platelets. The diagnostic clue is thrombocytopenia in a patient, typically female, who has received a red cell or platelet blood product in the past 7 to 10 days. Treatment consists of intravenous immunoglobulin [102] and plasmapheresis to remove the offending antibody (see Chapter 96). Hach-Wunderle V, Kainer K, Krug B, et al: Heparin-associated thrombosis despite normal platelet counts. Kang M, Alahmadi M, Sawh S, et al: Fondaparinux for the treatment of suspected heparin-induced thrombocytopenia: a propensity score- matched study. Donegani E, Hillebrandt D, Windsor J, et al: Pre-existing cardiovascular conditions and high altitude travel. Menne J, Nitschke M, Stingele R, et al: Validation of treatment strategies for enterohaemorrhagic Escherichia coli O104:H4 induced haemolytic uraemic syndrome: case-control study. Izzedine H, Isnard-Bagnis C, Launay-Vacher V, et al: Gemcitabine- induced thrombotic microangiopathy: a systematic review. Al Ustwani O, Lohr J, Dy G, et al: Eculizumab therapy for gemicitabine induced hemolytic uremic syndrome: case seriers and concise review. Minakami H, Morikawa M, Yamada T, et al: Differentiation of acute fatty liver of pregnancy from syndrome of hemolysis, elevated liver enzymes and low platelet counts. Scully M, Thomas M, Underwood M, et al: Thrombotic thrombocytopenic purpura and pregnancy: presentation, management, and subsequent pregnancy outcomes. Fakhouri F, Roumenina L, Provot F, et al: Pregnancy-associated hemolytic uremic syndrome revisited in the era of complement gene mutations. Wada H, Asakura H, Okamoto K, et al: Expert consensus for the treatment of disseminated intravascular coagulation in Japan. Francois B, Trimoreau F, Vignon P, et al: Thrombocytopenia in the sepsis syndrome: role of hemophagocytosis and macrophage colony- stimulating factor. Fricke W, Alling D, Kimball J, et al: Lack of efficacy of tranexamic acid in thrombocytopenic bleeding. Although homozygosity is rare, it is associated with a 70% increase in prothrombin levels and imparts a 3. Therefore, diagnostic testing should be performed in the absence of these conditions to ensure accurate interpretation [16]. It is associated with an 8- to 10-fold increased risk of thrombosis and is present in 1% to 2% of patients with thrombosis [20]. Dysfibrinogenemia Dysfibrinogenemia is a rare inherited thrombophilic state caused by mutations in the Aα, Bβ, or γ fibrinogen genes. Acquired dysfibrinogenemia is associated with chronic liver disease and cirrhosis as well as hepatocellular and renal cell carcinoma. Approximately one-third of cases of dysfibrinogenemia are complicated by thrombosis (venous more commonly than arterial), possibly because of reduced binding to thrombin or inhibition of fibrinolysis. Hyperhomocysteinemia Homocysteine is a thiol-containing amino acid that is converted to methionine by methionine synthase with vitamin B12 and 5- methyltetrahydrofolate as cofactors. Acquired causes of hyperhomocysteinemia include deficiency of vitamin B12, folate, and pyridoxine, as well as renal insufficiency [24]. Hyperhomocysteinemia has been associated with a 20% increase in cardiovascular disease for each 5 µmol per L increase in fasting homocysteine levels [25]. However, randomized studies of vitamin supplementation in patients with venous and arterial thrombotic disease did not demonstrate improved clinical outcomes [28]. The diagnosis of hyperhomocysteinemia is based upon demonstrating elevated levels of homocysteine in a fasting blood sample. Neoplasms of the pancreas, brain, and stomach place patients at high risk for development of thromboembolism, whereas lung and colon cancers are associated with intermediate risk and breast and prostate cancer are associated with a lower risk. Compared to squamous cell carcinoma, adenocarcinoma is associated with a higher risk of thromboembolism. In patients older than 60 years of age or those who have prior thromboembolic events, cytoreductive therapy with hydroxyurea, anagrelide, or α-interferon should be strongly considered.

