It was not until the 19th century that children were granted the same legal status as domesticated animals with regard to protection against cruelty and/or neglect. In 1962, the term "battered child syndrome" became part of the medical vocabulary and by 1976 all of the states in the United States had adopted laws mandating the reporting of suspected child abuse.
What is the scope of the child abuse problem?From the early 1970's when a national data bank was created, the yearly number of reports of child abuse has risen progressively. Initially, 700,000 incidents of child abuse were reported annually. Now there are approximately 2 million cases reported every year. While "reports" of alleged child abuse are not always substantiated during the investigation process, most authorities believe that a large under reporting bias is inherent in the data. There is much more child abuse than gets reported.
What age child is abused?All ages. The frequency of documented child abuse increases with the age of the victim: children less than 2 years of age (6 per 1000) versus 15 to 17 years of age (14 per 1000). This statistic may reflect a true increase in mistreatment with the age of the child or it may at least in part reflect a rise in reporting. Obviously, very young children are incapable of verbally communicating the harm inflicted on them. Other factors such as fear, guilt, or confusion about the abuser's erratic behavior may also hinder younger children from informing on their abuser.
Are girls more often abused than boys?Yes. Girls are somewhat more likely to be abused. According to statistics published in 1996, about 52% of victims of maltreatment were female and 48% were male.
Is the pattern of abuse different for girls and boys?Yes. Some differences exist in the types of maltreatment experienced by female and male children. A review of data from 11 states in the U.S. reveals that 77% of sexual abuse victims were girls compared to 23% boys. Victims of emotional mistreatment were also more likely to be female (53%) than male (47%).
Conversely, a slightly greater proportion of victims of other types of maltreatment were male. Males comprised approximately 51% of neglect victims and 52% of both physical abuse and medical neglect victims.
Is there an association between poverty and child abuse?While children of families in all income levels suffer maltreatment, research suggests that family income is strongly related to incidence rates. Children from families with annual incomes below $15,000 per year are more than 25 times more likely than children from families with annual income above $30,000 to be harmed or endangered by abuse or neglect. Poverty clearly predisposes to child abuse.
Who abuses children?According to the statistics, the majority of perpetrators of child mistreatment (77%) are parents and another 11% are other relatives of the victim. People who are in other care taking relationships to the victim (e.g., child care providers, foster parents, and facility staff) account for only 2 percent of the offenders. About 10% of all perpetrators are classified as non-caretakers or unknown. In many states, child abusers by definition must be in a care taking role.
An estimated 81% of all offenders are under age 40. Overall, approximately 61% of perpetrators are female, although the gender of the abuser differs by the type of mistreatment. Neglect and medical neglect are most often attributed to female caretakers, while sexual abuse is most often associated with male offenders.
What is child abuse?The term child abuse encompasses four basic types of mistreatment: child neglect, physical abuse of a child, emotional abuse of a child, and sexual abuse of a child.
What does the term child neglect include?Child neglect is the most frequently reported form of child abuse (60% of all cases) and the most lethal.
Neglect is defined as the failure to provide for the shelter, safety, supervision, and nutritional needs of the child. Child neglect may be physical, educational, or emotional. The assessment of child neglect requires the consideration of cultural values and standards of care as well as the recognition that the failure to provide the necessities of life may be related to poverty.
Physical neglect includes the refusal or delay in seeking health care, abandonment, inadequate supervision, expulsion from the home, or refusal to allow a runaway to return home.
Educational neglect includes the allowance of chronic truancy, failure to enroll a child of mandatory school age in school, and failure to attend to a special educational need.
Emotional neglect involves a marked inattention to the child's needs for affection, refusal of or failure to provide needed psychological care, spousal abuse or parental substance abuse in the child's presence, and permission of drug or alcohol use by the child.
What actions are viewed as physical child abuse?Physical abuse is the second most frequently reported form of child abuse (25% of all cases).
This form of mistreatment is defined as willful (as opposed to accidental) physical injury inflicted upon the child. Physical abuse can be the result of punching, beating, kicking, biting, burning, shaking, or otherwise harming the child's body. The parent or caretaker may not have intended to hurt the child; rather, the injury may have resulted from excessive disciplinary efforts or physical punishment.
There exists a significant controversy regarding physical methods of discipline (e.g. spanking) and their relationship to more orthodox forms of physical abuse.
What constitutes emotional child abuse?Emotional abuse is the third most frequently reported form of child abuse (17% of all cases). This form is felt to be markedly under reported since it can be difficult to detect and document.
Emotional abuse includes acts or omissions by the parents or other caregivers that could cause serious behavioral, emotional, or mental disorders. Verbal assaults on the child or on other members of the family in the child's presence is a common form of emotional abuse. In some cases of emotional abuse, the acts of the parents or other caregivers alone, without any harm evident in the child's behavior or condition, are sufficient to warrant child protective services intervention. For example, the parents/caregivers may use extreme or bizarre forms of punishment, such as confinement of the child in a dark closet.
Emotional child abuse is also sometimes termed psychological child abuse, verbal child abuse, or mental injury of a child.
What is sexual child abuse?Sexual abuse is the least frequently reported form of child mistreatment (6% of all cases). Experts believe that sexual abuse may be the most under-reported type of abuse because of the secrecy or "conspiracy of silence" that so often characterizes these cases.
Sexual abuse includes fondling a child's genitals, intercourse, incest, rape, sodomy, exhibitionism, and commercial exploitation through prostitution or the production of pornographic materials.
How is alleged child abuse evaluated?A thorough nonjudgmental history of the immediate events as well as a review of potential similar experiences are often independently done by a physician, social worker, and/or the police department. The child may be interviewed separately from the parents as part of this information gathering process.
A complete physical exam of the child (which may include the taking of photographs to document physical/sexual abuse) is often followed by x-rays and/or laboratory tests to support the potential diagnosis of inflicted trauma and to rule out the possibility of medical conditions which could account for the physical findings noted during the examination.
How is child abuse treated?Steps which are often taken to correct child abuse are as follows:
The safety of the abused child and any other potential victim of abuse in the household is paramount. Removal of the victim and placement in protective custody in a group home or foster care are often necessary.
Effective counseling for the child, family, and the abuser is essential to deal with the associated emotional and psychological stress and trauma.
In the event of neglect, establishing realistic expectations of the child's needs and capabilities is required.
Parental high-risk behaviors such as substance/alcohol abuse must be addressed.
Pedophiles (people who have sexually abused children) often require intense psychological and pharmacological therapy prior to release into the community, because of the high rate of repeat offenders.
How can child abuse be prevented?This, too, is a very complex matter and includes these measures:
A support group structure is needed to reinforce parenting skills and closely monitor the child's well-being.
Visiting home nurse or social worker visits are also required to Observe and evaluate the progress of the child and his/her caretaking situation.
The support group structure and visiting home nurse or social worker visits are not mutually exclusive. Many studies have demonstrated that the two measures must be coupled together for the best possible outcome.
Children's school programs regarding "good touch...bad touch" can provide children with a forum in which to role-play and learn to avoid potentially harmful scenarios.
Parents should make sure that their child's daycare center is licensed and has an open door policy regarding parental visitation.
What more can be done to prevent child neglect?As children's advocates, we wish to remind parents about the importance of preventative child health care, including:
Proper use of car seats and seat belts;
Consistent use of helmets for bicycling and skateboarding;
Pool and water safety;
Firearm safety; and
Poisoning prevention.
Are persons who were abused as children more likely to become criminals later in life?According to a 1992 study sponsored by the National Institute of Justice (NIJ), maltreatment in childhood increases the likelihood of arrest as a juvenile by 53% and as an adult by 38%. Abuse as a child also increases the prospect of arrest for a violent crime by 38%.
For females, being abused or neglected in childhood raises the likelihood of arrest by 77%. A related 1994 NIJ study indicated that children who were sexually abused were 28 times more likely than a control group of non-abused children to be arrested for prostitution as an adult.
Child Abuse At A Glance
Child abuse is a significant and dangerous problem.
It is in fact a series of serious problems.
These problems include child neglect and abuse -- whether it be physical, emotional, or sexual.
Neglect is the most frequently reported form of child abuse and the most lethal.
Poor nutrition is a form of child abuse.
Failure to provide a child with appropriate schooling is a type of educational child abuse.
Children can be neglected and abused by parents, other caregivers, or society.
Poverty is a factor which contributes to child abuse.
Child abuse should be reported, investigated, and evaluated.
Prevention is the best strategy for the management of child abuse.
Tuesday, January 29, 2008
Boils(Skin Abscesses)
What is a boil?
A boil, also referred to as a skin abscess, is a localized infection deep in the skin. A boil generally starts as a reddened, tender area. Over time, the area becomes firm and hard. Eventually, the center of the abscess softens and becomes filled with infection-fighting white blood cells that the body sends from the bloodstream to eradicate the infection. This collection of white blood cells, bacteria, and proteins is known as pus. Finally, the pus "forms a head," which can be surgically opened or spontaneously drain out through the surface of the skin.
What does a boil look like?
There are several different types of boils. Among these are:
Furuncle or carbuncle: This is an abscess in the skin caused by the bacterium Staphylococcus aureus. A furuncle can have one or more openings onto the skin and may be associated with a fever or chills.
Cystic acne: This is a type of abscess that is formed when oil ducts become clogged and infected. Cystic acne affects deeper skin tissue that the more superficial inflammation from common acne. Cystic acne is most common on the face and typically occurs in the teenage years.
Hidradenitis suppurativa: This is a condition in which there are multiple abscesses that form under the armpits and often in the groin area. These areas are a result of local inflammation of the sweat glands. This form of skin infection is difficult to treat with antibiotics alone and typically requires a surgical procedure to remove the involved sweat glands in order to stop the skin inflammation.
Pilonidal cyst: This is a unique kind of abscess that occurs in the crease of the buttocks. Pilonidal cysts often begin as tiny areas of infection in the base of the area of skin from which hair grows (the hair follicle). With irritation from direct pressure, over time the inflamed area enlarges to become a firm, painful, tender nodule making it difficult to sit without discomfort. These frequently form after long trips that involve prolonged sitting.
Why do boils occur?
There are many causes of boils. Some boils can be caused by an ingrown hair. Others can form as the result of a splinter or other foreign material that has become lodged in the skin. Others boils, such as those of acne, are caused by plugged sweat glands that become infected.
The skin is an essential part of our immune defense against materials and microbes that are foreign to our body. Any break in the skin, such as a cut or scrape, can develop into an abscess should it then become infected with bacteria.
Who is most likely to develop a boil?
Anyone can develop a boil. However, people with certain illnesses or medications that impair the body's immune system (the natural defense system against foreign materials or microbes) are more likely to develop boils. Among the illnesses that can be associated with impaired immune systems are diabetes and kidney failure. Diseases, such as hypogammaglobulinemia, that are associated with deficiencies in the normal immune system can increase the tendency to develop boils.
Many medications can suppress the normal immune system and increase the risk of developing boils. These medications include cortisone medications (prednisone and prednisolone) and medications used for cancer chemotherapy.
What is the treatment for a boil?
Most simple boils can be treated at home. Ideally, the treatment should begin as soon as a boil is noticed since early treatment may prevent later complications.
The primary treatment for most boils is heat application, usually with hot soaks or hot packs. Heat application increases the circulation to the area and allows the body to better fight off the infection by bringing antibodies and white blood cells to the site of infection.
As long as the boil is small and firm, opening the area and draining the boil is not helpful, even if the area is painful. However, once the boil becomes soft or "forms a head" (that is, a small pustule is noted in the boil), it can be ready to drain. Once drained, pain relief can be dramatic. Most small boils, such as those that form around hairs, drain on their own with soaking. On occasion, and especially with larger boils, the larger boil will need to be drained or "lanced" by a health-care practitioner. Frequently, these larger boils contain several pockets of pus that must be opened and drained.
Antibiotics are often used to eliminate the accompanying bacterial infection. Especially if there is an infection of the surrounding skin, the doctor often prescribes antibiotics. However, antibiotics are not needed in every situation. In fact, antibiotics have difficulty penetrating the outer wall of an abscess well and often will not cure an abscess without additional surgical drainage.
When should I seek medical attention?
Any boil or abscess in a patient with diabetes or a patient with an underlying illness that can be associated with a weakened immune system (such as cancer, rheumatoid arthritis, etc.) should be evaluated by a health-care practitioner. Additionally, many medicines, especially prednisone, that suppress the immune system (the natural infection-fighting system of the body) can complicate what would be an otherwise simple boil. Patients who are on such medications should consult their health-care practitioner if they develop boils. (If you are not sure about your medications' effects on the immune system, your pharmacist may be able to explain to you which medicines to be concerned about.)
Any boil that is associated with a fever should receive medical attention. A "pilonidal cyst," a boil that occurs between the buttocks, is a special case. These almost always require medical treatment including drainage and packing (putting gauze in the opened abscess to assure it continues to drain). Finally, any painful boil that is not rapidly improving should be seen by the health-care practitioner.
What can be done to prevent boils (abscesses)?
There are some measures that you can take to prevent boils from forming. The regular use of antibacterial soaps can help to prevent bacteria from building up on the skin. This can reduce the chance for the hair follicles to become infected and prevent the formation of boils. In some situations, your health-care practitioner may recommend special cleansers such as pHisoderm to even further reduce the bacteria on the skin. When the hair follicles on the back of the arms or around the thighs are continually inflamed, regular use of an abrasive brush (loofah brush) in the shower can be used break up oil plugs and build up around hair follicles.
Pilonidal cysts can be prevented by avoiding continued direct pressure or irritation of the buttock area when a local hair follicle becomes inflamed. At that point, regular soap and hot water cleaning and drying can be helpful.
For acne and hidradenitis suppurativa (see above), antibiotics may be required on a long-term basis to prevent recurrent abscess formation. As mentioned above, surgical resection of sweat glands in the involved skin may be necessary. Other medications, such as isotretinoin (Accutane), can be used for cystic acne and have been helpful in some patients with hidradenitis suppurativa. Recurrences are common in patients with hidradenitis suppurativa.
Finally, surgery may occasionally be needed, especially in pilonidal cysts that recur, but also for hidradenitis suppurativa. For pilonidal cysts, surgically removing the outer shell of the cyst is important to clear the boil. The procedure is typically performed in the operating room. For hidradenitis suppurativa, extensive involvement can require plastics surgical repair.
Boils At A Glance
A boil, or skin abscess, is a collection of pus that forms inside the body.
Antibiotics alone can be inadequate in treating abscesses.
