Elements of effective collaboration between domestic violence advocates and health care providers through new curriculum in Post-Graduate Medicine Programs

The goals of project was the creation new course by special program for licensing and re-certification for health care providers, development Domestic Violence Medical Resource Manual   and develop an effective health resposponce  to domestic violence. Training health care providers in 4 hospitals were most often apply victims. Organize round table with head of department of hospitals and discuss the way of implementation screening program.

On the bases of project was created the post-graduate training course “Impact domestic violence on reproductive health“ is designed to be a companion peace to improving the health care response to  domestic violence. Program grew out of the recognition that DV is widespread problem that has multiple, significant health consequences to victims.

We created new course “Impact domestic violence on reproductive health “provide accessible information to health care providers in regarding the screening and treatment of patients who have experience domestic violence.

The purpose of special course is to provide accessible information to health care providers in regards to advocacy and treatment of patients who have experience domestic violence. Because  effective advocacy and treatment can only occur if the health care providers has a thorough understanding of the complex dynamics of DV, information regarding victim safety, power and control tactics and community resources.

New course “ Impact domestic violence on reproductive health” was approved by the Ministry of Health and Social Affairs  on 6 September 2006 as certificate program for postgraduate training for  doctors, registration number of program N 2006001, duration training 5 days, fees which doctors pays for course $15, after accomplishment course doctors receive 25 credit scours (to receive permeation to work as doctor need during year to collect 75 credit scours).

Five days training modules for health care practitioners who work in primary care, obstetric /gynecologist.

The manual cover the following topics:

1. The dynamics of domestic violence and its impact on a victim's health.
2. Cultural competency in responding to domestic violence victims
3. Specific clinical strategies for domestic violence screening, assessment, intervention, and documentation
4. Practical applications of screening, assessment, intervention, and documentation
5. Legal issues and community recourses for domestic violence victims as well as legal and reporting issues for health care providers
6. Gynecology: vaginal bleeding; , anemone, dysfunctional bleeding, STD,  breast cancer, cervical cancer,  HIV/AIDS.
7. Obstetric: abortion, stillbirth, complication of pregnancy

These training are designed to provide the information needed for changes in the practice of both individual clinicians and health care system.

MATERIALS OF TRAINING COURSE

Approbation our program was  held  in 4 medical clinic and 133 doctors take part. Training packets containing lectures with extensive lecture notes, exercises for participants and pre- and post- tests for doctors . Also was published and distributed  booklet “Impact Domestic Violence on Health -1000 sample

A  .  DOMESTIC VIOLENCE  -some of the characteristics that often accompany violence in intimate relationships:

• physical violence is almost always accompanied by psychological abuse and in many cases by sexual  abuse.
• most women who suffer any physical aggression by a partner generally experience multiple acts over time.
• DV cuts across socio-economic class and religious and ethnic lines.
• men who batter their partners exhibit profound controlling behavior.
  
  

Impact of Domestic Violence on health

Women who are abused have poorer mental and physical health, more injuries and a greater need for medical resources than non-abused women. Health outcomes of DV has been associated with reproductive health risks and problems, chronic ailments, psychological consequences, injury and death (figure 2).

Reproductive health effects

Women who experience intimate partner abuse are three times more likely to have a gynecological problems than are non-abused women. These problems include: chronic pelvic pain, vaginal bleeding or discharge, vaginal infection, painful menstruation, sexual dysfunction, pelvic inflammatory disease, painful intercourse, urinary tract infection, infertility.

Sexual abuse can cause physical and mental trauma. In addition to damage to the urethra, vagina and anus, abuse can result in STIs, including HIV.

Abuse limits women’s sexual and reproductive autonomy. Women who have been sexually abused are much more likely than non-abused women to use family planning clandestinely, to have had their pertner stop them from used family planning and to have a partner refuse to use a condom to prevent disease.