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If the collection is felt to be the result of perforation of a hollow viscous (appendicitis cheap kamagra chewable 100mg without prescription, diverticulitis discount kamagra chewable express, and perforated ulcer) best kamagra chewable 100mg, or leakage from the biliary tree or urinary tract for example, then after drain placement and immediate aspiration of contents, a catheter sinogram can be performed. The chance of creating sepsis or transient bacteremia from performing a sinogram at the time of drainage is a theoretical concern but rare in practice. A: Chest X-ray showing large amount of free intraperitoneal air (asterisks) concerning for bowel perforation. D: Owing to high drainage output (>50 mL per day), abscessogram was performed demonstrating a fistulous communication (arrow) with the descending colon. It is useful to mark the level of the skin insertion on the catheter during initial placement to allow for easy assessment of catheter dislodgement. If dependent catheter position in the cavity undergoing drainage is not possible, Jackson–Pratt bulb suctioning can be used. Gentle irrigation of the abscess cavity with 10 to 20 mL of sterile saline is recommended three to four times daily to ensure patency [31]. In anticipation of the patient’s discharge from the hospital, the patient and his or her family should be instructed in catheter care, and visiting nursing service is arranged. The patient is advised to return to the department in the event of abdominal pain, leakage from the catheter entry site, fever, or chills. When long-term drainage is anticipated, catheters should be exchanged approximately every 3 months to avoid blockage from encrustation or debris. When to Remove a Catheter Removal of a drainage catheter too early is one of the more common causes of postprocedural morbidity and mortality. The percutaneous drainage catheter should remain in place until the volume of drainage is less than 10 mL per day for 2 consecutive days, and the patient is showing clinical improvement. Reflux around the catheter during irrigation or new pain during irrigation are also signs of complete collection response and cavity collapse. Continuous high drainage (>50 mL per day) should alert the radiologist for a possible fistulous tract to bowel, pancreas, or biliary tree, and the appropriate imaging modality should be used for further evaluation [10,32] if not already performed. Patient Response Depending on the location and makeup of an infected or sterile collection, image-guided percutaneous drainage is successful in 70% to 90% of cases. Following complete evacuation of purulent material from an infected cavity, improved clinical response should be seen in a matter of hours to several days [10,13]. The parameters of improving clinical status include defervescence, reduction in pain, and resolution of leukocytosis. If there is no improvement after 2 to 3 days, suspicion should be raised for a separate, undrained collection, catheter dislodgement, or malfunction. Semisolid collections, such as infected hematomas or pancreatic abscesses, are more resistant to drainage. In the case of a collection of necrotic debris from pancreatitis, one or more large-bore catheters (chest tubes) up to 24 Fr have been used with success, allowing a patient to avoid the morbidity of surgical debridement [33,34]. Major complications (under 5%) include infection, bleeding, septicemia, injury to adjacent structures such as bowel, and death. Mortality from the procedure usually related to sepsis or organ failure, compares favorably to the surgical literature rates of 10% to 20% [35]. Inadvertent contamination of a previously sterile collection is also a possibility with prolonged catheter drainage but only occurs among approximately 1% of cases [24]. Enteric transgression can usually be treated conservatively with delayed catheter removal to allow for a mature fistulous tract to develop. Minor complications include pain, infection at the skin insertion site, transient bacteremia, and malfunction of the catheter secondary to kinking, dislodgement, or clogging with debris, such as blood clots. Recurrence may be caused by early catheter removal, failure to completely drain a loculated collection, or fistulous communication with the bowel, pancreatic duct, or biliary system. Repeat drainage of these cavities has been shown to be successful in 50% of patients with the need for surgical drainage reduced by half [3,36]. In conclusion, image-guided percutaneous aspiration and drainage has been established as the first-line treatment for sterile or infected fluid collections in the abdomen and pelvis. Awareness of the advantages and limitations of the procedure together with an integrated management approach between interventional and critical care staff will serve to benefit the patient and improve clinical outcomes. Bufalari A, Giustozzi G, Moggi L: Postoperative intraabdominal abscesses: percutaneous versus surgical treatment. Walser E, Raza S, Hernandez A, et al: Sonographically guided transgluteal drainage of pelvic abscesses. Babilonia K, Trujillo T: the role of prothrombin complex concentrates in reversal of target specific anticoagulants. Kassi F, Dohan A, Soyer P, et al: Predictive factors for failure of percutaneous drainage of postoperative abscess after abdominal surgery. The