The primary treatments for boils include hot packs and draining ("lancing") the abscess, but only when it is soft and ready to drain.
If you have a fever or long-term illness, such as cancer or diabetes, or are taking medications that suppress the immune system, you should contact your health-care practitioner if you develop a boil (abscess).
There are a number of methods that can be used to prevent the various forms of boils.
A boil, also referred to as a skin abscess, is a localized infection deep in the skin. A boil generally starts as a reddened, tender area. Over time, the area becomes firm and hard. Eventually, the center of the abscess softens and becomes filled with infection-fighting white blood cells that the body sends from the bloodstream to eradicate the infection. This collection of white blood cells, bacteria, and proteins is known as pus. Finally, the pus "forms a head," which can be surgically opened or spontaneously drain out through the surface of the skin.
What does a boil look like?
There are several different types of boils. Among these are:
Furuncle or carbuncle: This is an abscess in the skin caused by the bacterium Staphylococcus aureus. A furuncle can have one or more openings onto the skin and may be associated with a fever or chills.
Cystic acne: This is a type of abscess that is formed when oil ducts become clogged and infected. Cystic acne affects deeper skin tissue that the more superficial inflammation from common acne. Cystic acne is most common on the face and typically occurs in the teenage years.
Hidradenitis suppurativa: This is a condition in which there are multiple abscesses that form under the armpits and often in the groin area. These areas are a result of local inflammation of the sweat glands. This form of skin infection is difficult to treat with antibiotics alone and typically requires a surgical procedure to remove the involved sweat glands in order to stop the skin inflammation.
Pilonidal cyst: This is a unique kind of abscess that occurs in the crease of the buttocks. Pilonidal cysts often begin as tiny areas of infection in the base of the area of skin from which hair grows (the hair follicle). With irritation from direct pressure, over time the inflamed area enlarges to become a firm, painful, tender nodule making it difficult to sit without discomfort. These frequently form after long trips that involve prolonged sitting.
Why do boils occur?
There are many causes of boils. Some boils can be caused by an ingrown hair. Others can form as the result of a splinter or other foreign material that has become lodged in the skin. Others boils, such as those of acne, are caused by plugged sweat glands that become infected.
The skin is an essential part of our immune defense against materials and microbes that are foreign to our body. Any break in the skin, such as a cut or scrape, can develop into an abscess should it then become infected with bacteria.
Who is most likely to develop a boil?
Anyone can develop a boil. However, people with certain illnesses or medications that impair the body's immune system (the natural defense system against foreign materials or microbes) are more likely to develop boils. Among the illnesses that can be associated with impaired immune systems are diabetes and kidney failure. Diseases, such as hypogammaglobulinemia, that are associated with deficiencies in the normal immune system can increase the tendency to develop boils.
Many medications can suppress the normal immune system and increase the risk of developing boils. These medications include cortisone medications (prednisone and prednisolone) and medications used for cancer chemotherapy.
What is the treatment for a boil?
Most simple boils can be treated at home. Ideally, the treatment should begin as soon as a boil is noticed since early treatment may prevent later complications.
The primary treatment for most boils is heat application, usually with hot soaks or hot packs. Heat application increases the circulation to the area and allows the body to better fight off the infection by bringing antibodies and white blood cells to the site of infection.
As long as the boil is small and firm, opening the area and draining the boil is not helpful, even if the area is painful. However, once the boil becomes soft or "forms a head" (that is, a small pustule is noted in the boil), it can be ready to drain. Once drained, pain relief can be dramatic. Most small boils, such as those that form around hairs, drain on their own with soaking. On occasion, and especially with larger boils, the larger boil will need to be drained or "lanced" by a health-care practitioner. Frequently, these larger boils contain several pockets of pus that must be opened and drained.
Antibiotics are often used to eliminate the accompanying bacterial infection. Especially if there is an infection of the surrounding skin, the doctor often prescribes antibiotics. However, antibiotics are not needed in every situation. In fact, antibiotics have difficulty penetrating the outer wall of an abscess well and often will not cure an abscess without additional surgical drainage.
When should I seek medical attention?
Any boil or abscess in a patient with diabetes or a patient with an underlying illness that can be associated with a weakened immune system (such as cancer, rheumatoid arthritis, etc.) should be evaluated by a health-care practitioner. Additionally, many medicines, especially prednisone, that suppress the immune system (the natural infection-fighting system of the body) can complicate what would be an otherwise simple boil. Patients who are on such medications should consult their health-care practitioner if they develop boils. (If you are not sure about your medications' effects on the immune system, your pharmacist may be able to explain to you which medicines to be concerned about.)
Any boil that is associated with a fever should receive medical attention. A "pilonidal cyst," a boil that occurs between the buttocks, is a special case. These almost always require medical treatment including drainage and packing (putting gauze in the opened abscess to assure it continues to drain). Finally, any painful boil that is not rapidly improving should be seen by the health-care practitioner.
What can be done to prevent boils (abscesses)?
There are some measures that you can take to prevent boils from forming. The regular use of antibacterial soaps can help to prevent bacteria from building up on the skin. This can reduce the chance for the hair follicles to become infected and prevent the formation of boils. In some situations, your health-care practitioner may recommend special cleansers such as pHisoderm to even further reduce the bacteria on the skin. When the hair follicles on the back of the arms or around the thighs are continually inflamed, regular use of an abrasive brush (loofah brush) in the shower can be used break up oil plugs and build up around hair follicles.
Pilonidal cysts can be prevented by avoiding continued direct pressure or irritation of the buttock area when a local hair follicle becomes inflamed. At that point, regular soap and hot water cleaning and drying can be helpful.
For acne and hidradenitis suppurativa (see above), antibiotics may be required on a long-term basis to prevent recurrent abscess formation. As mentioned above, surgical resection of sweat glands in the involved skin may be necessary. Other medications, such as isotretinoin (Accutane), can be used for cystic acne and have been helpful in some patients with hidradenitis suppurativa. Recurrences are common in patients with hidradenitis suppurativa.
Finally, surgery may occasionally be needed, especially in pilonidal cysts that recur, but also for hidradenitis suppurativa. For pilonidal cysts, surgically removing the outer shell of the cyst is important to clear the boil. The procedure is typically performed in the operating room. For hidradenitis suppurativa, extensive involvement can require plastics surgical repair.
Boils At A Glance
A boil, or skin abscess, is a collection of pus that forms inside the body.
Antibiotics alone can be inadequate in treating abscesses.
The primary treatments for boils include hot packs and draining ("lancing") the abscess, but only when it is soft and ready to drain.
If you have a fever or long-term illness, such as cancer or diabetes, or are taking medications that suppress the immune system, you should contact your health-care practitioner if you develop a boil (abscess).
There are a number of methods that can be used to prevent the various forms of boils.
Abscessed Tooth
An abscessed tooth is a painful infection at the root of a tooth or between the gum and a tooth. It's most commonly caused by severe tooth decay. Other causes of tooth abscess are trauma to the tooth, such as when it is broken or chipped, and gingivitis or gum disease.
These problems can cause openings in the tooth enamel, which allows bacteria to infect the center of the tooth (called the pulp). The infection may also spread from the root of the tooth to the bones supporting the tooth.
What are the symptoms of an abscessed tooth?
A toothache that is severe and continuous and results in gnawing or throbbing pain or sharp or shooting pain are common symptoms of an abscessed tooth. Other symptoms may include:
What does an abscessed tooth look like?
Fever
Pain when chewing
Sensitivity of the teeth to hot or cold
Bitter taste in the mouth
Foul smell to the breath
Swollen neck glands
General discomfort, uneasiness, or ill feeling
Redness and swelling of the gums
Swollen area of the upper or lower jaw
An open, draining sore on the side of the gum
If the root of the tooth dies as a result of infection, the toothache may stop. However, this doesn't mean the infection has healed; the infection remains active and continues to spread and destroy tissue. Therefore, if you experience any of the above listed symptoms, it is important to see a dentist even if the pain subsides.
How is an abscessed tooth diagnosed?
Your dentist will probe your teeth with a dental instrument. If you have an abscessed tooth, you will feel pain when the tooth is tapped by your dentist's probe. Your dentist will also ask you if your pain increases when you bite down or when you close your mouth tightly. In addition, your dentist may suspect an abscessed tooth because your gums may be swollen and red.
Your dentist may also take X-rays to look for erosion of the bone around the abscess.
How is an abscessed tooth treated?
Strategies to eliminate the infection, preserve the tooth, and prevent complications are the goals of treatment.
To eliminate infection, the abscess may need to be drained. Achieving drainage may be done through the tooth by a procedure known as a root canal. Root canal surgery may also be recommended to remove any diseased root tissue after the infection has subsided. Then, a crown may be placed over the tooth.
The tooth may also be extracted, allowing drainage through the socket.
Finally, a third way to drain the abscess would be by incision into the swollen gum tissue.
Antibiotics are prescribed to help fight the infection. To relieve the pain and discomfort associated with an abscessed tooth, warm salt-water rinses and over-the-counter pain-reducing medication like ibuprofen (Advil or Motrin) can be used.
Can an abscessed tooth be prevented?
Following good oral hygiene practices can reduce the risk of developing a tooth abscess. Also, if your teeth experience trauma (for example, become loosened or chipped), seek prompt dental attention.
Source: MedicineNet.com http://www.medicinenet.com/abscessed_tooth/article.htm
These problems can cause openings in the tooth enamel, which allows bacteria to infect the center of the tooth (called the pulp). The infection may also spread from the root of the tooth to the bones supporting the tooth.
What are the symptoms of an abscessed tooth?
A toothache that is severe and continuous and results in gnawing or throbbing pain or sharp or shooting pain are common symptoms of an abscessed tooth. Other symptoms may include:
What does an abscessed tooth look like?
Fever
Pain when chewing
Sensitivity of the teeth to hot or cold
Bitter taste in the mouth
Foul smell to the breath
Swollen neck glands
General discomfort, uneasiness, or ill feeling
Redness and swelling of the gums
Swollen area of the upper or lower jaw
An open, draining sore on the side of the gum
If the root of the tooth dies as a result of infection, the toothache may stop. However, this doesn't mean the infection has healed; the infection remains active and continues to spread and destroy tissue. Therefore, if you experience any of the above listed symptoms, it is important to see a dentist even if the pain subsides.
How is an abscessed tooth diagnosed?
Your dentist will probe your teeth with a dental instrument. If you have an abscessed tooth, you will feel pain when the tooth is tapped by your dentist's probe. Your dentist will also ask you if your pain increases when you bite down or when you close your mouth tightly. In addition, your dentist may suspect an abscessed tooth because your gums may be swollen and red.
Your dentist may also take X-rays to look for erosion of the bone around the abscess.
How is an abscessed tooth treated?
Strategies to eliminate the infection, preserve the tooth, and prevent complications are the goals of treatment.
To eliminate infection, the abscess may need to be drained. Achieving drainage may be done through the tooth by a procedure known as a root canal. Root canal surgery may also be recommended to remove any diseased root tissue after the infection has subsided. Then, a crown may be placed over the tooth.
The tooth may also be extracted, allowing drainage through the socket.
Finally, a third way to drain the abscess would be by incision into the swollen gum tissue.
Antibiotics are prescribed to help fight the infection. To relieve the pain and discomfort associated with an abscessed tooth, warm salt-water rinses and over-the-counter pain-reducing medication like ibuprofen (Advil or Motrin) can be used.
Can an abscessed tooth be prevented?
Following good oral hygiene practices can reduce the risk of developing a tooth abscess. Also, if your teeth experience trauma (for example, become loosened or chipped), seek prompt dental attention.
Source: MedicineNet.com http://www.medicinenet.com/abscessed_tooth/article.htm
Cuts, Scrapes and Puncture Wounds
What is the best way to care for a cut or scrape?
The first step in the care of cuts and scrapes is to stop the bleeding. Most wounds respond to gentle direct pressure with a clean cloth or bandage. Hold the pressure continuously for approximately 10-20 minutes. If this fails to stop the bleeding or if bleeding is rapid you should seek medical assistance.
The next step is to thoroughly clean the wound with soap and water. Remove any foreign material, such as dirt or bits of grass, that might be in the wound and which can lead to infection. You may use tweezers (clean them with alcohol first) to remove foreign material from the wound edges, but do not dig into the wound as this may push bacteria deeper into the wound. You may also gently scrub the wound with a washcloth to remove dirt and debris. Hydrogen peroxide and providone-iodine (Betadine) products may be used to clean the wound initially, but may inhibit wound healing if used long-term.
Cover the area with a bandage (such as gauze or a Band-Aid) to help prevent infection and dirt from getting in the wound. A first aid antibiotic ointment such as Bacitracin or Neosporin can be applied to help prevent infection and keep the wound moist.
Continued care to the wound is also important. Three times a day, wash the area gently with soap and water, apply an antibiotic ointment and cover with a bandage. Also, change the bandage immediately if it gets dirty or wet.
Who should seek medical care for a cut?
If you cannot control the bleeding from a cut, seek medical attention. Any cut that goes beyond the top layer of skin or is deep enough to see into might need stitches (sutures), and should be seen by a healthcare professional as soon as possible. Generally, the sooner sutures are put in, the lower the risk of infection. Ideally, wounds should be repaired within six hours of the injury.
People with suppressed immune systems (including diabetics, cancer patients on chemotherapy, people who take steroid medications, such as prednisone, or people with HIV) are more likely to develop a wound infection and should be seen by a healthcare professional.
Any wound that shows signs of infection should be seen by a healthcare professional (the "What are the signs of a wound infection" section).
What are the signs of a wound infection?
If the wound begins to drain yellow or greenish fluid (pus), or if the skin around the wound becomes red, warm, swollen, or increasingly painful; a wound infection may be present and medical care should be sought. Any red streaking of the skin around the wound may indicate an infection in the system that drains fluid from the tissues, called the lymph system. This infection (lymphangitis) can be serious, especially if it is accompanied by a fever. Prompt medical care should be sought if streaking redness from a wound is noticed.
How are puncture wounds different?
A puncture wound is caused by an object piercing the skin, creating a small hole. Some punctures can be very deep, depending on the source and cause.
Puncture wounds do not usually bleed much, however, treatment is necessary to prevent infection. A puncture wound can cause infection because it forces bacteria and debris deep into the tissue and the wound closes quickly forming an ideal place for bacteria to grow.
For example, if a nail penetrates deep into the foot, it can hit a bone and introduce bacteria into the bone. This risk is especially great if an object has gone through a pair of sneakers. The foam in sneakers can harbor a bacteria (Pseudomonas) that can lead to serious infection in the tissues.
