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By T. Falk. University of Notre Dame. 2018.

Abnormal bleeding can be a symptom of If the bleeding is heavy or her blood malignancy generic ibuprofen 400 mg amex, from the vagina proven ibuprofen 400 mg, cervix or count low, then it is best to have her lie uterus. Cancer of the cervix is several days to three a day, then two a more common but a normal Pap smear day, and then one a day. For those women with abnormal bleeding over age 40, an endometrial Since most (90%) of the non-pregnancy biopsy is a wise precaution during the bleeding is caused by hormonal factors, evaluation and treatment of abnormal your best bet is to: bleeding. These organs include the following: urethra, bladder, rectum, small intestine, uterus, and the vagina (vaginal vault) itself. The urethra and bladder are anatomically situated above the “roof”’ or top wall of the vagina, the cervix and uterus at the very deepest part of the vagina (the apex), and the rectum below the “foor” or bottom wall of the vagina. Thus, when prolapse develops, one or more of the following may occur: the urethra and bladder may descend into the vaginal roof, the cervix and uterus may descend into the vaginal canal, and the rectum may ascend into the vaginal foor. Pelvic relaxation can vary from minimal descent—causing few, if any, symptoms—to major descent— in which one or more of the pelvic organs literally prolapse outside the vagina at all times and cause signifcant symptoms. The degree of descent often varies with position and activity level, increasing with the assumption of the upright position and with exertional activities, and decreasing with lying down and resting. Pelvic relaxation usually results from a combination of factors including multiple pregnancies and vaginal deliveries (especially deliveries of large babies), menopause, hysterectomy, aging, weight gain, and any condition associated with chronic increases in abdominal pressure, such as asthma and bronchitis (chronic wheezing and coughing), seasonal allergies (chronic sneezing), or constipation (chronic straining). Passage of the large human head through the female pelvis causes tissue trauma, separation or weakness of connective tissue attachments, and alterations in the geometry of the pelvis. It is unusual for women who have not had children or who have delivered by elective caesarian section to develop signifcant pelvic relaxation. Because the female genital tract and urinary tract are intimately related (due to their anatomic proximity as well as a common embryological origin), pelvic relaxation can cause signifcant changes in normal urinary function. These range from stress urinary incontinence (a spurt-like leakage of urine from the urethra associated with an increase in abdominal pressure such as occurs with sneezing, coughing, etc. Non-operative treatment of pelvic relaxation is used when symptoms are minimal or when surgery cannot be performed because of infrmity and frailty. Such conservative treatment options include change of activities, management of constipation and other circumstances that increase abdominal pressure, pelvic foor exercises, hormone replacement, and pessaries. Pessaries are mechanical devices that are inserted into the vagina to act as a “strut” to help provide pelvic support. The side effects of pessaries are vaginitis (vaginal infection and discharge), extrusion (the inability to retain the pessary in proper position), and the “unmasking” of stress incontinence. You may wonder why a urologist is interested in female pelvic relaxation, since for many years urology was traditionally considered to be a male feld. In the late 1970’s, female urology emerged as a specialty branch of urology much as pediatric urology had done previously. Raz, a world-renowned physician and surgeon, developed the feld of female urology into a comprehensive surgical discipline. In addition to writing the textbook Atlas of Transvaginal Surgery and editing the textbook Female Urology, Dr. I was fortunate to be selected for one of these positions and after the completion of my urology residency at the University of Pennsylvania School of Medicine, spent the years 1987–1988 operating with Dr. Obviously, prolapse is an exclusively female feld, but incontinence and voiding dysfunction encompass both females and males. My practice is, in fact, almost equally divided between women and men, and I fnd that I enjoy this balance. Similarly, the gynecologist’s role in female pelvic relaxation was focused on prolapse of the bladder, uterus, and rectum, but ignored the urethral prolapse that is often responsible for stress urinary incontinence. Thus there was a division of labor, a “territoriality” within the realm of Figure 1 female pelvic surgery, as illustrated in this cartoon demonstrating the roles of the urologist, gynecologist, as well as the colon/rectal surgeon. Raz espoused the concept of a pelvic surgeon, one capable of dealing with any and all aspects of female pelvic relaxation, with a thorough knowledge of pelvic anatomy and plastic surgical reconstructive principles. Raz established became to train accomplished pelvic surgeons who could then obtain academic positions at University medical centers throughout the United States, the appropriate venue for further dissemination of the art and science of female urology and pelvic reconstructive surgery to medical students and residents in training. Thus, at Hackensack University Medical Center, one of my roles is to instruct urology residents and medical students from the University of Medicine and Dentistry of New Jersey in the principles and surgical techniques of Dr. Female pelvic reconstructive surgery incorporates principles of both urological, gynecological, and plastic surgery. A pelvic reconstruction for pelvic prolapse is not dissimilar to cosmetic facial surgical procedures performed by plastic surgeons for aging and sagging eyelids and jowels. Both pelvic reconstructive and plastic facial reconstructive surgery require some degree of creativity and artistic talent in addition to the requisite scientifc knowledge of anatomy and surgical principles. I personally fnd female reconstructive surgery to be particularly gratifying because of both the instant ability to assess the results before leaving the operating room as well as the great potential to improve the lifestyle and function of the person suffering with prolapse.