Studies show that physical abuse occurs in approximately 4 to 15 percent of pregnancies in the USA, UK, Canada, Sweden, South Africa, Nicaragua. Abuse during pregnancy may be a more significant risk factor for pregnancy complications than other conditions for which pregnant women are routinely screened, such as hypertension and diabetes. Abuse during pregnancy has been linked with delays in obtaining prenatal care, increased smoking and drug/alcohol abuse, poor maternal weight gain and depression. Abuse of pregnant women is associated with unsafe abortion, miscarriage, stillbirth, low birth weight and neonatal mortality. Although it is difficult to determine a causal relationship between abuse and these adverse outcomes, a recent meta-analysis of 14 studies indicates a significant association between low birth weight and abuse during pregnancy. Research has found a four-fold increase in low birth weight among infants born to women who had  been physically abused in pregnancy. Abuse may directly influence birth weight through, for example, blows to the abdomen precipitating premature labor. Indirectly, abuse is associated with factors also known to contribute to low birth weight, for example, smoking, alcohol and substance abuse, STIs, elevated stress level, poor nutrition.

Reproductive health -Risks and consequences of violence against women

• Men who are physically abusive are also more likely to have multiple sexual partners, and to coerce their partners into sex, thereby exposing them to sexually transmitted infections (STI),including HIV.
  
  
• Women in abusive relationships are less able to refuse forced sex, use contraception, or negotiate condom use, thereby increasing their risk of unwanted pregnancies and STI/HIV.
  
  
• Sexual and physical violence increase women’s risk for many reproductive health problems, such as chronic pelvic pain, vaginal discharge, sexual dysfunction, and premenstrual problems, as well as pregnancy loss from abortion or miscarriage, and low birth weight in infants.
  
  
• Fear, geographical isolation, and lack of economic resources may prevent women from seeking reproductive health services – prenatal care, gynecological and contraceptive services, STI/HIV screening and care – and to adequately care for their children.
  
  
• Witnessing or experiencing violence against women during childhood has been associated with risk-taking behavior during adolescence and adulthood: early sexual initiation, adolescent pregnancy, multiple partners, substance abuse, trading sex, and not using condoms or other forms of contraception.

Based on information from Population Reports (Heise, Ellsberg, and Gottemoeller 1999)

Why is this important for physicians?

Health care providers can play a crucial role in detecting, referring and caring for women living with violence. Abused women often seek health care, even when they don’t disclose the violent event.

Health care providers have the opportunity and the obligation to identify cases of abuse. For many women a visit to a health clinic for reproductive or child health services may be their only contact with the health care system. The health care sector can capitalize on this opportunity by ensuring a supportive and safe environment for clients, helping women receive the care they need.

The acronym RADAR, developed by Massachusetts Medical Society, summarizes the steps physicians should take in diagnosing and treating victims of DV:

R – Routinely ask about domestic violence
A – Ask direct questions
D – Document findings
A – Assess patient’s safety
R – Refer to appropriate resources

Ask about abuse

Asking women about abuse in a direct interview can be an effective way to identify survivors of abuse. Nonetheless, few health practitioners routinely ask about abuse. In some programs, screening of all women may be impractical and even unethical if not done appropriately and confidentially. Screening of specific groups, such as women seeking prenatal care or other health services, may be feasible

When should you suspect, that a patient is a victim of Domestic Violence?

Clues from the history:

• Inconsistent explanation for injuries
• Delay in treatment for injuries
• Frequent ER or office visits
• Termination of medical visits
• Somatic complaints: headaches, fatigue, insomnia, chronic abdominal pain
• Associated disorders: eating disorders, substance abuse, anxiety, depression
• Gynecologic presentations: STDs including HIV, unintended pregnancy, chronic pelvic pain, sexual dysfunction.
• Obstetric presentations: late prenatal care
• Learning problems in children

Clues from the physical exam:

• Demeanor: flat affect, avoiding eye contact, fearful, evasive, hostile
• Injuries on the central part of the body, head and neck
• Injuries to the forearms – occur when victim tries to defend herself
• Bruises of different ages

Clues from the partner’s behavior:

• Overly solicitous
• Answers questions addressed to the woman
• Refuses to leave the exam room

Screening for DV should be a routine part of the medical history.