First aid for puncture wounds includes cleaning the area thoroughly with soap and water. These wounds are very difficult to clean out. If the area is swollen, ice can be applied and the area punctured should be elevated. Apply antibiotic ointments (bacitracin or Polysporin) to prevent infection. Cover the wound with a bandage to keep out harmful bacteria and dirt.
Monitor at least daily (ideally three times a day) for signs of infection (the same signs as above in the cuts section). Change the bandage at least daily, or any time it becomes wet or dirty.
Additionally, people with suppressed immune systems or any particularly deep puncture wounds should be seen by a healthcare professional. If it is difficult to remove the puncturing object, it may have penetrated the bone and requires medical care.
Most puncture wounds do not become infected, but if redness, swelling or bleeding persists, see your healthcare professional.
Feet are a particular concern. Wear shoes to minimize the risk of a puncture wound from a nail or glass, especially if you have diabetes or loss of sensation in the feet for any reason.
Additional common causes of puncture wounds can include animal or human bites, or splinters from wood or other plant material, which carry a high risk of infection and should be treated by a physician.
Will I need a tetanus shot?
Most people in the United States have been immunized against tetanus (lockjaw). If you have been immunized, you will need a booster shot if you have not had one within 10 years (if it is a very dirty wound or occurs in a tetanus prone area-you need a booster within five years). If you have never had a tetanus shot, or if your series is incomplete (fewer than three shots), you might need tetanus immunoglobulin, a medication that can prevent lockjaw.
Cuts, Scrapes & Puncture Wounds At A Glance
Washing a cut or scrape with soap and water and keeping it clean and dry is all that is required to care for most wounds.
Cleaning the wound with hydrogen peroxide and iodine is acceptable initially but can delay healing and should be avoided long-term.
Apply antibiotic ointment and keep the wound covered.
Seek medical care within six hours if you think you might need stitches. Any delay can increase the rate of wound infection.
Any puncture wound through sneakers has a high risk of infection and should be seen by your healthcare professional.
Any redness, swelling, increased pain, fever or pus draining from the wound may indicate an infection that requires professional care.
The first step in the care of cuts and scrapes is to stop the bleeding. Most wounds respond to gentle direct pressure with a clean cloth or bandage. Hold the pressure continuously for approximately 10-20 minutes. If this fails to stop the bleeding or if bleeding is rapid you should seek medical assistance.
The next step is to thoroughly clean the wound with soap and water. Remove any foreign material, such as dirt or bits of grass, that might be in the wound and which can lead to infection. You may use tweezers (clean them with alcohol first) to remove foreign material from the wound edges, but do not dig into the wound as this may push bacteria deeper into the wound. You may also gently scrub the wound with a washcloth to remove dirt and debris. Hydrogen peroxide and providone-iodine (Betadine) products may be used to clean the wound initially, but may inhibit wound healing if used long-term.
Cover the area with a bandage (such as gauze or a Band-Aid) to help prevent infection and dirt from getting in the wound. A first aid antibiotic ointment such as Bacitracin or Neosporin can be applied to help prevent infection and keep the wound moist.
Continued care to the wound is also important. Three times a day, wash the area gently with soap and water, apply an antibiotic ointment and cover with a bandage. Also, change the bandage immediately if it gets dirty or wet.
Who should seek medical care for a cut?
If you cannot control the bleeding from a cut, seek medical attention. Any cut that goes beyond the top layer of skin or is deep enough to see into might need stitches (sutures), and should be seen by a healthcare professional as soon as possible. Generally, the sooner sutures are put in, the lower the risk of infection. Ideally, wounds should be repaired within six hours of the injury.
People with suppressed immune systems (including diabetics, cancer patients on chemotherapy, people who take steroid medications, such as prednisone, or people with HIV) are more likely to develop a wound infection and should be seen by a healthcare professional.
Any wound that shows signs of infection should be seen by a healthcare professional (the "What are the signs of a wound infection" section).
What are the signs of a wound infection?
If the wound begins to drain yellow or greenish fluid (pus), or if the skin around the wound becomes red, warm, swollen, or increasingly painful; a wound infection may be present and medical care should be sought. Any red streaking of the skin around the wound may indicate an infection in the system that drains fluid from the tissues, called the lymph system. This infection (lymphangitis) can be serious, especially if it is accompanied by a fever. Prompt medical care should be sought if streaking redness from a wound is noticed.
How are puncture wounds different?
A puncture wound is caused by an object piercing the skin, creating a small hole. Some punctures can be very deep, depending on the source and cause.
Puncture wounds do not usually bleed much, however, treatment is necessary to prevent infection. A puncture wound can cause infection because it forces bacteria and debris deep into the tissue and the wound closes quickly forming an ideal place for bacteria to grow.
For example, if a nail penetrates deep into the foot, it can hit a bone and introduce bacteria into the bone. This risk is especially great if an object has gone through a pair of sneakers. The foam in sneakers can harbor a bacteria (Pseudomonas) that can lead to serious infection in the tissues.
First aid for puncture wounds includes cleaning the area thoroughly with soap and water. These wounds are very difficult to clean out. If the area is swollen, ice can be applied and the area punctured should be elevated. Apply antibiotic ointments (bacitracin or Polysporin) to prevent infection. Cover the wound with a bandage to keep out harmful bacteria and dirt.
Monitor at least daily (ideally three times a day) for signs of infection (the same signs as above in the cuts section). Change the bandage at least daily, or any time it becomes wet or dirty.
Additionally, people with suppressed immune systems or any particularly deep puncture wounds should be seen by a healthcare professional. If it is difficult to remove the puncturing object, it may have penetrated the bone and requires medical care.
Most puncture wounds do not become infected, but if redness, swelling or bleeding persists, see your healthcare professional.
Feet are a particular concern. Wear shoes to minimize the risk of a puncture wound from a nail or glass, especially if you have diabetes or loss of sensation in the feet for any reason.
Additional common causes of puncture wounds can include animal or human bites, or splinters from wood or other plant material, which carry a high risk of infection and should be treated by a physician.
Will I need a tetanus shot?
Most people in the United States have been immunized against tetanus (lockjaw). If you have been immunized, you will need a booster shot if you have not had one within 10 years (if it is a very dirty wound or occurs in a tetanus prone area-you need a booster within five years). If you have never had a tetanus shot, or if your series is incomplete (fewer than three shots), you might need tetanus immunoglobulin, a medication that can prevent lockjaw.
Cuts, Scrapes & Puncture Wounds At A Glance
Washing a cut or scrape with soap and water and keeping it clean and dry is all that is required to care for most wounds.
Cleaning the wound with hydrogen peroxide and iodine is acceptable initially but can delay healing and should be avoided long-term.
Apply antibiotic ointment and keep the wound covered.
Seek medical care within six hours if you think you might need stitches. Any delay can increase the rate of wound infection.
Any puncture wound through sneakers has a high risk of infection and should be seen by your healthcare professional.
Any redness, swelling, increased pain, fever or pus draining from the wound may indicate an infection that requires professional care.
Miscarriage(Spontaneous Abortion)
What is a miscarriage?
A miscarriage (spontaneous abortion) is any pregnancy that ends spontaneously before the fetus can survive. The World Health Organization defines this unsurvivable state as an embryo or fetus weighing 500 grams or less, which typically corresponds to a fetal age (gestational age) of 20 to 22 weeks or less. Miscarriage occurs in about 15-20% of all recognized pregnancies, and usually occurs before the 13th week of pregnancy. The actual percentage of miscarriages is estimated to be as high as 50% of all pregnancies, since many miscarriages occur without the woman ever having known she was pregnant. Of those miscarriages that occur before the eighth week, 30% have no fetus associated with the sac or placenta. This condition is called blighted ovum, and many women are surprised to learn that there was never an embryo inside the sac.
Some miscarriages occur before women recognize that they are pregnant. About 15% of fertilized eggs are lost before the egg even has a chance to implant (embed itself) in the wall of the uterus. A woman would not generally identify this type of miscarriage. Another 15% of conceptions are lost before eight weeks' gestation. Once fetal heart function is detected in a given pregnancy, the chance of miscarriage is less than 5%.
A woman who may be showing the signs of a possible miscarriage (such as vaginal bleeding) may hear the term "threatened abortion" used to describe her situation.
What causes a miscarriage, and what are the tests for the different causes?
The cause of a miscarriage cannot always be determined. The most common known causes of miscarriage in the first third of pregnancy (1st trimester) are chromosomal abnormalities, collagen vascular disease (such as lupus), diabetes, other hormonal problems infection, and congenital (present at birth) abnormalities of the uterus. Chromosomal abnormalities of the fetus are the most common cause of early miscarriages, including blighted ovum (see above). Each of the causes will be described below.
Chromosomes are microscopic components of every cell in the body that carry all of the genetic material that determine hair color, eye color, and our overall appearance and makeup. These chromosomes duplicate themselves and divide many times during the process of development, and there are numerous points along the way where a problem can occur. Certain genetic abnormalities are known to be more prevalent in couples that experience repeated pregnancy losses. These genetic traits can be screened for by blood tests prior to attempting to become pregnant. Half of the fetal tissue from1st trimester miscarriages contain abnormal chromosomes. This number drops to 20% with 2nd trimester miscarriages. In other words, abnormal chromosomes are more common with 1st trimester than with 2nd trimester miscarriages. First trimester miscarriages are so very common that unless they occur more than once, they are not considered "abnormal" per se. They do not prompt further evaluation unless they occur more than once. In contrast, 2nd trimester miscarriages are more unusual, and therefore may trigger evaluation even after a first occurrence. It is therefore clear that causes of miscarriages seem to vary according to trimester.
Chromosomal abnormalities also become more common with aging, and women over age 35 have a higher rate of miscarriage than younger women. Advancing maternal age is the most significant risk factor for early miscarriage in otherwise healthy women.
Collagen vascular diseases are illnesses in which a person's own immune system attacks their own organs. These diseases can be potentially very serious, either during or between pregnancies. In these diseases, a woman makes antibodies to her own body's tissues. Examples of collagen vascular diseases associated with an increased risk of miscarriage are systemic lupus erythematosus, and antiphospholipid antibody syndrome. Blood tests can confirm the presence of abnormal antibodies and are used to diagnose these conditions.
Diabetes generally can be well-managed during pregnancy, if a woman and her doctor work closely together. However, if the diabetes is insufficiently controlled, not only is the risk of miscarriages higher, but the baby can have major birth defects. Other problems can also occur in relation to diabetes during pregnancy. Good control of blood sugars during pregnancy is very important.
Hormonal factors may be associated with an increased risk of miscarriage, including Cushing's Syndrome, thyroid disease, and polycystic ovary syndrome. It has also been suggested that inadequate function of the corpus luteum in the ovary (which produced progesterone necessary for maintenance of the very early stages of pregnancy) may lead to miscarriage. Termed luteal phase defect, this is a controversial issue, since several studies have not supported the theory of luteal phase defect as a cause of pregnancy loss.
Maternal infection with a large number of different organisms has been associated with an increased risk of miscarriage. Fetal or placental infection by the offending organism then leads to pregnancy loss. Examples of infections that have been associated with miscarriage include infections by Listeria monocytogenes, Toxoplasma gondii, parvovirus B19, rubella, herpes simplex, cytomegalovirus, and lymphocytic choriomeningitis virus. Abnormal anatomy of the uterus can also cause miscarriages. In some women there can be a tissue bridge (uterine septum), that acts like a partial wall dividing the uterine cavity into sections. The septum usually has a very poor blood supply, and is not well suited for placental attachment and growth. Therefore, an embryo implanting on the septum would be at increased risk of miscarriage.
Other structural abnormalities can result from benign growths in the uterus called fibroids. Fibroid tumors (leiomyomata) are benign growths of muscle cells in the uterus. While most fibroid tumors do not cause miscarriages, (in fact, they are a rare cause of infertility), some can interfere with the embryo implantation and the embryo's blood supply, thereby causing miscarriage.
Invasive surgical procedures in the uterus, such as amniocentesis and chorionic villus sampling, also slightly increase the risk of miscarriage.
What does NOT cause miscarriage?
It must be emphasized that exercise, working, and sexual intercourse do not increase the risk of pregnancy loss in routine (uncomplicated) pregnancies. However, in the unusual circumstance where a woman is felt by her physician to be at higher risk of spontaneous abortion, she may be advised to stop work and intercourse. Women with past history of premature delivery and other specific obstetrical conditions might fall under this category.
Are there lifestyle factors associated with miscarriage?
Smoking more than 10 cigarettes per day is associated with an increased risk of pregnancy loss, and some studies have even shown that the risk of miscarriage increases with paternal smoking. Other factors, such as alcohol use, fever, use of nonsteroidal anti-inflammatory drugs around the time of embryo implantation, and caffeine use have all been suggested to increase the risk of miscarriage, although more studies are needed to fully clarify any potential risks associated with these factors. Of course, alcohol is a known teratogen (a chemical that can damage the developing fetus), so pregnant women are advised to abstain from drinking alcoholic beverages.
What are the symptoms of a miscarriage?
Cramping and vaginal bleeding are the most common symptoms noticed with spontaneous abortion. The cramping and bleeding may be very mild, moderate, or severe. There is no particular pattern as to how long the symptoms will last.
Vaginal bleeding during early pregnancy is often referred to as a "threatened abortion." The term "threatened" abortion is used since miscarriage does not always follow vaginal bleeding in early pregnancy, even after repeated episodes or large amounts of bleeding. Studies have shown that 90-96% of pregnancies with fetal cardiac activity that result in vaginal bleeding at 7 to 11 weeks of gestation will result in an ongoing pregnancy.
What will the doctor look for during an examination with suspected miscarriage?
A woman's cervix might have some bloody discharge, but nothing else unusual will be characteristic of threatened abortion. Some women will have mild uterine tenderness during the manual examination of the uterus. The doctor may look to see if the cervix is dilated and will check to see if the uterus is enlarged to an extent appropriate for gestational age of the pregnancy.
How is threatened abortion evaluated?
Pelvic ultrasound is used to visualize fetal heartbeat and to determine whether a pregnancy is still viable. The ultrasound examination can also distinguish between intrauterine and ectopic pregnancies. The doctor may also order blood levels of serial human chorionic gonadotrophin (HCG) to help determine the viability of a pregnancy if the ultrasound examination is not conclusive. During the evaluation, the woman may be advised to rest and avoid sexual intercourse (activity).