procedure for placement of a small diameter catheter is rapid, safe, and easily accomplished at the bedside under local anesthesia. This chapter will first address methods for urethral catheterization before discussing the percutaneous approach. A history and physical examination with particular attention to the patient’s genitourinary system is important. Patients with a history of prior prostatic surgery such as transurethral resection of the prostate, open prostatectomy, or radical prostatectomy may have an irregular bladder neck as a result of contracture after surgery. The use of a coude tip catheter, which has an upper deflected tip, may help in negotiating the altered anatomy after prostate surgery. In this situation, urethral integrity must be demonstrated by retrograde urethrogram before urethral catheterization is attempted. Urethral catheterization for gross hematuria requires large catheters such as the 22 or 24 Fr, which have larger holes for irrigation and removal of clots. Alternatively, a three-way urethral catheter may be used to provide continuous bladder irrigation to prevent clotting. Large catheters impede excretion of urethral secretions, however, and can lead to urethritis or epididymitis if used for prolonged periods. Technique In males, after the patient is prepared and draped, 10 mL of a 2% lidocaine hydrochloride jelly is injected retrograde into the urethra. Anesthesia of the urethral mucosa requires 5 to 10 minutes after occluding the urethral meatus either with a penile clamp or manually to prevent loss of the jelly. The balloon of the catheter is tested, and the catheter tip is covered with a water-soluble lubricant. After stretching the penis upward perpendicular to the body, the catheter is inserted into the urethral meatus. The balloon is not inflated until urine is observed in the drainage tubing to prevent urethral trauma. A common site of resistance to catheter passage is the external urinary sphincter within the membranous urethra, which may contract voluntarily. In patients with prior prostate surgery, an assistant’s finger placed in the rectum may elevate the urethra and allow the catheter to pass into the bladder.

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Treatment of uterine fibroids Moreover purchase kamagra chewable 100 mg line, it inhibits neovascularization generic kamagra chewable 100 mg otc, cell prolifera- the management of fibroids depends on the symptoms kamagra chewable 100mg on line, tion and cell survival in the fibroid but not in the normal the type and size of the fibroid, the patient’s age and the surrounding myometrium. Medical treatments nist action may lead to unopposed oestrogen stimulation do not eradicate fibroids but are designed to provide of the endometrium. Rupture of the uterus in labour is also a risk after Long‐term studies are needed to evaluate outcomes myomectomy if the cavity is breached during the after prolonged use. Pelvic tional uterine bleeding and may be one of the reasons arterial embolization has been used in the treatment of why the hysterectomy rate has declined over recent massive obstetric haemorrhage for more than three dec- years. However, the use of this system in women with ades, and was first reported by the French gynaecologist fibroids is considered to be a relative contraindication, Ravina [47]. Visualization of the latter is placement should be checked after a very heavy bleeding facilitated by the use of a contrast medium and digital episode to exclude expulsion. The procedure may be performed under Other medical treatments tending to reduce menstrual local anaesthesia, or under intravenous conscious seda- bleeding without effect on fibroid size include progesto- tion. Opiate analgesia is usually required up to 24 hours gens, the oral contraceptive pill and tranexamic acid. Surgical treatment For poorly understood reasons, the blood supply to Hysterectomy the normal myometrium renews itself via the rich pelvic Hysterectomy remains the most common surgical treat- collateral circulation, with contributions from ovarian and ment option for uterine fibroids. However, the fibroids do not usually revas- and definitive resolution of fibroid‐associated symp- cularize to a significant extent. However, it also guarantees infertility, which may fibroids and subsequent relief of fibroid‐related symptoms. Observational complications are all increased in the presence of uterine data suggest that there is a significant beneficial effect on fibroids [46]. Patient satisfaction rates following the procedure are Myomectomy also high and comparable to those found after hysterec- In women who wish to retain their fertility, uterine‐spar- tomy. Complications lowing treatment, resulting in an anatomically normal during hysteroscopic myomectomy include uterine per- uterus. However, variable recurrence rates for fibroids foration and the associated potential for visceral damage, have been reported after embolization as occurs haemorrhage, infection and fluid overload. Unlike hysterectomy, there is no Benign Disease of the Uterus 831 guarantee that the procedure will eliminate all menstrual blood flow and with non‐target embolization, may increase symptoms and revascularization with subsequent regrowth the risk of premature ovarian failure. More recently, longer‐term data from rand- following treatment when compared with