Providers must ensure a safe, confidential environment and establish a relationship of trust and respect for their clients prior to asking about abuse. Client waiting areas can offer educational materials, including posters on the walls and informational brochures, to let clients know that abuse can be discussed safely at the facility. Providers must be careful not to place clients at increased risk by violating their confidentiality. It is the provider’s role to empathize and validate clients’ experiences and to support their autonomy in deciding what to do about their situations (Figure 3).

What to ask:

• Have you ever felt hurt emotionally or psychologically by your partner?
• Has your partner ever caused you physical harm?
• Were you ever forced to have sexual contact?
• When you were a child, were you ever touched in a way that made you feel uncomfortable?

The act of asking questions about violence can let women know that providers consider violence to be an important medical problem and not the client’s fault. Even if an abused woman doesn’t disclose the violence on a first visit, asking about it shows that the clinician cares and may encourage her to talk about it on  a later visit.

It is not enough to simply wait for women to dislose violence on their own. Experience has shown that many women are willing to talk about violence, but it is usually necessary for health personnel to take the initiative. Women are waiting for someone to knock on their door…

Document findings

Careful documentation of a woman’s symptoms or injuries, as well as of her history of abuse, are helpful for future medical follow-up. Documentation is also important in the event that she decides to press charges against the abuser or to seek custody of the children. Documentation should be as thorough as possible and clearly state the identity of the offender and his relationship to the victim. Photographs of injuries will be a  big help too. 

DEVELOPING A SAFETY PLAN

Health care providers can help women protect themselves from intimate partner violence, even if the women may not be ready to leave home or report abusive partners to authorities. When clients have a personal safety plan, they are better able to deal with violent situations. Providers can review these points below to help each woman develop her own personal safety plan:

Identify one or more neighbors you can tell about the violence, and ask them to seek help if they hear a disturbance in your home.

If an argument seems unavoidable, try to have it in a room or an area that you can leave easily.
Stay away from any room where weapons might be available.

Practice how to get out of your home safely, identify which doors, windows, elevator, or stairwell would be best.

Have a packed bag ready, containing spare keys, money, important documents, and clothes. Keep it at the home of a relative or friend, in case you need to leave your own home in a hurry.

Devise a code word to use with your children, family, friends, and neighbors when you need emergency help or want them to call the police.

Decide where you will go if you have to leave home, and have a plan to get there.

Use your instincts and judgment. If the situation is dangerous, consider giving the abuser what he is demanding to calm him down. You have the right to protect yourself and your children.

Remember: you do not deserve to be hit or threatened.

Find out whether the woman feels that she or her children are in immediate danger. If so, help her consider various courses of action. Is there a friend or relative who can help her? If there is a women’s shelter or crisis center in the area, offer to make the contact for her.

Provide appropriate care

Women who suffer intimate partner violence often have specific reproductive health care needs, including STI testing and treatment, and special concerns about keeping their contraceptive use secret. Women who have been raped may need emergency contraception and prophylactic antibiotics.Unless clearly necessary, clinicians should avoid prescribing tranquilizers and mood – altering drugs to women who are living with an abusive partner since these may impair their ability to predict and react to their partners’ attacks.

B.  Diagnosis of   Disorders

I. Basic Principles

Domestic violence has direct impact  on reproductive health and can be reason of  Hormonal disorders  which are not only very frequent in gynecology, but are also very distressful to the patient due to the sterility that often results. For these reasons it is important in gynecology, as in medicine generally, to obtain as much informa­tion as possible using simple diagnostic methods and then to institute specific treatment.

By this reason  we discuss the most important methods currently used for the investigation . The diagnostic pro­gram must necessarily be individualized, although a few purely clinical tests will often suffice for practical purposes. In cases of amenorrhea, an accurate diagnosis can be made on the basis of the basal temperature curve, gestagen test, and pituitary gonadotropin assay.