What are common terms a woman might hear during evaluation for miscarriage?
Miscarriage (spontaneous abortion) is termination of pregnancy before the fetus is viable (able to survive).
Complete abortion describes spontaneous (not intentionally induced by medication or procedures) passage of all fetal and placental tissue. This is common prior to 12 weeks' gestation.
Incomplete abortion is when some, but not all, the fetal and placental tissue is expelled.
Products of conception refers to the combination of fetal and placental tissue.
Threatened abortion is when a miscarriage does not actually occur, but there is vaginal bleeding from the uterus. The cervix will not be dilated and does not show signs of imminent passage of fetal and placental tissue.
Missed abortion describes a fetal death in the uterus prior to viability, but the products of conception are not passed.
A septic (infectious) abortion is caused by bacterial infection and accompanied by fever, chills, pain, and a pus-containing discharge.
What treatment can a woman expect when she has had a miscarriage?
The central goal of the doctor in this situation will be to try to figure out whether the woman has passed all of the tissue from the fetus and placenta. If she has passed all the tissue, she may only require observation by medical personnel. On the other hand, a woman who has not passed all of the tissue (incomplete abortion) will usually need suction dilation and curettage of the uterus to remove any retained products of the pregnancy. This procedure is done with local anesthesia, and sometimes antibiotics may be prescribed for the woman.
When should a woman receive evaluation for underlying causes of pregnancy loss?
Currently, most practitioners will not initiate an extensive medical evaluation for a single pregnancy loss, since the chance of having a normal pregnancy subsequent to even two consecutive miscarriages is 80-90%. For women with recurrent pregnancy loss, an evaluation will focus on the pattern and history of the prior miscarriages. Three consecutive miscarriages would suggest a woman should receive further evaluation.
Thus, the following tests are considered for women with three consecutive miscarriages. Blood testing can be done to identify chromosomal abnormalities in the couple that could be transmitted to the fetus. The couple can each appear completely normal but still carry chromosomal defects, which, when combined, can be lethal to the embryo. This type of testing is called karyotyping, and it is performed on both members of the couple. A hysterosalpingogram (HSG) can identify anatomical abnormalities within the uterus. Antinuclear antibody, anticardiolipin antibody, VDRL, RPR, and lupus anticoagulant are some of the blood tests used to diagnose autoimmune diseases that can cause recurrent miscarriage. As described above, some of these illnesses will already by apparent to the woman and her doctor, but not all cases. Other antibody tests may be performed as well.
Can something be done to prevent future miscarriages?
The treatment of recurrent miscarriage depends on what is believed to be the underlying cause. This often is not as simple as it sounds. Careful evaluation may turn up several potential factors which alone or together may be responsible for the losses. If a chromosomal problem is found in one or both spouses, then counseling as to future risks is the only option for the couple, since there is currently no method to correct genetic problems.
If a structural problem is encountered with the uterus, surgical correction could be contemplated. It should be emphasized that just because a structural abnormality is found, it does not necessarily mean that it caused the miscarriage. Removal of a fibroid or uterine septum does not guarantee a future successful pregnancy, since the fibroid or uterine septum may not have been the cause of miscarriage in the first place.
Adequate control of diabetes and thyroid disease is critical in trying to prevent recurrent pregnancy loss in women with those conditions. For women with immunologic problems, certain medications are being studied that may be useful in achieving successful pregnancy outcomes. Blood thinners such as aspirin and heparin can, in some cases, prevent further pregnancy loss.
The use of progesterone to increase the blood levels of this hormone is sometimes used for patients with recurrent pregnancy loss, although large-scale controlled studies that confirm the utility of progesterone supplementation have not been carried out. However, many physicians report success with progesterone therapy. Progesterone may be given as vaginal suppositories, or in tablet or gel form. In dealing with recurrent pregnancy loss, it is important to realize that even though apparently obvious problems can be corrected, a miscarriage can still occur. This is not to say that attempts should not be taken to correct identified abnormalities that have been historically associated with miscarriage. However, no treatment can be guaranteed. Even with repeated miscarriages, there is still a very good chance of achieving a successful pregnancy. Early pregnancy and pre-pregnancy counseling can help identify risk factors and allow the practitioner to provide any special care that may be needed.
Miscarriage At A Glance
Spontaneous miscarriage is the loss of a pregnancy that ends spontaneously before the fetus can survive.
Exercise, working, and intercourse do NOT increase risk of miscarriage for women without underlying specific medical conditions that place them at risk.
Causes for miscarriage include genetic abnormalities, infection, medications, hormonal effects, structural abnormality of the uterus, and immune abnormalities.
After an isolated miscarriage, the chance of having a normal term pregnancy in the future is near 90%.
Treatment of recurrent miscarriage is directed toward the underlying cause.
A miscarriage (spontaneous abortion) is any pregnancy that ends spontaneously before the fetus can survive. The World Health Organization defines this unsurvivable state as an embryo or fetus weighing 500 grams or less, which typically corresponds to a fetal age (gestational age) of 20 to 22 weeks or less. Miscarriage occurs in about 15-20% of all recognized pregnancies, and usually occurs before the 13th week of pregnancy. The actual percentage of miscarriages is estimated to be as high as 50% of all pregnancies, since many miscarriages occur without the woman ever having known she was pregnant. Of those miscarriages that occur before the eighth week, 30% have no fetus associated with the sac or placenta. This condition is called blighted ovum, and many women are surprised to learn that there was never an embryo inside the sac.
Some miscarriages occur before women recognize that they are pregnant. About 15% of fertilized eggs are lost before the egg even has a chance to implant (embed itself) in the wall of the uterus. A woman would not generally identify this type of miscarriage. Another 15% of conceptions are lost before eight weeks' gestation. Once fetal heart function is detected in a given pregnancy, the chance of miscarriage is less than 5%.
A woman who may be showing the signs of a possible miscarriage (such as vaginal bleeding) may hear the term "threatened abortion" used to describe her situation.
What causes a miscarriage, and what are the tests for the different causes?
The cause of a miscarriage cannot always be determined. The most common known causes of miscarriage in the first third of pregnancy (1st trimester) are chromosomal abnormalities, collagen vascular disease (such as lupus), diabetes, other hormonal problems infection, and congenital (present at birth) abnormalities of the uterus. Chromosomal abnormalities of the fetus are the most common cause of early miscarriages, including blighted ovum (see above). Each of the causes will be described below.
Chromosomes are microscopic components of every cell in the body that carry all of the genetic material that determine hair color, eye color, and our overall appearance and makeup. These chromosomes duplicate themselves and divide many times during the process of development, and there are numerous points along the way where a problem can occur. Certain genetic abnormalities are known to be more prevalent in couples that experience repeated pregnancy losses. These genetic traits can be screened for by blood tests prior to attempting to become pregnant. Half of the fetal tissue from1st trimester miscarriages contain abnormal chromosomes. This number drops to 20% with 2nd trimester miscarriages. In other words, abnormal chromosomes are more common with 1st trimester than with 2nd trimester miscarriages. First trimester miscarriages are so very common that unless they occur more than once, they are not considered "abnormal" per se. They do not prompt further evaluation unless they occur more than once. In contrast, 2nd trimester miscarriages are more unusual, and therefore may trigger evaluation even after a first occurrence. It is therefore clear that causes of miscarriages seem to vary according to trimester.
Chromosomal abnormalities also become more common with aging, and women over age 35 have a higher rate of miscarriage than younger women. Advancing maternal age is the most significant risk factor for early miscarriage in otherwise healthy women.
Collagen vascular diseases are illnesses in which a person's own immune system attacks their own organs. These diseases can be potentially very serious, either during or between pregnancies. In these diseases, a woman makes antibodies to her own body's tissues. Examples of collagen vascular diseases associated with an increased risk of miscarriage are systemic lupus erythematosus, and antiphospholipid antibody syndrome. Blood tests can confirm the presence of abnormal antibodies and are used to diagnose these conditions.
Diabetes generally can be well-managed during pregnancy, if a woman and her doctor work closely together. However, if the diabetes is insufficiently controlled, not only is the risk of miscarriages higher, but the baby can have major birth defects. Other problems can also occur in relation to diabetes during pregnancy. Good control of blood sugars during pregnancy is very important.
Hormonal factors may be associated with an increased risk of miscarriage, including Cushing's Syndrome, thyroid disease, and polycystic ovary syndrome. It has also been suggested that inadequate function of the corpus luteum in the ovary (which produced progesterone necessary for maintenance of the very early stages of pregnancy) may lead to miscarriage. Termed luteal phase defect, this is a controversial issue, since several studies have not supported the theory of luteal phase defect as a cause of pregnancy loss.
Maternal infection with a large number of different organisms has been associated with an increased risk of miscarriage. Fetal or placental infection by the offending organism then leads to pregnancy loss. Examples of infections that have been associated with miscarriage include infections by Listeria monocytogenes, Toxoplasma gondii, parvovirus B19, rubella, herpes simplex, cytomegalovirus, and lymphocytic choriomeningitis virus. Abnormal anatomy of the uterus can also cause miscarriages. In some women there can be a tissue bridge (uterine septum), that acts like a partial wall dividing the uterine cavity into sections. The septum usually has a very poor blood supply, and is not well suited for placental attachment and growth. Therefore, an embryo implanting on the septum would be at increased risk of miscarriage.
Other structural abnormalities can result from benign growths in the uterus called fibroids. Fibroid tumors (leiomyomata) are benign growths of muscle cells in the uterus. While most fibroid tumors do not cause miscarriages, (in fact, they are a rare cause of infertility), some can interfere with the embryo implantation and the embryo's blood supply, thereby causing miscarriage.
Invasive surgical procedures in the uterus, such as amniocentesis and chorionic villus sampling, also slightly increase the risk of miscarriage.
What does NOT cause miscarriage?
It must be emphasized that exercise, working, and sexual intercourse do not increase the risk of pregnancy loss in routine (uncomplicated) pregnancies. However, in the unusual circumstance where a woman is felt by her physician to be at higher risk of spontaneous abortion, she may be advised to stop work and intercourse. Women with past history of premature delivery and other specific obstetrical conditions might fall under this category.
Are there lifestyle factors associated with miscarriage?
Smoking more than 10 cigarettes per day is associated with an increased risk of pregnancy loss, and some studies have even shown that the risk of miscarriage increases with paternal smoking. Other factors, such as alcohol use, fever, use of nonsteroidal anti-inflammatory drugs around the time of embryo implantation, and caffeine use have all been suggested to increase the risk of miscarriage, although more studies are needed to fully clarify any potential risks associated with these factors. Of course, alcohol is a known teratogen (a chemical that can damage the developing fetus), so pregnant women are advised to abstain from drinking alcoholic beverages.
What are the symptoms of a miscarriage?
Cramping and vaginal bleeding are the most common symptoms noticed with spontaneous abortion. The cramping and bleeding may be very mild, moderate, or severe. There is no particular pattern as to how long the symptoms will last.
Vaginal bleeding during early pregnancy is often referred to as a "threatened abortion." The term "threatened" abortion is used since miscarriage does not always follow vaginal bleeding in early pregnancy, even after repeated episodes or large amounts of bleeding. Studies have shown that 90-96% of pregnancies with fetal cardiac activity that result in vaginal bleeding at 7 to 11 weeks of gestation will result in an ongoing pregnancy.
What will the doctor look for during an examination with suspected miscarriage?
A woman's cervix might have some bloody discharge, but nothing else unusual will be characteristic of threatened abortion. Some women will have mild uterine tenderness during the manual examination of the uterus. The doctor may look to see if the cervix is dilated and will check to see if the uterus is enlarged to an extent appropriate for gestational age of the pregnancy.
How is threatened abortion evaluated?
Pelvic ultrasound is used to visualize fetal heartbeat and to determine whether a pregnancy is still viable. The ultrasound examination can also distinguish between intrauterine and ectopic pregnancies. The doctor may also order blood levels of serial human chorionic gonadotrophin (HCG) to help determine the viability of a pregnancy if the ultrasound examination is not conclusive. During the evaluation, the woman may be advised to rest and avoid sexual intercourse (activity).
What are common terms a woman might hear during evaluation for miscarriage?
Miscarriage (spontaneous abortion) is termination of pregnancy before the fetus is viable (able to survive).
Complete abortion describes spontaneous (not intentionally induced by medication or procedures) passage of all fetal and placental tissue. This is common prior to 12 weeks' gestation.
Incomplete abortion is when some, but not all, the fetal and placental tissue is expelled.
Products of conception refers to the combination of fetal and placental tissue.
Threatened abortion is when a miscarriage does not actually occur, but there is vaginal bleeding from the uterus. The cervix will not be dilated and does not show signs of imminent passage of fetal and placental tissue.
Missed abortion describes a fetal death in the uterus prior to viability, but the products of conception are not passed.
A septic (infectious) abortion is caused by bacterial infection and accompanied by fever, chills, pain, and a pus-containing discharge.
What treatment can a woman expect when she has had a miscarriage?
The central goal of the doctor in this situation will be to try to figure out whether the woman has passed all of the tissue from the fetus and placenta. If she has passed all the tissue, she may only require observation by medical personnel. On the other hand, a woman who has not passed all of the tissue (incomplete abortion) will usually need suction dilation and curettage of the uterus to remove any retained products of the pregnancy. This procedure is done with local anesthesia, and sometimes antibiotics may be prescribed for the woman.
When should a woman receive evaluation for underlying causes of pregnancy loss?
Currently, most practitioners will not initiate an extensive medical evaluation for a single pregnancy loss, since the chance of having a normal pregnancy subsequent to even two consecutive miscarriages is 80-90%. For women with recurrent pregnancy loss, an evaluation will focus on the pattern and history of the prior miscarriages. Three consecutive miscarriages would suggest a woman should receive further evaluation.
Thus, the following tests are considered for women with three consecutive miscarriages. Blood testing can be done to identify chromosomal abnormalities in the couple that could be transmitted to the fetus. The couple can each appear completely normal but still carry chromosomal defects, which, when combined, can be lethal to the embryo. This type of testing is called karyotyping, and it is performed on both members of the couple. A hysterosalpingogram (HSG) can identify anatomical abnormalities within the uterus. Antinuclear antibody, anticardiolipin antibody, VDRL, RPR, and lupus anticoagulant are some of the blood tests used to diagnose autoimmune diseases that can cause recurrent miscarriage. As described above, some of these illnesses will already by apparent to the woman and her doctor, but not all cases. Other antibody tests may be performed as well.