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Prostaglandins Like a hormone purchase ibuprofen 400 mg visa, a prostaglandin is one of a group of signaling molecules 400 mg ibuprofen for sale, but prostaglandins are derived from unsaturated fatty acids (see Figure 2. One reason that the omega-3 fatty acids found in fish are beneficial is that they stimulate the production of certain prostaglandins that help regulate aspects of blood pressure and inflammation, and thereby reduce 72 Chapter 2 | The Chemical Level of Organization the risk for heart disease. Proteins You might associate proteins with muscle tissue, but in fact, proteins are critical components of all tissues and organs. Proteins include the keratin in the epidermis of skin that protects underlying tissues, the collagen found in the dermis of skin, in bones, and in the meninges that cover the brain and spinal cord. Proteins are also components of many of the body’s functional chemicals, including digestive enzymes in the digestive tract, antibodies, the neurotransmitters that neurons use to communicate with other cells, and the peptide-based hormones that regulate certain body functions (for instance, growth hormone). While carbohydrates and lipids are composed of hydrocarbons and oxygen, all proteins also contain nitrogen (N), and many contain sulfur (S), in addition to carbon, hydrogen, and oxygen. Microstructure of Proteins Proteins are polymers made up of nitrogen-containing monomers called amino acids. An amino acid is a molecule composed of an amino group and a carboxyl group, together with a variable side chain. Just 20 different amino acids contribute to nearly all of the thousands of different proteins important in human structure and function. Body proteins contain a unique combination of a few dozen to a few hundred of these 20 amino acid monomers. What distinguishes the 20 amino acids from one another is their variable group, which is referred to as a side chain or an R-group. This group can vary in size and can be polar or nonpolar, giving each amino acid its unique characteristics. Strands containing fewer than about 100 amino acids are generally referred to as polypeptides rather than proteins. The body is able to synthesize most of the amino acids from components of other molecules; however, nine cannot be synthesized and have to be consumed in the diet. Free amino acids available for protein construction are said to reside in the amino acid pool within cells. If a particular essential amino acid is not available in sufficient quantities in the amino acid pool, however, synthesis of proteins containing it can slow or even cease. Shape of Proteins Just as a fork cannot be used to eat soup and a spoon cannot be used to spear meat, a protein’s shape is essential to its function. A protein’s shape is determined, most fundamentally, by the sequence of amino acids of which it is made (Figure 2. The example shown here is hemoglobin, a protein in red blood cells which transports oxygen to body tissues. Although some polypeptides exist as linear chains, most are twisted or folded into more complex secondary structures that form when bonding occurs between amino acids with different properties at different regions of the polypeptide. If you were to take a length of string and simply twist it into a spiral, it would not hold the shape. Similarly, a strand of amino acids could not maintain a stable spiral shape without the help of hydrogen bonds, which create bridges between different regions of the same strand (see Figure 2. Less commonly, a polypeptide chain can form a beta-pleated sheet, in which hydrogen bonds form bridges between different regions of a single polypeptide that has folded back upon itself, or between two or more adjacent polypeptide chains. The secondary structure of proteins further folds into a compact three-dimensional shape, referred to as the protein’s tertiary structure (see Figure 2. In this configuration, amino acids that had been very distant in the primary chain can be brought quite close via hydrogen bonds or, in proteins containing cysteine, via disulfide bonds. Often, two or more separate polypeptides bond to form an even larger protein with a quaternary structure (see Figure 2. For instance, hemoglobin, the protein found in red blood cells is composed of four tertiary polypeptides, two of which are called alpha chains and two of which are called beta chains. When they are exposed to extreme heat, acids, bases, and certain other substances, proteins will denature. For example, the long, slender shape of protein strands that make up muscle tissue is essential to their ability to contract (shorten) and relax (lengthen). As another example, bones contain long threads of a protein called collagen that acts as scaffolding upon which bone minerals are deposited. Proteins Function as Enzymes If you were trying to type a paper, and every time you hit a key on your laptop there was a delay of six or seven minutes before you got a response, you would probably get a new laptop. In a similar way, without enzymes to catalyze chemical reactions, the human body would be nonfunctional. This characteristic, called specificity, is due to the fact that a substrate with a particular shape and electrical charge can bind only to an active site corresponding to that substrate.