II. Clinical Aspects

1. Anamnesis
Anamnesis plays a key role in the investigation of hormonal disorders in gynecol­ogy. Besides the usual questions, special attention is given to the  screening on DV
The patient is then questioned about inter-, pre-, and postmenstrual bleeding, as well as dysmenorrhea, premenstrual complaints, and discharge. Parous women should be asked about the course of their pregnancy, the delivery . Also important are weight changes, which are typical of Cushing's syndrome and anorexia nervosa, voice changes, and hirsutism in virilization, as well as the presence of flushes in premature menopause- or headaches and visual disturbances in pituitary tumors. Finally, since menstrual dysfunction is sometimes of psychological origin, the physician should examine the patient's relationships to her marital or sexual partner, school, home, or place of employment. These factors are particularly important in women with secondary amenorrhea.

2. Clinical Examination
The general examination also provides much useful information. Besides the phys­ical appearance and physique, weight, and size, particular attention is given to the development of secondary sex characteristics, the breasts and body hair. In many diseases, such as marked  anorexia nervosa . The examiner should also be alert for signs of disorders of other endocrine glands, particularly the thyroid, adrenal cortex, and anterior pituitary;  which is associated with stress.

3. Gynecologic Examination
The gynecologic exploration is undertaken in the usual manner, though extra tact is required due to the sensitiveness of many of these patients. The speculum examination gives information on the presence of a vagina, the vaginal contents, the size of the portio, and the character of the cervical mucus  which in turn may be suggestive of sexual violence

Finally, bimanual examination is done to assess the shape and size of the uterus. The adnexal regions in particular are carefully palpated. Ovarian enlargement is found in the secondary to a hormone-producing tumor ,chronic pelvic pain, vaginal discharge.

Menstrual Disorders which connected with impact of Domestic violence

Abnormalities of Rhythm

Abnormalities in the rhythm of the menstrual cycle include infrequent menstruation, or oligomenorrhea, as well as menstruation at abnormally frequent intervals, or polimenorrhea.

There are certain vagaries in the exact definitions of these abnormalities. However, since 95% of menstrual cycles are from 21 to 35 days in duration during reproductive life, we may take this range as the “normal” periodicity and assume that only marked deviations constitute true abnormalities of rhythm.

Oligomenorrhea

The often-scanty menstrual flows occur at intervals of 36-90 days. Longer menstrual intervals are considered to fall within the amenorrheal range.

Pathogenesis:  Oligomenorrhea may be primary, and thus in evidence since the menarche, or may arise secondarily during the reproductive year. It is usually the result of a hypothalamic dysfunction which, as in amenorrhea, is very often based upon emotional conflicts related to job, family, sexual activity, or a change of environment. Oligomenorrhea also occurs in other endocrine syndromes, such as disorders of the adrenal cortex and thyroid, as well as in obesity and anorexia. Polycycstic ovaries are also the common cause of this abnormality. Usually the cycles are anovulatory, although occasionally ovulation occurs after an extended proliferative phase.

Diagnosis: Besides the psychologic history and physical examination, it is important to obtain an accurate record of bleeding and basal temperature graph. Specific assays for hormones such as gonadotropins and estrogens and simple function studies such as gonadotropins and estrogens and simple function studies such as the gestagen test are seldom very informative, since the results generally are in the mid- to low-normal range.

On the other hand, prolactin assay, adrenocortical function tests, and the exclusion of thyroid disease can be helpful in certain cases.

Polymenorrhea

This term is applied the menstrual bleeding that occurs at intervals of less than 21 days.

Pathogenesis: The bleeding of polymenorrhea may be of the anovulatory withdrawal type or may be ovulatory with an abnormally short proliferate secretory phase. Generally, the cause lies in a defect of hypothalamic control. Polymenorrhea is most common during the transitional phases of life, i.e., puberty and the climacteric..

A short luteal phase is of particular clinical importance. If it is shorter then 10 days in an ovulatory cycle, functional sterility will result. There are two variants of this defect according to etiology: a central determined, hypoluteotropic from with inadequate LH stimulation of the corpus luteum. In each case there is deficient secretory preparation of the endometrium and inadequate progesterone production during the second half of the cycle. As a result of this, the fertilized ovum is unable to implant.