Can something be done to prevent future miscarriages?
The treatment of recurrent miscarriage depends on what is believed to be the underlying cause. This often is not as simple as it sounds. Careful evaluation may turn up several potential factors which alone or together may be responsible for the losses. If a chromosomal problem is found in one or both spouses, then counseling as to future risks is the only option for the couple, since there is currently no method to correct genetic problems.
If a structural problem is encountered with the uterus, surgical correction could be contemplated. It should be emphasized that just because a structural abnormality is found, it does not necessarily mean that it caused the miscarriage. Removal of a fibroid or uterine septum does not guarantee a future successful pregnancy, since the fibroid or uterine septum may not have been the cause of miscarriage in the first place.
Adequate control of diabetes and thyroid disease is critical in trying to prevent recurrent pregnancy loss in women with those conditions. For women with immunologic problems, certain medications are being studied that may be useful in achieving successful pregnancy outcomes. Blood thinners such as aspirin and heparin can, in some cases, prevent further pregnancy loss.
The use of progesterone to increase the blood levels of this hormone is sometimes used for patients with recurrent pregnancy loss, although large-scale controlled studies that confirm the utility of progesterone supplementation have not been carried out. However, many physicians report success with progesterone therapy. Progesterone may be given as vaginal suppositories, or in tablet or gel form. In dealing with recurrent pregnancy loss, it is important to realize that even though apparently obvious problems can be corrected, a miscarriage can still occur. This is not to say that attempts should not be taken to correct identified abnormalities that have been historically associated with miscarriage. However, no treatment can be guaranteed. Even with repeated miscarriages, there is still a very good chance of achieving a successful pregnancy. Early pregnancy and pre-pregnancy counseling can help identify risk factors and allow the practitioner to provide any special care that may be needed.
Miscarriage At A Glance
Spontaneous miscarriage is the loss of a pregnancy that ends spontaneously before the fetus can survive.
Exercise, working, and intercourse do NOT increase risk of miscarriage for women without underlying specific medical conditions that place them at risk.
Causes for miscarriage include genetic abnormalities, infection, medications, hormonal effects, structural abnormality of the uterus, and immune abnormalities.
After an isolated miscarriage, the chance of having a normal term pregnancy in the future is near 90%.
Treatment of recurrent miscarriage is directed toward the underlying cause.
Vaginal Bleeding(Menstruation)
What is normal vaginal bleeding?
Normal vaginal bleeding is the periodic blood that flows as a discharge from the woman's uterus. Normal vaginal bleeding is also called menorrhea. The process by which menorrhea occurs is called menstruation.
Normal vaginal bleeding occurs as a result of cyclic hormonal changes. The ovaries are the main source of female hormones, which control the development of female body characteristics such as the breasts, body shape, and body hair. The hormones also regulate the menstrual cycle. The ovary, or female gonad, is one of a pair of reproductive glands in women. They are located in the pelvis, one on each side of the uterus. Each ovary is about the size and shape of an almond. The ovaries produce eggs (ova) and female hormones. During each monthly menstrual cycle, an egg is released from one ovary. The egg travels from the ovary through a Fallopian tube to the uterus. Unless pregnancy occurs, the cycle ends with the shedding of part of the inner lining of uterus, which is menstruation. Although it is actually the end of the physical cycle, the first day of menstrual bleeding is designated as "day 1" of the menstrual cycle in medical jargon.
The time of the cycle during which menstruation occurs is referred to as menses. The menses occurs at approximately 4 week intervals, representing the menstrual cycle.
Menarche is the time in a girl's life when menstruation first begins. Menopause is the time in a woman's life when the function of the ovaries ceases. The average age of menopause is 51 years old.
What is abnormal vaginal bleeding?
Abnormal vaginal bleeding is a flow of blood from the vagina that occurs either at the wrong time during the month or in inappropriate amounts. In order to determine whether bleeding is abnormal, and its cause, the doctor must answer 3 questions: Is the woman pregnant? What is the pattern of the bleeding? Is she ovulating?
Every woman who thinks she has an irregular menstrual bleeding pattern should think carefully about the specific characteristics of her vaginal bleeding in order to help her doctor evaluate her particular situation. Her doctor will require the details of her menstrual history. Each category of menstrual disturbance has a particular list of causes, necessary testing, and treatment. Each type of abnormality is discussed individually below.
1. Is the woman having abnormal vaginal bleeding during pregnancy?
Much of the abnormal vaginal bleeding during pregnancy occurs so early in the pregnancy that the woman doesn't realize she is pregnant. Therefore, irregular bleeding that is new may be a sign of very early pregnancy, even before a woman is aware of her condition.
2. What is the pattern of the abnormal vaginal bleeding?
The duration, interval, and amount of vaginal bleeding may suggest what type of abnormality is responsible for the bleeding.
An abnormal duration of menstrual bleeding can be either bleeding for too long of a period (hypermenorrhea), or too short of a period (hypomenorrhea).
The interval of the bleeding can be abnormal in several ways. A woman's menstrual periods can occur too frequently (polymenorrhea) or too seldom (oligomenorrhea). Additionally, the duration can vary excessively from cycle to cycle (metrorrhagia).
The amount (volume) of bleeding can also be abnormal. A woman can either have too much bleeding (menorrhagia) or too little volume (hypomenorrhea).
3. Is the woman ovulating?
Usually, the ovary releases an egg every month in a process called ovulation. Normal ovulation is necessary for regular menstrual periods. There are certain clues that a woman is ovulating normally including regular menstrual intervals, vaginal mucus discharge halfway between menstrual cycles, and monthly symptoms including breast tenderness, fluid retention, menstrual cramps, back pain, and mood changes. If necessary, doctors will order hormone blood tests (progesterone level), daily home body temperature testing, or rarely, a sampling of the lining of the uterus (endometrial sampling) to determine whether or not a woman is ovulating normally.
On the other hand, signs that a woman is not ovulating regularly include prolonged bleeding at irregular intervals after not having a menstrual period for several months, excessively low blood progesterone levels in the 2nd half of the menstrual cycle, and lack of the normal body temperature fluctuation during the time of expected ovulation. Sometimes, a doctor determines that a woman is not ovulating by sampling the lining of the uterus (endometrial sampling).
What conditions cause abnormal vaginal bleeding in women who are ovulating regularly?
Abnormal vaginal bleeding in women who are ovulating regularly, most commonly involve excessive, frequent, irregular, or decreased bleeding. Some of the common conditions that produce each of these symptoms are discussed below.
Excessively heavy menstrual bleeding (menorrhagia)
Excessively heavy menstrual bleeding, called menorrhagia, is menstrual bleeding of greater than 5 tablespoons per month. This condition occurs in about 10% of women. The most common pattern of menorrhagia is excessive bleeding that occurs in regular menstrual cycles and with normal ovulation.
There are several important reasons that menorrhagia should be evaluated by a doctor. First, menorrhagia can cause a woman substantial emotional distress and physical symptoms, such as severe cramping . Second, the blood loss can be so severe that it causes a dangerously lowered blood count (anemia), which can lead to medical complications and symptoms such as dizziness and fainting. Third, there can be dangerous causes of menorrhagia that require more urgent treatment.
Benign (noncancerous) causes of menorrhagia include:
uterine fibroids (benign tumors of smooth muscle tissue),
endometrial polyps (tiny benign growths that protrude into the womb),
adenomyosis,
intrauterine devices (IUD's) ,
underactive thyroid function (hypothyroidism),
an autoimmune disorder called systemic lupus erythematosus , and
blood clotting disorders.
Though not common, menorrhagia can be a sign of endometrial cancer. This situation is more frequent in women who are over the age of 40.
Although there are many causes of menorrhagia, in most women, the specific cause of menorrhagia is not found even after a full medical evaluation. These women are said to have dysfunctional uterine bleeding. Although no specific cause of the abnormal vaginal bleeding is found in women with dysfunctional uterine bleeding, there are treatments available to reduce the severity of the condition.
Sometimes, a woman has a condition that is well known to cause menorrhagia, but another condition may actually be the cause of her menorrhagia. For example, a woman with uterine fibroids may actually be experiencing menorrhagia because she has endometrial hyperplasia. Therefore, a woman should not assume that her heavy bleeding does not require further evaluation without consulting a doctor.
A woman with menorrhagia should visit a gynecologist in certain situations. As explained above, because more serious disorders are more common causes of menorrhagia in women who are over 40 as compared to those under age 40, women over age 40 are often referred to a gynecologist for further evaluation. If a woman persistently bleeds between her periods (intermenstrual bleeding) or medical treatment has not controlled the bleeding, she may then be referred to a gynecologist.
Irregular vaginal bleeding; menstrual periods that are too frequent (polymenorrhea)
Menstrual periods that are abnormally frequent (polymenorrhea) can be caused by certain sexually transmitted diseases (STDs) (such as chlamydia or gonorrhea) that cause inflammation in the uterus. This condition is called pelvic inflammatory disease. Endometriosis is a condition of unknown cause that can lead to pelvic pain and polymenorrhea. Sometimes, the cause of polymenorrhea is unclear, in which case the woman is said to have dysfunctional uterine bleeding.
Menstrual periods at irregular intervals (metrorrhagia)
Irregular menstrual periods (metrorrhagia) can be due to benign growths in the cervix, such as cervical polyps. The cause of these growths is usually not known. Metrorrhagia can also be caused by infections of the uterus (endometritis) and use of birth control pills (oral contraceptives). Sometimes after an evaluation, a woman's doctor might determine that her metrorrhagia does not have an identifiable cause and that further evaluation is not necessary at that time.
Decreased amount or duration of menstrual flow (hypomenorrhea)
An overactive thyroid function (hyperthyroidism) or certain kidney diseases can both cause hypomenorrhea. Oral contraceptive pills can also cause hypomenorrhea. It is important for women to know that lighter, shorter, or even absent menstrual periods as a result of taking oral contraceptive pills does not indicate that the contraceptive effect of the oral contraceptive pills is inadequate. In fact, many women enjoy this "side effect" of oral contraceptives.
Bleeding between menstrual periods (intermenstrual bleeding)
Women who are ovulating normally can experience light bleeding (sometimes referred to as “spotting”) between menstrual periods. Hormonal birth control methods (oral contraceptive pills or patches) as well as IUD use for contraception may sometimes lead to light bleeding between periods. Psychological stress, certain medications such as anticoagulant drugs, and fluctuations in hormone levels may all be causes of light bleeding between periods. Other conditions that cause abnormal menstrual bleeding, or bleeding in women who are not ovulating regularly (see below) can also be the cause of intermenstrual bleeding.
What conditions cause abnormal vaginal bleeding in women who are NOT ovulating regularly or vaginal bleeding after menopause?
Many conditions can interfere with the proper function of female hormones that are necessary for ovulation. For example, many conditions or circumstances may cause oligomenorrhea (reduction in the number of menstrual periods and/or amount of flow than usual) such as:
If a woman has chronic medical illnesses or is under significant medical or emotional stress, can begin to have a loss of her menstrual periods.
Malfunction of a particular part of the brain, called the hypothalamus, can cause oligomenorrhea.
Anorexia nervosa is an eating disorder associated with excessive thinness that causes many serious medical consequences as well as oligomenorrhea.
Polycystic ovarian syndrome (PCO) is a hormonal problem that causes women to have a variety of symptoms that include irregular or no menstrual periods, acne, obesity, infertility, and excessive hair growth; that are detectable with blood tests. For more, please read the Polycystic Ovarian Syndrome article.
The complete loss of ovulation is referred to as anovulation. Since ovulation allows the body to maintain an adequate supply of progesterone, anovulation is a condition in which a woman's hormonal balance is tipped toward too much estrogen and not enough progesterone. The excess estrogen is like a vitamin for the lining of the uterus. The result is that the lining of the uterus becomes too thick, which eventually leads to an increased risk of uterine pre-cancer or uterine cancer over many years. In order to replace progesterone and establish a proper hormonal balance, doctors will prescribe either progesterone to be taken at regular intervals, or an oral contraceptive that contains progesterone. Such treatment dramatically decreases the risk of uterine cancer in women who do not ovulate. Because uterine cancer results from many years of anovulation, any woman with prolonged anovulation needs to be treated to avoid developing uterine cancer.
Women who are postmenopausal should not experience vaginal bleeding. Any vaginal bleeding is considered abnormal in postmenopausal women. Women who are taking combined estrogen and progesterone hormone therapy (HRT) may experience some light, irregular vaginal bleeding during the first six months of treatment. Likewise, postmenopausal women who are taking a cyclic hormone regimen (oral estrogen and a progestin for 10-12 days per month) may experience some vaginal bleeding that is similar to a menstrual period for a few days each month.
Postmenopausal women who experience heavy or prolonged vaginal bleeding while on HRT should always see a doctor to rule-out more serious causes of vaginal bleeding. Less frequent but serious causes of vaginal bleeding in postmenopausal women include endometrial cancer or hyperplasia (overgrowth of the lining tissues of the uterus, which can be precancerous in some cases).
What causes vaginal bleeding during or after sexual intercourse?
Vaginal bleeding may occur during or after sexual intercourse for a number of reasons including:
Injuries to the vaginal wall or introitus (opening to the vagina) during intercourse
Infections (e.g. gonorrhea, chlamydia, yeast infections) are a cause of vaginal bleeding after intercourse.
Lowered estrogen levels in peri-menopausal or postmenopausal women may cause the lining of the vagina to become thinned and easily inflamed or infected, and these changes can be associated with vaginal bleeding after intercourse.
Anatomical lesions, such as tumors or polyps on the cervix or vaginal wall may lead to vaginal bleeding during or after intercourse.
Women who experience vaginal bleeding during or following sexual intercourse should always visit their doctor to determine the cause of the bleeding.
What causes abnormal vaginal bleeding during pregnancy?
Many women have some amount of vaginal bleeding during pregnancy. Some studies show that up to 30% of pregnant women will experience some degree of vaginal bleeding while they are pregnant. Vaginal bleeding during pregnancy is more common with twins and other multiple gestations than with singleton pregnancies (pregnancy with one fetus). Sometimes woman experience a very scant amount of bleeding in the first two weeks of pregnancy, usually around the time of the expected menstrual period. This slight bleeding is sometimes referred to as "implantation bleeding." Doctors do not know for certain what causes this bleeding, but it may occur as a result of the fertilized egg implanting in the uterine wall.
The amount of the bleeding, the stage of pregnancy, and any associated symptoms can all help determine the cause of vaginal bleeding in pregnancy. While vaginal bleeding in pregnancy does not signify a problem with the pregnancy, women who experience bleeding during pregnancy should always be evaluated by a doctor.