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Photoreceptors are activated 600mg ibuprofen amex, and the signal is transferred to the retinal ganglion cells that send an action potential along the optic nerve into the diencephalon effective ibuprofen 400 mg. If light levels are low, the sympathetic system sends a signal out through the upper thoracic spinal cord to the superior cervical ganglion of the sympathetic chain. The postganglionic fiber then projects to the iris, where it releases norepinephrine onto the radial fibers of the iris (a smooth muscle). If light levels are too high, the parasympathetic system sends a signal out from the Eddinger–Westphal nucleus through the oculomotor nerve. The output of the sympathetic system projects through the superior cervical ganglion, whereas the parasympathetic system originates out of the midbrain and projects through the oculomotor nerve to the ciliary ganglion, which then projects to the iris. The postganglionic fibers of either division release neurotransmitters onto the smooth muscles of the iris to cause changes in the pupillary size. It is a homeostatic reflex mechanism that keeps the activation of photoreceptors within certain limits. In the context of avoiding a threat like the lioness on the savannah, the sympathetic response for fight or flight will increase pupillary diameter so that more light hits the retina and more visual information is available for running away. Likewise, the parasympathetic response of rest reduces the amount of light reaching the retina, allowing the photoreceptors to cycle through bleaching and be regenerated for further visual perception; this is what the homeostatic process is attempting to maintain. The pupillary light reflex involves sensory input through the optic nerve and motor response through the oculomotor nerve to the ciliary ganglion, which projects to the circular fibers of the iris. As shown in this short animation, pupils will constrict to limit the amount of light falling on the retina under bright lighting conditions. Autonomic Tone Organ systems are balanced between the input from the sympathetic and parasympathetic divisions. When something upsets that balance, the homeostatic mechanisms strive to return it to its regular state. For each organ system, there may be more of a sympathetic or parasympathetic tendency to the resting state, which is known as the autonomic tone of the system. Because the resting heart rate is the result of the parasympathetic system slowing the heart down from its intrinsic rate of 100 bpm, the heart can be said to be in parasympathetic tone. In a similar fashion, another aspect of the cardiovascular system is primarily under sympathetic control. Blood pressure is partially determined by the contraction of smooth muscle in the walls of blood vessels. These tissues have adrenergic receptors that respond to the release of norepinephrine from postganglionic sympathetic fibers by constricting and increasing blood pressure. The hormones released from the adrenal medulla—epinephrine and norepinephrine—will also bind to these receptors. Those hormones travel through the bloodstream where they can easily interact with the receptors in the vessel walls. The parasympathetic system has no significant input to the systemic blood vessels, so the sympathetic system determines their tone. It does not have an overall effect on blood pressure to alter the tone of the vessels, but rather allows for blood flow to increase for those skeletal muscles that will be active in the fight-or-flight response. The blood vessels that have a parasympathetic projection are limited to those in the erectile tissue of the reproductive organs. Acetylcholine released by these postganglionic parasympathetic fibers cause the vessels to dilate, leading to the engorgement of the erectile tissue. This is because, for one reason or another, blood is not getting to your brain so it is briefly deprived of oxygen. When you change position from sitting or lying down to standing, your cardiovascular system has to adjust for a new challenge, keeping blood pumping up into the head while gravity is pulling more and more blood down into the legs. The reason for this is a sympathetic reflex that maintains the output of the heart in response to postural change. Both changes will make it possible for the cardiovascular system to maintain the rate of blood delivery to the brain. Blood is being pumped superiorly through the internal branch of the carotid arteries into the brain, against the force of gravity. Gravity is not increasing while standing, but blood is more likely to flow down into the legs as they are extended for standing. This sympathetic reflex keeps the brain well oxygenated so that cognitive and other neural processes are not interrupted. If the sympathetic system cannot increase cardiac output, then blood pressure into the brain will decrease, and a brief neurological loss can be felt. This can be brief, as a slight “wooziness” when standing up too quickly, or a loss of balance and neurological impairment for a period of time. The name for this is orthostatic hypotension, which means that blood pressure goes below the homeostatic set point when standing. It can be the result of standing up faster than the reflex can occur, which may be referred to as a benign “head rush,” or it may be the result of an underlying cause. This hypovolemia may be the result of dehydration or medications that affect fluid balance, such as diuretics or vasodilators.

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