Hypermenorrhea

Hypermenorrhea is characterized by excessive menstrual flow with coagula, because the fibrinolytic enzymes released from endometrium are no longer adequate to keep all the menstrual blood from clotting.

Pathogenesis: Hypermenorrhea is usually the result of organic changes, which interfere with hemostasis, particularly a reduction of uterine contractility or, occasionally, an enlargement of the endometrial surface. Frequent causes are intramural or submucous myomas, mucosal polyps, and adenomyosis; inflammatory pelvic disease and anatomic anomalies are occasionally responsible.

Diagnosis: The diagnosis rests upon the history, a thorough clinical examination, and a hemoglobin determination to check for anemia. Fractional curettage is often useful both diagnostically and therapeutically. Other studies, particularly hormone assays, are of little value.

Hypomenorrhea

Hypomenorrhea is the term applied to scantly menstrual flow lasting only 1-2 days, and sometimes only a few hours.

Pathogenesis: In contact to other types of abnormalities hypomenorrhea is usually caused by endocrine disturbances, particularly those which are also responsible for oligomenorrhea and the secondary amenorrhea that occasionally develops from it. Sometimes hypomenorrhea is observed after endometrial atrophy following the long-term use of oral contraceptives, as well as after overvigorous curettage.

Diagnosis: Special investigations are usually unnecessary in practice; hormone assays are indicated only if hypogonadism or sterility is present.

Menorragia

Menorrhagia is the term applied to menstrual flows lasting more 7 but less than 14 days. More prolonged flows are classified as menometrorrhagia. The quantity may be normal or increased; heavy bleeding may cause anemia.

Pathogenesis: As in hypermenorrhea, the cause is usually organic.

Diagnosis: Is based mainly on the gynecologic examination. Hormone studies are not helpful.

Acyclic Bleeding

Acyclic Bleeding or metrorrhagia is an aberration of the menstrual pattern in which bleeding occurs outside the regular intervals. It may be dysfunctional or organic in origin.

Pathogenesis: Metrorrhagia in the form of irregular inter-menstrual or prolonged bleeding may be organic or dysfunctional in origin. Such functional disorders are particularly common in adolescents and pre-menopausal women. The cause usually lies in persistence of the unruptured follicle before the establishment of regular menstruation or after its cessation.
Regular pre- and post-menstrual bleeding has a dysfunctional origin in many cases. Pre-menstrual staining may result from an inadequate luteal phase with premature fall of estrogen and progesterone production. On the other hand post-menstrual staining occurs when regression of the corpus luteal is delayed.

iagnosis: Because serious organic causes often can not be ruled out, fractional curettage is necessary in almost every case. An exception is inter-menstrual bleeding which can be accurately correlated with ovulation based on the basal temperature curve or the presence of inter-menstrual pain. Hormone assays are seldom helpful; histologic studies are considerably more informative.

Dysmenorrhea

Dysmenorrhea is painful menstruation with cramping and sometimes persistent lower abdominal discomfort, which usually accompanies the onset of bleeding, but may precede it. Nausea, vomiting, diarrhea, headaches and irritability may also be present. The duration of these complaints may vary from a few hours to 2 days, and in some cases the pain persists through out the menstrual period.

Pathogenesis: Dysmenorrhea may be primary or secondary, depending on time of onset. The primary form appears during or soon after the menarche and is precipitated by emotional factors in about 90% of cases. The typical patients are leptosomatic girls or socially isolated women with schizoid traits who tend to reject their own femininity.

Secondary: dysmenorrhea is the frequently the result of organic changes. The most important is endometriosis, or the presence of ectopic endometrial implants.  

Diagnosis: It is often difficult to isolate the cause of dysmenorrhea due to the presence of superimposed psychic factors. The patient’s history is of prime importance; organic causes are excluded by a thorough gynecologic examination. Laparoscopy may be useful in verifying the sites of endometrial implants. Hormone assays are of no value.