Causes of vaginal bleeding in pregnancy include miscarriage, an abnormal location of the placenta, ectopic pregnancy, cervical infection or polyp, and premature labor. Chronic medical conditions and medication use can also be related to vaginal bleeding during pregnancy.
What diagnostic tests are used to evaluate abnormal vaginal bleeding?
A woman who has irregular menstrual periods requires a physical examination with a special emphasis on the thyroid, breast, and pelvic area. During the pelvic examination, the physician attempts to detect cervical polyps or any unusual masses in the uterus. A Pap smear is also done to rule out cervical cancer. While the Pap smear is being obtained, samples might be taken from the cervix to test for the presence of infections such as chlamydia or gonorrhea.
A pregnancy test is routine if the woman is premenopausal. A blood count may be done to rule out a low blood count (anemia) resulting from excessive blood loss. If something in the patient's (or her family's) medical background or physical examination raises a doctor's suspicion, tests to rule-out certain blood clotting disorders may be done. Sometimes, a blood sample will be tested to evaluate thyroid function, liver function, or kidney function abnormalities. A blood test for progesterone levels or daily body temperature charting may be recommended to verify that the woman ovulates. If the doctor suspects that the ovaries are failing, such as with menopause, blood levels of follicle-stimulating hormone (FSH) may be tested. Additional blood hormone tests are done if the doctor suspects PCO or if excessive hair growth is present.
A pelvic ultrasound is often performed based on the woman's medical history and pelvic examination. If a woman does not adequately respond to medical treatment, if she is over age 40, or if she has persistent vaginal bleeding between her periods, a sampling of the lining of her uterus (termed endometrial sampling or endometrial biopsy) is analyzed. Endometrial sampling helps to rule out cancer or precancer in the uterus, or it can confirm a suspicion that a woman is not ovulating.
How is irregular vaginal bleeding treated?
Treatment for irregular vaginal bleeding depends on the underlying cause. After the cause is determined, the doctor decides if treatment is actually necessary. Sometimes, all that is needed is for dangerous causes to be ruled out and to determine that the irregular vaginal bleeding does not bother the woman enough to warrant medication or treatment. If thyroid, liver, kidney, or clotting problems are discovered, treatment is directed toward these conditions.
Medications for treatment of irregular vaginal bleeding depend on the cause. Examples are described below:
If the cause of the bleeding is lack of ovulation (anovulation), doctors may prescribe either progesterone to be taken at regular intervals, or an oral contraceptive, which contains progesterone, to achieve a proper hormonal balance. Such treatment dramatically decreases the risk of uterine cancer in women who do not ovulate.
If the cause of irregular vaginal bleeding is a precancerous change in the lining of the uterus, progesterone medications may be prescribed to reduce the buildup of precancerous uterine lining tissues in an attempt to avoid surgery.
When a woman has been without menses for less than 6 months and is bleeding irregularly, the cause may be menopausal transition. During this transition, a woman is sometimes offered an oral contraceptive to establish a more regular bleeding pattern, to provide contraception until she completes menopause, and to relieve hot flashes. A woman who is found to be menopausal as the cause of her irregular bleeding should also receive menopause counseling. (For more information about menopause treatment, see the Menopause article.)
If the cause of irregular vaginal bleeding is polyps or other benign growths, these are sometimes removed surgically to control bleeding because they cannot be treated with medication.
If the cause of bleeding is infection, antibiotics are necessary. Bleeding during pregnancy requires urgent evaluation by an obstetrician. Endometriosis can be treated with medications and/or surgery (such as laparoscopy). (For more information about the treatment of endometriosis, see the Endometriosis article.)
Sometimes, the cause of excessive bleeding is not apparent after completion of testing (dysfunctional uterine bleeding). In these cases, oral contraceptives can improve cycle control and lessen bleeding.
If bleeding is excessive and cannot be controlled by medication, a surgical procedure called dilation and curettage (D&C) may be necessary. In addition to alleviating the excessive bleeding, the D&C provides additional information that can rule out abnormalities of the lining of the uterus.
Occasionally, a hysterectomy is necessary when hormonal medications cannot control excessive bleeding. However, unless the cause is pre-cancerous or cancerous, this surgery should only be an option after other solutions have been tried.
Many new procedures are being developed to treat certain types of irregular vaginal bleeding. For example, studies are underway to evaluate techniques that selectively block the blood vessels involved in the bleeding. These newer methods may be less complicated options for some patients and as they are further evaluated they will likely become more widely available.
Vaginal Bleeding At A Glance
Normal vaginal bleeding is the periodic blood that flows as a discharge from the woman's uterus.
Normal vaginal bleeding is also called menorrhea. The process by which menorrhea occurs is called menstruation.
In order to determine whether bleeding is abnormal, and its cause, the doctor must answer 3 questions: Is the woman pregnant? What is the pattern of the bleeding? Is she ovulating?
Abnormal vaginal bleeding in women who are ovulating regularly most commonly involves excessive, frequent, irregular, or decreased bleeding.
There are many causes of abnormal vaginal bleeding that are associated with irregular ovulation.
A woman who has irregular menstrual periods requires a physical examination with a special emphasis on the thyroid, breast, and pelvic area.
Treatment for irregular vaginal bleeding depends on the underlying cause. After the cause is determined, the doctor decides if treatment is actually necessary.
Normal vaginal bleeding is the periodic blood that flows as a discharge from the woman's uterus. Normal vaginal bleeding is also called menorrhea. The process by which menorrhea occurs is called menstruation.
Normal vaginal bleeding occurs as a result of cyclic hormonal changes. The ovaries are the main source of female hormones, which control the development of female body characteristics such as the breasts, body shape, and body hair. The hormones also regulate the menstrual cycle. The ovary, or female gonad, is one of a pair of reproductive glands in women. They are located in the pelvis, one on each side of the uterus. Each ovary is about the size and shape of an almond. The ovaries produce eggs (ova) and female hormones. During each monthly menstrual cycle, an egg is released from one ovary. The egg travels from the ovary through a Fallopian tube to the uterus. Unless pregnancy occurs, the cycle ends with the shedding of part of the inner lining of uterus, which is menstruation. Although it is actually the end of the physical cycle, the first day of menstrual bleeding is designated as "day 1" of the menstrual cycle in medical jargon.
The time of the cycle during which menstruation occurs is referred to as menses. The menses occurs at approximately 4 week intervals, representing the menstrual cycle.
Menarche is the time in a girl's life when menstruation first begins. Menopause is the time in a woman's life when the function of the ovaries ceases. The average age of menopause is 51 years old.
What is abnormal vaginal bleeding?
Abnormal vaginal bleeding is a flow of blood from the vagina that occurs either at the wrong time during the month or in inappropriate amounts. In order to determine whether bleeding is abnormal, and its cause, the doctor must answer 3 questions: Is the woman pregnant? What is the pattern of the bleeding? Is she ovulating?
Every woman who thinks she has an irregular menstrual bleeding pattern should think carefully about the specific characteristics of her vaginal bleeding in order to help her doctor evaluate her particular situation. Her doctor will require the details of her menstrual history. Each category of menstrual disturbance has a particular list of causes, necessary testing, and treatment. Each type of abnormality is discussed individually below.
1. Is the woman having abnormal vaginal bleeding during pregnancy?
Much of the abnormal vaginal bleeding during pregnancy occurs so early in the pregnancy that the woman doesn't realize she is pregnant. Therefore, irregular bleeding that is new may be a sign of very early pregnancy, even before a woman is aware of her condition.
2. What is the pattern of the abnormal vaginal bleeding?
The duration, interval, and amount of vaginal bleeding may suggest what type of abnormality is responsible for the bleeding.
An abnormal duration of menstrual bleeding can be either bleeding for too long of a period (hypermenorrhea), or too short of a period (hypomenorrhea).
The interval of the bleeding can be abnormal in several ways. A woman's menstrual periods can occur too frequently (polymenorrhea) or too seldom (oligomenorrhea). Additionally, the duration can vary excessively from cycle to cycle (metrorrhagia).
The amount (volume) of bleeding can also be abnormal. A woman can either have too much bleeding (menorrhagia) or too little volume (hypomenorrhea).
3. Is the woman ovulating?
Usually, the ovary releases an egg every month in a process called ovulation. Normal ovulation is necessary for regular menstrual periods. There are certain clues that a woman is ovulating normally including regular menstrual intervals, vaginal mucus discharge halfway between menstrual cycles, and monthly symptoms including breast tenderness, fluid retention, menstrual cramps, back pain, and mood changes. If necessary, doctors will order hormone blood tests (progesterone level), daily home body temperature testing, or rarely, a sampling of the lining of the uterus (endometrial sampling) to determine whether or not a woman is ovulating normally.
On the other hand, signs that a woman is not ovulating regularly include prolonged bleeding at irregular intervals after not having a menstrual period for several months, excessively low blood progesterone levels in the 2nd half of the menstrual cycle, and lack of the normal body temperature fluctuation during the time of expected ovulation. Sometimes, a doctor determines that a woman is not ovulating by sampling the lining of the uterus (endometrial sampling).
What conditions cause abnormal vaginal bleeding in women who are ovulating regularly?
Abnormal vaginal bleeding in women who are ovulating regularly, most commonly involve excessive, frequent, irregular, or decreased bleeding. Some of the common conditions that produce each of these symptoms are discussed below.
Excessively heavy menstrual bleeding (menorrhagia)
Excessively heavy menstrual bleeding, called menorrhagia, is menstrual bleeding of greater than 5 tablespoons per month. This condition occurs in about 10% of women. The most common pattern of menorrhagia is excessive bleeding that occurs in regular menstrual cycles and with normal ovulation.
There are several important reasons that menorrhagia should be evaluated by a doctor. First, menorrhagia can cause a woman substantial emotional distress and physical symptoms, such as severe cramping . Second, the blood loss can be so severe that it causes a dangerously lowered blood count (anemia), which can lead to medical complications and symptoms such as dizziness and fainting. Third, there can be dangerous causes of menorrhagia that require more urgent treatment.
Benign (noncancerous) causes of menorrhagia include:
uterine fibroids (benign tumors of smooth muscle tissue),
endometrial polyps (tiny benign growths that protrude into the womb),
adenomyosis,
intrauterine devices (IUD's) ,
underactive thyroid function (hypothyroidism),
an autoimmune disorder called systemic lupus erythematosus , and
blood clotting disorders.
Though not common, menorrhagia can be a sign of endometrial cancer. This situation is more frequent in women who are over the age of 40.
Although there are many causes of menorrhagia, in most women, the specific cause of menorrhagia is not found even after a full medical evaluation. These women are said to have dysfunctional uterine bleeding. Although no specific cause of the abnormal vaginal bleeding is found in women with dysfunctional uterine bleeding, there are treatments available to reduce the severity of the condition.
Sometimes, a woman has a condition that is well known to cause menorrhagia, but another condition may actually be the cause of her menorrhagia. For example, a woman with uterine fibroids may actually be experiencing menorrhagia because she has endometrial hyperplasia. Therefore, a woman should not assume that her heavy bleeding does not require further evaluation without consulting a doctor.
A woman with menorrhagia should visit a gynecologist in certain situations. As explained above, because more serious disorders are more common causes of menorrhagia in women who are over 40 as compared to those under age 40, women over age 40 are often referred to a gynecologist for further evaluation. If a woman persistently bleeds between her periods (intermenstrual bleeding) or medical treatment has not controlled the bleeding, she may then be referred to a gynecologist.
Irregular vaginal bleeding; menstrual periods that are too frequent (polymenorrhea)
Menstrual periods that are abnormally frequent (polymenorrhea) can be caused by certain sexually transmitted diseases (STDs) (such as chlamydia or gonorrhea) that cause inflammation in the uterus. This condition is called pelvic inflammatory disease. Endometriosis is a condition of unknown cause that can lead to pelvic pain and polymenorrhea. Sometimes, the cause of polymenorrhea is unclear, in which case the woman is said to have dysfunctional uterine bleeding.
Menstrual periods at irregular intervals (metrorrhagia)
Irregular menstrual periods (metrorrhagia) can be due to benign growths in the cervix, such as cervical polyps. The cause of these growths is usually not known. Metrorrhagia can also be caused by infections of the uterus (endometritis) and use of birth control pills (oral contraceptives). Sometimes after an evaluation, a woman's doctor might determine that her metrorrhagia does not have an identifiable cause and that further evaluation is not necessary at that time.
Decreased amount or duration of menstrual flow (hypomenorrhea)
An overactive thyroid function (hyperthyroidism) or certain kidney diseases can both cause hypomenorrhea. Oral contraceptive pills can also cause hypomenorrhea. It is important for women to know that lighter, shorter, or even absent menstrual periods as a result of taking oral contraceptive pills does not indicate that the contraceptive effect of the oral contraceptive pills is inadequate. In fact, many women enjoy this "side effect" of oral contraceptives.
Bleeding between menstrual periods (intermenstrual bleeding)
Women who are ovulating normally can experience light bleeding (sometimes referred to as “spotting”) between menstrual periods. Hormonal birth control methods (oral contraceptive pills or patches) as well as IUD use for contraception may sometimes lead to light bleeding between periods. Psychological stress, certain medications such as anticoagulant drugs, and fluctuations in hormone levels may all be causes of light bleeding between periods. Other conditions that cause abnormal menstrual bleeding, or bleeding in women who are not ovulating regularly (see below) can also be the cause of intermenstrual bleeding.
What conditions cause abnormal vaginal bleeding in women who are NOT ovulating regularly or vaginal bleeding after menopause?
Many conditions can interfere with the proper function of female hormones that are necessary for ovulation. For example, many conditions or circumstances may cause oligomenorrhea (reduction in the number of menstrual periods and/or amount of flow than usual) such as:
If a woman has chronic medical illnesses or is under significant medical or emotional stress, can begin to have a loss of her menstrual periods.
Malfunction of a particular part of the brain, called the hypothalamus, can cause oligomenorrhea.
Anorexia nervosa is an eating disorder associated with excessive thinness that causes many serious medical consequences as well as oligomenorrhea.
Polycystic ovarian syndrome (PCO) is a hormonal problem that causes women to have a variety of symptoms that include irregular or no menstrual periods, acne, obesity, infertility, and excessive hair growth; that are detectable with blood tests. For more, please read the Polycystic Ovarian Syndrome article.