surgery, irre- omized trials have been published, stating that health‐ spective of age [54,55]. While some suggest that the outcome is not Some women may require further treatment with hys- adversely affected [56], others report increased rates of terectomy, myomectomy, endometrial ablation or a repeat miscarriage, intrauterine growth restriction, preterm embolization. Importantly, with increasing long‐term delivery, malpresentation and postpartum haemorrhage follow‐up, it appears that such reinterventions associated following embolization [57]. Short‐term data reported embolization to be eral malaise and pelvic pain in association with a mild more cost‐effective at 1 year [60], but more recent pyrexia and raised white cell count. Endometrial ablation may be performed with or with- Another significant problem resulting from emboliza- out myomectomy and is associated with a high rate of tion is infection. Provided that the uterine cavity is not too antibiotics but, rarely, sepsis may occur, a complication enlarged or distorted, ablation appears to be a success- that may lead to the patient’s death. It would seem that microwave and bipolar There is a radiation penalty to the ovaries associated radiofrequency endometrial ablation may be the best with the procedure which occurs during digital fluoros- of the second‐generation techniques, although rand- copy. This, in combination with disruption of uterine omized data looking at fibroids in particular are not available [61]. A new transcervical device (VizAblate®) is currently available, allowing radiofrequency ablation of fibroids Groin injury: haematoma, infection under real‐time sonographic guidance. The first reports Contrast allergy have shown a significant reduction in fibroid size, Radiation exposure to ovaries together with symptomatic relief in the first 12 months Non‐target or mis‐embolization: ovary, bowel or bladder after the procedure [62]. This modal- associated with fibroid regrowth and subsequent ity is neither suitable for large fibroids nor large num- adhesion formation. Intra‐cavitary uterine pathology in definitions and measurements to describe sonographic women with abnormal uterine bleeding: a prospective features of myometrium and uterine masses: a study of 1220 women. Facts Views Vis Obgyn consensus opinion from the Morphological Uterus 2015;7:17–24. Uterine junctional the Study of Women’s Health Across the Nation zone: function and disease. Estrogen levonorgestrel‐releasing intrauterine device in receptor alpha polymorphism and susceptibility to patients with adenomyosis. Leiomyoma related bleeding: a the oncogenic potential of endometrial polyps: a classic hypothesis updated for the molecular era. Saline contrast hysterosonography in abnormal uterine J Reprod Med 1996;41:316–320. Baillieres Clin definitions and measurements to describe the Obstet Gynaecol 1998;12:225–243. Clinical presentation of sonography versus gel instillation sonography: a uterine fibroids. Shrinkage of uterine fibroids during therapy with ultrasonography and office endometrial sampling in the goserelin (Zoladex): a luteinising hormone releasing diagnosis of endometrial disease in postmenopausal hormone agonist administered as a monthly women. Removal of focal intracavity lesions results in cessation 41 Lethaby A, Vollenhoven B, Sowter M. Efficacy of of abnormal uterine bleeding in the vast majority of pre‐operative gonadotrophin hormone releasing women. Therapeutic potential for the selective Menstrual Bleeding: Assessment and Management. Pregnancy outcomes after uterine artery Arterial embolization to treat uterine myomata. Evaluation of the effect of uterine artery embolization 59 Mara M, Maskova J, Fucikova Z, Kuzel D, Belsan T, on menstrual blood loss and uterine volume. Gynecol vs hysterectomy in the treatment of symptomatic uterine Surg 2016;13:27–35. Sonographically guided high‐intensity does not have adverse effects on ovarian reserve in focused ultrasound for the management of uterine regularly cycling women younger than 40 years. The effects of of focused ultrasound therapy of uterine fibroids: early uterine artery embolization and surgical treatment on results. The lifetime risk diagnosed in those under the age of 50 years rose from of developing vulval cancer is now estimated at 1 in 275. A similar trend has been Age‐specific incidence rates rise gradually from around documented in other countries [7,8]. These tumours age 35–39, and more sharply from around age 65–69, appear to be more frequently associated with vulval reaching the highest rates in the 90+ age group [1]. There appears to be an association between vulval This suggests that there are at least two oncogenic cancer incidence and social deprivation. Other cohort studies have shown Dewhurst’s Textbook of Obstetrics & Gynaecology, Ninth Edition. The association ● squamous cell carcinomas; between cervical and vulval cancers is probably mainly ● malignant melanoma; due to shared risk factors (e. First is the classic de does have a bearing on management, largely because of novo neoplasm in the elderly that is frequently seen in the different risks of nodal metastases and the predilec- association with conditions such as lichen sclerosus. Recent studies have focused on the genetic, epigenetic and molecular changes in vul- Presentation val squamous cell carcinoma and associated lichen scle- rosus [23].