Premenstrual Tension

Premenstrual tension is the term given to the physical and psychological com­plaints that accompany the approach of menstruation. The most prominent symp­toms are painful swelling of the breasts, a sensation of fullness, pallor, edema, headaches, irritability, shifts of mood, and occasionally, genuine depression.

Pre­menstrual water retention may be substantial. These manifestations occur as mild complaints in a great many women and may be regarded as physiologic; only about 2%-5% of cases are serious enough to warrant treatment.

Pathogenesis. Again, psychogenic factors play a significant causal role; the patients are often emotionally unstable and neurotic. Hormonal events are also a factor, since premenstrual tension is, as a rule, restricted to ovulatory cycles. However, the estrogen and progesterone levels do not differ significantly from normal val­ues. According to one hypothesis, the substantial fluid retention is caused by increased aldosterone secretion under the influence of progesterone on the one hand, and by emotional stress on the other. An increase of vasopressin secretion has also been postulated.

Diagnosis. Special investigations are unnecessary. The diagnosis is based upon  subjective complaints and clinical findings. Hormone assays are pointless.

II. Amenorrhea

Amenorrhea can be classified according to a variety of criteria, as illustrated in Table 7.

Primary amenorrhea may be diagnosed if menstruation has failed to occur after the irl has passed the age of 18. This age was selected because only about 0.3% of girls experience spontaneous menarche after that time. Secondary amenorrhea is diagnosed in a patient who has menstruated but then fails to bleed for more than 3 months.

In first-degree (“generative”) amenorrhea, only ovulation and luteinization are absent. Second-degree (“autonomic”) amenorrhea is a much more serious dis­turbance in which follicular maturation, and thus estrogen production, are impaired.

Hypogonadotropic amenorrhea encompasses all serious hypothalamic-pituitary derangements. Hypergonadotropic amenorrhea is based upon an intractable fail­ure of ovarian function, while normogonadotropic amenorrhea is due either to a uterine cause or to a mild defect of hypothalamic-pituitary regulation, such as an absence of the ovulatory LH peak.

Amenorrhea can also be classified according to local pathogenic criteria, i. e., a hypothalamic, pituitary, ovarian, uterine, or vaginal cause. Finally, there is the physiologic form of amenorrhea normally present during childhood, pregnancy, lactation, and after menopause.

Classification of amenorrhea

1. Primary Amenorrhea

a) Hypothalamic-Pituitary Disorders

Pathogenesis. The principal feature of primary amenorrhea due to hypothalamic dysfunction is hypogonadism. Demonstrable organic changes such as aneurysms, tumors, infections, or traumata are relatively rare; the etiology is very often ob-scure. Lesions incurred during embryonic development have been suggested. Psychological causes are infrequent, in contrast to secondary amenorrhea (see p 79), although they are an important factor in patients with anorexia nervosa or endogenous psychoses^ The picture may be further complicated by dysfunctions of other endocrine systems, such as hyper- and hypothyroidism, juvenile diabetes, or adrenogenital syndrome (see p 97).

Diagnosis. The clinical picture is that of hypogonadism, marked by underde­veloped breasts, hypoplastic genitalia, and paucity of pubic hair. Due to the lack of estrogen stimulation, there is little or no buildup of the vaginal epithelium. The gestagen test is negative, and the estrogen and gonadotropin levels are usually very low. The gonadotropin findings allow a clear differentiation from ovarian forms. In obvious cases the clomiphene test is always negative and the LH-RH test often so.

b) Central Disturbances

Pathogenesis. Emotional factors play perhaps the greatest role in the origin of secondary amenorrhea. Psychogenic conflicts of all types, familial and occupa­tional stresses, tests, marital discord, sexual problems, fear of pregnancy, and changes of environment can all produce amenorrheal symptoms.  A special case is anorexia nervosa, a psychoneurosis characterized by aversion to eating with consequent emaciation  It is usually the result of environmen­tal problems, especially as regards the patient's relationship to her parents. An equally dramatic form of psychogenic amenorrhea is pseudocyesis, or false preg­nancy. Owing to an exaggerated fear of or longing for pregnancy, the patient develops all the subjective signs including substantial weight gain, the appearance of striae, breast enlargement, and the perception of fetal movements. Besides these psychoreactive forms, secondary amenorrhea may also occur in true psychoses and particularly in endogenous depression.