The complete loss of ovulation is referred to as anovulation. Since ovulation allows the body to maintain an adequate supply of progesterone, anovulation is a condition in which a woman's hormonal balance is tipped toward too much estrogen and not enough progesterone. The excess estrogen is like a vitamin for the lining of the uterus. The result is that the lining of the uterus becomes too thick, which eventually leads to an increased risk of uterine pre-cancer or uterine cancer over many years. In order to replace progesterone and establish a proper hormonal balance, doctors will prescribe either progesterone to be taken at regular intervals, or an oral contraceptive that contains progesterone. Such treatment dramatically decreases the risk of uterine cancer in women who do not ovulate. Because uterine cancer results from many years of anovulation, any woman with prolonged anovulation needs to be treated to avoid developing uterine cancer.
Women who are postmenopausal should not experience vaginal bleeding. Any vaginal bleeding is considered abnormal in postmenopausal women. Women who are taking combined estrogen and progesterone hormone therapy (HRT) may experience some light, irregular vaginal bleeding during the first six months of treatment. Likewise, postmenopausal women who are taking a cyclic hormone regimen (oral estrogen and a progestin for 10-12 days per month) may experience some vaginal bleeding that is similar to a menstrual period for a few days each month.
Postmenopausal women who experience heavy or prolonged vaginal bleeding while on HRT should always see a doctor to rule-out more serious causes of vaginal bleeding. Less frequent but serious causes of vaginal bleeding in postmenopausal women include endometrial cancer or hyperplasia (overgrowth of the lining tissues of the uterus, which can be precancerous in some cases).
What causes vaginal bleeding during or after sexual intercourse?
Vaginal bleeding may occur during or after sexual intercourse for a number of reasons including:
Injuries to the vaginal wall or introitus (opening to the vagina) during intercourse
Infections (e.g. gonorrhea, chlamydia, yeast infections) are a cause of vaginal bleeding after intercourse.
Lowered estrogen levels in peri-menopausal or postmenopausal women may cause the lining of the vagina to become thinned and easily inflamed or infected, and these changes can be associated with vaginal bleeding after intercourse.
Anatomical lesions, such as tumors or polyps on the cervix or vaginal wall may lead to vaginal bleeding during or after intercourse.
Women who experience vaginal bleeding during or following sexual intercourse should always visit their doctor to determine the cause of the bleeding.
What causes abnormal vaginal bleeding during pregnancy?
Many women have some amount of vaginal bleeding during pregnancy. Some studies show that up to 30% of pregnant women will experience some degree of vaginal bleeding while they are pregnant. Vaginal bleeding during pregnancy is more common with twins and other multiple gestations than with singleton pregnancies (pregnancy with one fetus). Sometimes woman experience a very scant amount of bleeding in the first two weeks of pregnancy, usually around the time of the expected menstrual period. This slight bleeding is sometimes referred to as "implantation bleeding." Doctors do not know for certain what causes this bleeding, but it may occur as a result of the fertilized egg implanting in the uterine wall.
The amount of the bleeding, the stage of pregnancy, and any associated symptoms can all help determine the cause of vaginal bleeding in pregnancy. While vaginal bleeding in pregnancy does not signify a problem with the pregnancy, women who experience bleeding during pregnancy should always be evaluated by a doctor.
Causes of vaginal bleeding in pregnancy include miscarriage, an abnormal location of the placenta, ectopic pregnancy, cervical infection or polyp, and premature labor. Chronic medical conditions and medication use can also be related to vaginal bleeding during pregnancy.
What diagnostic tests are used to evaluate abnormal vaginal bleeding?
A woman who has irregular menstrual periods requires a physical examination with a special emphasis on the thyroid, breast, and pelvic area. During the pelvic examination, the physician attempts to detect cervical polyps or any unusual masses in the uterus. A Pap smear is also done to rule out cervical cancer. While the Pap smear is being obtained, samples might be taken from the cervix to test for the presence of infections such as chlamydia or gonorrhea.
A pregnancy test is routine if the woman is premenopausal. A blood count may be done to rule out a low blood count (anemia) resulting from excessive blood loss. If something in the patient's (or her family's) medical background or physical examination raises a doctor's suspicion, tests to rule-out certain blood clotting disorders may be done. Sometimes, a blood sample will be tested to evaluate thyroid function, liver function, or kidney function abnormalities. A blood test for progesterone levels or daily body temperature charting may be recommended to verify that the woman ovulates. If the doctor suspects that the ovaries are failing, such as with menopause, blood levels of follicle-stimulating hormone (FSH) may be tested. Additional blood hormone tests are done if the doctor suspects PCO or if excessive hair growth is present.
A pelvic ultrasound is often performed based on the woman's medical history and pelvic examination. If a woman does not adequately respond to medical treatment, if she is over age 40, or if she has persistent vaginal bleeding between her periods, a sampling of the lining of her uterus (termed endometrial sampling or endometrial biopsy) is analyzed. Endometrial sampling helps to rule out cancer or precancer in the uterus, or it can confirm a suspicion that a woman is not ovulating.
How is irregular vaginal bleeding treated?
Treatment for irregular vaginal bleeding depends on the underlying cause. After the cause is determined, the doctor decides if treatment is actually necessary. Sometimes, all that is needed is for dangerous causes to be ruled out and to determine that the irregular vaginal bleeding does not bother the woman enough to warrant medication or treatment. If thyroid, liver, kidney, or clotting problems are discovered, treatment is directed toward these conditions.
Medications for treatment of irregular vaginal bleeding depend on the cause. Examples are described below:
If the cause of the bleeding is lack of ovulation (anovulation), doctors may prescribe either progesterone to be taken at regular intervals, or an oral contraceptive, which contains progesterone, to achieve a proper hormonal balance. Such treatment dramatically decreases the risk of uterine cancer in women who do not ovulate.
If the cause of irregular vaginal bleeding is a precancerous change in the lining of the uterus, progesterone medications may be prescribed to reduce the buildup of precancerous uterine lining tissues in an attempt to avoid surgery.
When a woman has been without menses for less than 6 months and is bleeding irregularly, the cause may be menopausal transition. During this transition, a woman is sometimes offered an oral contraceptive to establish a more regular bleeding pattern, to provide contraception until she completes menopause, and to relieve hot flashes. A woman who is found to be menopausal as the cause of her irregular bleeding should also receive menopause counseling. (For more information about menopause treatment, see the Menopause article.)
If the cause of irregular vaginal bleeding is polyps or other benign growths, these are sometimes removed surgically to control bleeding because they cannot be treated with medication.
If the cause of bleeding is infection, antibiotics are necessary. Bleeding during pregnancy requires urgent evaluation by an obstetrician. Endometriosis can be treated with medications and/or surgery (such as laparoscopy). (For more information about the treatment of endometriosis, see the Endometriosis article.)
Sometimes, the cause of excessive bleeding is not apparent after completion of testing (dysfunctional uterine bleeding). In these cases, oral contraceptives can improve cycle control and lessen bleeding.
If bleeding is excessive and cannot be controlled by medication, a surgical procedure called dilation and curettage (D&C) may be necessary. In addition to alleviating the excessive bleeding, the D&C provides additional information that can rule out abnormalities of the lining of the uterus.
Occasionally, a hysterectomy is necessary when hormonal medications cannot control excessive bleeding. However, unless the cause is pre-cancerous or cancerous, this surgery should only be an option after other solutions have been tried.
Many new procedures are being developed to treat certain types of irregular vaginal bleeding. For example, studies are underway to evaluate techniques that selectively block the blood vessels involved in the bleeding. These newer methods may be less complicated options for some patients and as they are further evaluated they will likely become more widely available.
Vaginal Bleeding At A Glance
Normal vaginal bleeding is the periodic blood that flows as a discharge from the woman's uterus.
Normal vaginal bleeding is also called menorrhea. The process by which menorrhea occurs is called menstruation.
In order to determine whether bleeding is abnormal, and its cause, the doctor must answer 3 questions: Is the woman pregnant? What is the pattern of the bleeding? Is she ovulating?
Abnormal vaginal bleeding in women who are ovulating regularly most commonly involves excessive, frequent, irregular, or decreased bleeding.
There are many causes of abnormal vaginal bleeding that are associated with irregular ovulation.
A woman who has irregular menstrual periods requires a physical examination with a special emphasis on the thyroid, breast, and pelvic area.
Treatment for irregular vaginal bleeding depends on the underlying cause. After the cause is determined, the doctor decides if treatment is actually necessary.
Liver Blood Tests
Introduction
An initial step in detecting liver damage is a simple blood test to determine the presence of certain liver enzymes in the blood. Under normal circumstances, these enzymes reside within the cells of the liver. But when the liver is injured, these enzymes are spilled into the blood stream.
Among the most sensitive and widely used of these liver enzymes are the aminotransferases. They include aspartate aminotransferase (AST or SGOT) and alanine aminotransferase (ALT or SGPT). These enzymes are normally contained within liver cells. If the liver is injured, the liver cells spill the enzymes into blood, raising the enzyme levels in the blood and signaling the liver damage.
What are the aminotransferases?The aminotransferases catalyze chemical reactions in the cells in which an amino group is transferred from a donor molecule to a recipient molecule. Hence, the names "aminotransferases".
Medical terms can sometimes be confusing, as is the case with these enzymes. Another name for aminotransferase is transaminase. The enzyme aspartate aminotransferase (AST) is also known as serum glutamic oxaloacetic transaminase (SGOT); and alanine aminotransferase (ALT) is also known as serum glutamic pyruvic transaminase (SGPT). To put matters briefly, AST = SGOT and ALT = SGPT.
Normally, where are the aminotransferases?AST (SGOT) is normally found in a diversity of tissues including liver, heart, muscle, kidney, and brain. It is released into serum when any one of these tissues is damaged. For example, its level in serum rises with heart attacks and with muscle disorders. It is therefore not a highly specific indicator of liver injury.
ALT (SGPT) is, by contrast, normally found largely in the liver. This is not to say that it is exclusively located in liver but that is where it is most concentrated. It is released into the bloodstream as the result of liver injury. It therefore serves as a fairly specific indicator of liver status.
What are normal levels of AST and ALT?The normal range of values for AST (SGOT) is from 5 to 40 units per liter of serum (the liquid part of the blood).
The normal range of values for ALT (SGPT) is from 7 to 56 units per liter of serum.
What do elevated AST and ALT mean?AST (SGOT) and ALT (SGPT) are sensitive indicators of liver damage from different types of disease. But it must be emphasized that higher-than-normal levels of these liver enzymes should not be automatically equated with liver disease. They may mean liver problems or they may not. The interpretation of elevated AST and ALT levels depends upon the whole clinical picture and so it is best done by doctors experienced in evaluating liver disease.
The precise levels of these enzymes do not correlate well with the extent of liver damage or the prognosis (outlook). Thus, the exact levels of AST (SGOT) and ALT (SGPT) cannot be used to determine the degree of liver disease or predict the future. For example, patients with acute viral hepatitis A may develop very high AST and ALT levels (sometimes in the thousands of units/liter range). But most patients with acute viral hepatitis A recover fully without residual liver disease. For a contrasting example, patients with chronic hepatitis C infection typically have only a little elevation in their AST and ALT levels. Some of these patients may have quietly developed chronic liver disease such as chronic hepatitis and cirrhosis (advanced scarring of the liver).
What liver diseases cause abnormal aminotransferase levels?The highest levels of AST and ALT are found with disorders that cause the death of numerous liver cells (extensive hepatic necrosis). This occurs in such conditions as acute viral hepatitis A or B, pronounced liver damage inflicted by toxins as from an overdose of acetaminophen (brand-name Tylenol), and prolonged collapse of the circulatory system (shock) when the liver is deprived of fresh blood bringing oxygen and nutrients. AST and ALT serum levels in these situations can range anywhere from ten times the upper limits of normal to thousands of units/liter.
Mild to moderate elevations of the liver enzymes are commonplace. They are often unexpectedly encountered on routine blood screening tests in otherwise healthy individuals. The AST and ALT levels in such cases are usually between twice the upper limits of normal and several hundred units/liter.
The most common cause of mild to moderate elevations of these liver enzymes is fatty liver. In the United States, the most frequent cause of fatty liver is alcohol abuse. Other causes of fatty liver include diabetes mellitus and obesity. Chronic hepatitis C is also becoming an important cause of mild to moderate liver enzyme elevations.
What medications cause abnormal aminotransferase levels?A host of medications can cause abnormal liver enzymes levels. Examples include:
Pain relief medications such as aspirin, acetaminophen (Tylenol), ibuprofen (Advil, Motrin), neproxen (Narosyn), diclofenac (Voltaren), and phenybutazone (Butazolidine)
Anti-seizure medications such as phenytoin (Dilantin), valproic acid, carbamazepine (Tegretol), and phenobarbital
Antibiotics such as the tetracyclines, sulfonamides, isoniazid (INH), sulfamethoxazole, trimethoprim, nitrofurantoin, etc.
Cholesterol lowering drugs such as the "statins" (Mevacor, Pravachol, Lipitor, etc.) and niacin
Cardiovascular drugs such as amiodarone (Cordarone), hydralazine, quinidine, etc.
Anti-depressant drugs of the tricyclic type
With drug-induced liver enzyme abnormalities, the enzymes usually normalize weeks to months after stopping the medications.
What are less common causes of abnormal aminotransferase levels?Less common causes of abnormal liver enzymes in the United States include chronic hepatitis B, hemachromatosis, Wilson's disease, alpha-1-antitrypsin deficiency, celiac sprue, Crohn's disease, ulcerative colitis, and autoimmune hepatitis. Though not as common as hepatitis C, hepatitis B can cause chronic liver disease with persistently abnormal liver enzymes.
Hemachromatosis is a genetic (inherited) disorder in which there is excessive absorption of dietary iron leading to accumulation of iron in the liver with resultant inflammation and scarring of the liver.
Wilson's disease is an inherited disorder with excessive accumulation of copper in diverse tissues including the liver and the brain. Copper in liver can lead to chronic liver inflammation, while copper in brain can cause psychiatric and motor disturbances.
Alpha-1-antitrypsin deficiency is an inherited disorder in which the lack of a glycoprotein (carbohydrate-protein complex) called alpha-1-antitrypsin lead to chronic lung disease (emphysema) and to liver disease.
Autoimmune hepatitis results from liver injury brought about by the body's own antibodies and defense systems attacking the liver.
Celiac sprue is a small intestinal illness where a patient has allergy to gluten and develops gas, bloating, diarrhea, and in advanced cases malnutrition. Patietns with celiac sprue can also develop mildly abnormal ALT and AST levels.