Extreme emaciation in anorexia nervosa (24 years)

A relatively common form of secondary amenorrhea is the “oversuppression syn­drome” that may follow the use of oral contraceptives. It is caused by excessive central inhibition, which tends to occur mainly after the use of gestagen-base preparations and in women with antecedent menstrual irregularity. Organic changes in the CNS, such as inflammatory processes, tumors such as raniopharyngeomas, and cranial traumata are much less common causes of amenorrhea.

Diagnosis. The patient's history and clinical examination are of greatest impor­tance. The basal temperature curve is always monophasic due to the absence of ovulation. Estrogen and gonadotropin levels are within or slightly below normal limits; the progesterone levels are always low. The gestagen test is usually positive, as are the clomiphene and LH-RH tests. Thyroid and adrenocortical function are normal, except in anorexia nervosa and organic changes in the region of the diencephalon.

d) Premature Menopause

Pathogenesis. The premature failure of ovulation before the age of 40 is not entirely uncommon. The etiology is unclear but may involve vascular processes linked to the genetic makeup. The course is essentially that of the normal climac­teric, except that it occurs years prematurely: The periods first become irregular and theft cease altogether, accompanied by hot flushes and other deficiency symp­toms.

Diagnosis. The early clinical findings are somewhat uncharacteristic, but the high level of gonadotropins and low estrogen values help to establish the diagnosis.

Sheehan's syndrome (29 years)

IV. The Peri- and Postmenopausal Period

1. Deficiency Symptoms

Pathogenesis. The progressive decline of ovarian estrogen production during the climacteric and especially after menopause creates a "menopausai syndrome" in many women. It is also brought on by castration. The syndrome not only affects the hypothalamic-pituitary-ovarian axis, but also leads to functional derangements of other autonomic centers in the diencephalon. Symptoms include irritability, headaches, forgetfulness, insomnia, and depression; but the most characteristic complaint is the hot flush, which occurs in over 80% of women. It takes the form of disturbing paroxysmal hyperemia of the face, neck, chest, and hands, accom­panied by a sensation of heat and sweating. The pathogenic details are unclear but may involve regulation disturbances in the region of the cervical sympathicus. Circulatory symptoms include palpitation of the heart, vertigo, and tinnitus aurium (Table 9).

Besides disturbances of endocrine origin, menopausal women often experience psychological difficulties relating mainly to changes in living habits and to aging in general. Loss of the figure, children moving away or occupational problems may be precipitating factors.

One result of the estrogen deficiency, of course, is the occurrence of organic changes such as involution of the genital organs. Dyspareunia, senile vaginitis, and urethrocystitis are expressions of these changes. After menopause, senile osteoporosis develops much more frequently than in men. There also appears to be a link between estrogen deprivation and the obesity common in this age group, although lack of exercise and increased caloric intake are primarily responsible. In some circumstances the menopausal syndrome may considerably precede the menopausal event. The symptoms usually regress within a few years but occasion­ally persist to an advanced age. Both the duration and intensity of the syndrome depend strongly on the psychological makeup of the woman involved. Her educa­tion, environment, and degree of adjustment play a decisive role. Hormone assays are of little value, since subjective complaints generally are sufficient to establish the diagnosis, except in premature menopause, q. v. The gonadotropin levels are elevated and the estrogen levels reduced, but these bear no direct relation to the severity of symptoms.

Menopausal syndrome

2. Bleeding

a) Pre- and Perimenopausal Bleeding

Pathogenesis. As in juveniles , dysfunctional bleeding in climacteric women is usually the result of a persistent unruptured follicle. In such cases the follicle develops to the tertiary or vesicular stage (see p 7), but ovulation does not occur due to the inadequacy of hypothalamic regulation. The increasing estrogenic effect causes excessive endometrial proliferation, leading after several weeks to cystic glandular hyperplasia  In very rare cases, a granulosa cell tumor may create the same situation (see p 94). When the estrogen level falls below that required to sustain the hyperplastic endometrium, varying degrees of bleeding occur, ranging from slight staining to severe hemorrhage that may persist for weeks.

Diagnosis. Hormone assays yield little information, though estrogen levels may be somewhat elevated. Since organic changes are present in over 20% of climacteric menometrorrhagia, fractional curettage should be performed in every case. In cystic glandular hyperplasia, curettage has both a diagnostic and therapeutic role. Abnormal bleeding tends to recur in approximately two-thirds of cases, which may then be treated hormonally after malignancy is excluded. Bleeding can be effec­tively controlled with orally active estrogen-gestagen preparations, e. g., three to five tablets Primosiston (Schering) daily for 10 days. This regimen provokes heavy withdrawal bleeding and thus serves as a "hormonal curettage." For long-term therapy, oral contraceptives with a high gestagen content are suitable, such as Eugynon (Schering) or Ovulen (Searle). Parenteral depot preparations are less suitable, because their prolonged hormonal activity may lead to sustained, heavy withdrawal bleeding.

b) Postmenopausal Bleeding

Pathogenesis. In most cases postmenopausal bleeding is the result of organic changes. It may also be caused by cystic glandular hyperplasia due to the long-term administration of estrogen-containing preparations with considerable endometrial activity. In rare cases the estrogen source is a follicle which matures postmenopausally or an ovarian neoplasm, notably a granulosa cell tumor or a theca cell tumor. These are estrogen-producing, usually unilateral, semimalignant tumors whose volume is highly variable; they may reach an enormous size, or may be only a few millimeters in diameter and thus difficult to locate.

Diagnosis. Curettage is always indicated in postmenopausal bleeding. Further investigations depend upon histologic findings. If cystic glandular hyperplasia is discovered, all estrogen-containing ointments and tablets must be withdrawn. Moderately elevated estrogen levels in the serum or urine accompanied by an abnormally low postmenopausal level of pituitary gonadotropins are indicative of a hormone-producing ovarian tumor. In doubtful cases the diagnosis is verified by laparoscopy.

4. Galactorrhea

Pathogenesis. Galactorrhea refers to the unilateral or bilateral secretion of milk outside the lactation period  This occurs physiologically during preg­nancy and sometimes for a short time after weaning. In some cases bilateral galactorrhea is also observed during the use of oral contraceptives and psycho-tropic drugs, as well as in cause is functional hyperprolactinemia or pituitary adenoma Unilateral galactorrhea may be associated with intraductal carcinoma; in such cases the secretion is often grayish in color, but may also be serous or bloody.

 Pathogenesis

Diagnosis. On the one hand, the diagnosis must exclude local processes. This can be done by careful clinical examination and by mammography, galactoductogra-phy, or thermography; also, a smear should be prepared and examined histologi-cally. On the other hand, it is necessary to perform multiple prolactin determina­tions in order to rule out an endocrine disturbance. If values are elevated, a roentgenographic or tomographic survey of the sella turcica is indicated so that a prolactinoma, if present, can be recognized as early as possible.

According the plan was trained 133 doctors in 4 medical clinic. Training packets containing lectures with extensive lecture notes, exercises for participants and pre- and post- tests for doctors .

Round table was organized with the head of department of hospitals,  key persons and discuss the way of implementation screening program. multidisciplinary approach and strategy for future collaboration

Agenda

PUBLICATION

1000 sample of booklet “Impact Domestic Violence on Health “ were published

Round table discussion with  head of department of hospitals, key persons Parliamentarians representatives with Ministry of Health and Social Affairs came to conclusion about strategy for future collaboration and necessarily of creation screening program  and implementation in medical records.