Crohn's disease and ulcerative colitis are diseases with chronic inflammation of the intestines. In these patients inflammation of the liver (hepatitis) or bile ducts (primary sclerosing cholangitis) also can occur, causing abnormal liver tests.
Rarely, abnormal liver enzymes can be a sign of cancer in the liver. Cancer arising from liver cells is called hepatocellularcarcinoma or hepatoma. Cancers spreading to the liver from other organs (such as colon, pancreas, stomach, etc) are called metastatic malignancies.
How are healthy people evaluated for mild to moderate rises in aminotransferase levels?Evaluation of healthy patients with abnormal liver enzymes needs to be individualized. A doctor may ask for blood test data from old records for comparison. If no old records are available, the doctor may repeat blood tests in weeks to months to see whether these abnormalities persist. The doctor will search for risk factors for hepatitis B and C including sexual exposures, history of blood transfusions, injectable drug use, and occupational exposure to blood products. A family history of liver disease may raise the possibility of inherited diseases such as hemachromatosis, Wilson's disease, or alpha-1- antitrypsin deficiency.
The pattern of liver enzyme abnormalities can provide useful clues to the cause of the liver disease. For example, the majority of patients with alcoholic liver disease have enzyme levels that are not as high as the levels reached with acute viral hepatitis and the AST tends to be above the ALT. Thus, in alcoholic liver disease, AST is usually under 300 units/liter while the ALT is usually under 100 units/ liter.
If alcohol or medication is responsible for the abnormal liver enzyme levels, stopping alcohol or the medication (under a doctor's supervision only) should bring the enzyme levels to normal or near normal levels in weeks to months. If obesity is suspected as the cause of fatty liver, weight reduction of 5% to 10% should also bring the liver enzyme levels to normal or near normal levels.
If abnormal liver enzymes persist despite abstinence from alcohol, weight reduction and stopping certain suspected drugs, blood tests can be performed to help diagnose treatable liver diseases. The blood can be tested for the presence of hepatitis B and C virus and their related antibodies. Blood levels of iron, iron saturation, and ferritin (another measure of the amount of iron stored in the body) are usually elevated in patients with hemachromatosis. Blood levels of a substance called ceruloplasmin are usually decreased inpatients with Wilson's disease. Blood levels of certain antibodies (anti- nuclear antibody or ANA, anti-smooth muscle antibody, and anti-liver and kidney microsome antibody) are elevated in patients with autoimmune hepatitis.
Ultrasound and CAT scan of the abdomen are sometimes used to exclude tumors in the liver or other conditions such as gallstones or tumors obstructing the ducts that drain the liver.
Liver biopsy is a procedure where a needle is inserted through the skin over the right upper abdomen to obtain a thin strand of liver tissue to be examined under a microscope. The procedure is oftentimes performed after ultrasound study has located the liver. Not everybody with abnormal liver enzymes needs a liver biopsy. The doctor will usually recommend this procedure if 1) the information obtained from the liver biopsy will likely be helpful in planning treatment, 2) the doctor needs to know the extent and severity of liver inflammation/damage, or 3) to evaluate the effectiveness of treatment.
Liver biopsy is most useful in confirming a diagnosis of a potentially treatable condition. These potentially treatable liver diseases include chronic hepatitis B and C, hemachromatosis, Wilson's disease, autoimmune hepatitis, and alpha-1-antitrypsin deficiency.
How about monitoring aminotransferase levels?What is usually most helpful is serial testing of AST (SGOT) and ALT (SGPT) over time to determine whether the levels are going up, staying stable, or going down. For example, patients undergoing treatment for chronic hepatitis C should be monitored with serial liver enzyme tests. Those responding to treatment will experience lowering of liver enzyme levels to normal or near normal levels. Those who develop relapse of hepatitis C after completion of treatment will usually develop abnormal liver enzyme levels again.
What about other liver enzymes?Aside from AST and ALT, there are other enzymes including alkaline phosphatase, 5'-nucleotidase ("5 prime" nucleotidase), and gamma-glutamyltranspeptidase (GGT) that are often tested for liver disease.
We have restricted this consideration of liver enzymes to AST and ALT because they are biochemically related to each other and, more importantly, they are the two most useful liver enzymes.
An initial step in detecting liver damage is a simple blood test to determine the presence of certain liver enzymes in the blood. Under normal circumstances, these enzymes reside within the cells of the liver. But when the liver is injured, these enzymes are spilled into the blood stream.
Among the most sensitive and widely used of these liver enzymes are the aminotransferases. They include aspartate aminotransferase (AST or SGOT) and alanine aminotransferase (ALT or SGPT). These enzymes are normally contained within liver cells. If the liver is injured, the liver cells spill the enzymes into blood, raising the enzyme levels in the blood and signaling the liver damage.
What are the aminotransferases?The aminotransferases catalyze chemical reactions in the cells in which an amino group is transferred from a donor molecule to a recipient molecule. Hence, the names "aminotransferases".
Medical terms can sometimes be confusing, as is the case with these enzymes. Another name for aminotransferase is transaminase. The enzyme aspartate aminotransferase (AST) is also known as serum glutamic oxaloacetic transaminase (SGOT); and alanine aminotransferase (ALT) is also known as serum glutamic pyruvic transaminase (SGPT). To put matters briefly, AST = SGOT and ALT = SGPT.
Normally, where are the aminotransferases?AST (SGOT) is normally found in a diversity of tissues including liver, heart, muscle, kidney, and brain. It is released into serum when any one of these tissues is damaged. For example, its level in serum rises with heart attacks and with muscle disorders. It is therefore not a highly specific indicator of liver injury.
ALT (SGPT) is, by contrast, normally found largely in the liver. This is not to say that it is exclusively located in liver but that is where it is most concentrated. It is released into the bloodstream as the result of liver injury. It therefore serves as a fairly specific indicator of liver status.
What are normal levels of AST and ALT?The normal range of values for AST (SGOT) is from 5 to 40 units per liter of serum (the liquid part of the blood).
The normal range of values for ALT (SGPT) is from 7 to 56 units per liter of serum.
What do elevated AST and ALT mean?AST (SGOT) and ALT (SGPT) are sensitive indicators of liver damage from different types of disease. But it must be emphasized that higher-than-normal levels of these liver enzymes should not be automatically equated with liver disease. They may mean liver problems or they may not. The interpretation of elevated AST and ALT levels depends upon the whole clinical picture and so it is best done by doctors experienced in evaluating liver disease.
The precise levels of these enzymes do not correlate well with the extent of liver damage or the prognosis (outlook). Thus, the exact levels of AST (SGOT) and ALT (SGPT) cannot be used to determine the degree of liver disease or predict the future. For example, patients with acute viral hepatitis A may develop very high AST and ALT levels (sometimes in the thousands of units/liter range). But most patients with acute viral hepatitis A recover fully without residual liver disease. For a contrasting example, patients with chronic hepatitis C infection typically have only a little elevation in their AST and ALT levels. Some of these patients may have quietly developed chronic liver disease such as chronic hepatitis and cirrhosis (advanced scarring of the liver).
What liver diseases cause abnormal aminotransferase levels?The highest levels of AST and ALT are found with disorders that cause the death of numerous liver cells (extensive hepatic necrosis). This occurs in such conditions as acute viral hepatitis A or B, pronounced liver damage inflicted by toxins as from an overdose of acetaminophen (brand-name Tylenol), and prolonged collapse of the circulatory system (shock) when the liver is deprived of fresh blood bringing oxygen and nutrients. AST and ALT serum levels in these situations can range anywhere from ten times the upper limits of normal to thousands of units/liter.
Mild to moderate elevations of the liver enzymes are commonplace. They are often unexpectedly encountered on routine blood screening tests in otherwise healthy individuals. The AST and ALT levels in such cases are usually between twice the upper limits of normal and several hundred units/liter.
The most common cause of mild to moderate elevations of these liver enzymes is fatty liver. In the United States, the most frequent cause of fatty liver is alcohol abuse. Other causes of fatty liver include diabetes mellitus and obesity. Chronic hepatitis C is also becoming an important cause of mild to moderate liver enzyme elevations.
What medications cause abnormal aminotransferase levels?A host of medications can cause abnormal liver enzymes levels. Examples include:
Pain relief medications such as aspirin, acetaminophen (Tylenol), ibuprofen (Advil, Motrin), neproxen (Narosyn), diclofenac (Voltaren), and phenybutazone (Butazolidine)
Anti-seizure medications such as phenytoin (Dilantin), valproic acid, carbamazepine (Tegretol), and phenobarbital
Antibiotics such as the tetracyclines, sulfonamides, isoniazid (INH), sulfamethoxazole, trimethoprim, nitrofurantoin, etc.
Cholesterol lowering drugs such as the "statins" (Mevacor, Pravachol, Lipitor, etc.) and niacin
Cardiovascular drugs such as amiodarone (Cordarone), hydralazine, quinidine, etc.
Anti-depressant drugs of the tricyclic type
With drug-induced liver enzyme abnormalities, the enzymes usually normalize weeks to months after stopping the medications.
What are less common causes of abnormal aminotransferase levels?Less common causes of abnormal liver enzymes in the United States include chronic hepatitis B, hemachromatosis, Wilson's disease, alpha-1-antitrypsin deficiency, celiac sprue, Crohn's disease, ulcerative colitis, and autoimmune hepatitis. Though not as common as hepatitis C, hepatitis B can cause chronic liver disease with persistently abnormal liver enzymes.
Hemachromatosis is a genetic (inherited) disorder in which there is excessive absorption of dietary iron leading to accumulation of iron in the liver with resultant inflammation and scarring of the liver.
Wilson's disease is an inherited disorder with excessive accumulation of copper in diverse tissues including the liver and the brain. Copper in liver can lead to chronic liver inflammation, while copper in brain can cause psychiatric and motor disturbances.
Alpha-1-antitrypsin deficiency is an inherited disorder in which the lack of a glycoprotein (carbohydrate-protein complex) called alpha-1-antitrypsin lead to chronic lung disease (emphysema) and to liver disease.
Autoimmune hepatitis results from liver injury brought about by the body's own antibodies and defense systems attacking the liver.
Celiac sprue is a small intestinal illness where a patient has allergy to gluten and develops gas, bloating, diarrhea, and in advanced cases malnutrition. Patietns with celiac sprue can also develop mildly abnormal ALT and AST levels.
Crohn's disease and ulcerative colitis are diseases with chronic inflammation of the intestines. In these patients inflammation of the liver (hepatitis) or bile ducts (primary sclerosing cholangitis) also can occur, causing abnormal liver tests.
Rarely, abnormal liver enzymes can be a sign of cancer in the liver. Cancer arising from liver cells is called hepatocellularcarcinoma or hepatoma. Cancers spreading to the liver from other organs (such as colon, pancreas, stomach, etc) are called metastatic malignancies.
How are healthy people evaluated for mild to moderate rises in aminotransferase levels?Evaluation of healthy patients with abnormal liver enzymes needs to be individualized. A doctor may ask for blood test data from old records for comparison. If no old records are available, the doctor may repeat blood tests in weeks to months to see whether these abnormalities persist. The doctor will search for risk factors for hepatitis B and C including sexual exposures, history of blood transfusions, injectable drug use, and occupational exposure to blood products. A family history of liver disease may raise the possibility of inherited diseases such as hemachromatosis, Wilson's disease, or alpha-1- antitrypsin deficiency.
The pattern of liver enzyme abnormalities can provide useful clues to the cause of the liver disease. For example, the majority of patients with alcoholic liver disease have enzyme levels that are not as high as the levels reached with acute viral hepatitis and the AST tends to be above the ALT. Thus, in alcoholic liver disease, AST is usually under 300 units/liter while the ALT is usually under 100 units/ liter.
If alcohol or medication is responsible for the abnormal liver enzyme levels, stopping alcohol or the medication (under a doctor's supervision only) should bring the enzyme levels to normal or near normal levels in weeks to months. If obesity is suspected as the cause of fatty liver, weight reduction of 5% to 10% should also bring the liver enzyme levels to normal or near normal levels.
If abnormal liver enzymes persist despite abstinence from alcohol, weight reduction and stopping certain suspected drugs, blood tests can be performed to help diagnose treatable liver diseases. The blood can be tested for the presence of hepatitis B and C virus and their related antibodies. Blood levels of iron, iron saturation, and ferritin (another measure of the amount of iron stored in the body) are usually elevated in patients with hemachromatosis. Blood levels of a substance called ceruloplasmin are usually decreased inpatients with Wilson's disease. Blood levels of certain antibodies (anti- nuclear antibody or ANA, anti-smooth muscle antibody, and anti-liver and kidney microsome antibody) are elevated in patients with autoimmune hepatitis.
Ultrasound and CAT scan of the abdomen are sometimes used to exclude tumors in the liver or other conditions such as gallstones or tumors obstructing the ducts that drain the liver.
Liver biopsy is a procedure where a needle is inserted through the skin over the right upper abdomen to obtain a thin strand of liver tissue to be examined under a microscope. The procedure is oftentimes performed after ultrasound study has located the liver. Not everybody with abnormal liver enzymes needs a liver biopsy. The doctor will usually recommend this procedure if 1) the information obtained from the liver biopsy will likely be helpful in planning treatment, 2) the doctor needs to know the extent and severity of liver inflammation/damage, or 3) to evaluate the effectiveness of treatment.
Liver biopsy is most useful in confirming a diagnosis of a potentially treatable condition. These potentially treatable liver diseases include chronic hepatitis B and C, hemachromatosis, Wilson's disease, autoimmune hepatitis, and alpha-1-antitrypsin deficiency.
How about monitoring aminotransferase levels?What is usually most helpful is serial testing of AST (SGOT) and ALT (SGPT) over time to determine whether the levels are going up, staying stable, or going down. For example, patients undergoing treatment for chronic hepatitis C should be monitored with serial liver enzyme tests. Those responding to treatment will experience lowering of liver enzyme levels to normal or near normal levels. Those who develop relapse of hepatitis C after completion of treatment will usually develop abnormal liver enzyme levels again.
What about other liver enzymes?Aside from AST and ALT, there are other enzymes including alkaline phosphatase, 5'-nucleotidase ("5 prime" nucleotidase), and gamma-glutamyltranspeptidase (GGT) that are often tested for liver disease.
We have restricted this consideration of liver enzymes to AST and ALT because they are biochemically related to each other and, more importantly, they are the two most useful liver enzymes.
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