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The medicine are used both as a quick lived palliation or may be utilized in rare circumstances anxiety 24 hour helpline buy emsam 5 mg otc, as an different to anxiety symptoms visual disturbances emsam 5 mg buy discount line surgical procedure anxiety symptoms muscle tension cheap 5 mg emsam with mastercard. Preoperative Assessment Apart from routine preoperative investigations anxiety disorder key symptoms discount emsam 5 mg otc, intravenous pyelography to note the anatomic changes of the ureter may be useful. As such, the surgeon ought to be glad with the operation designed to serve the objective. It is certainly ineffective to carry out a hectic surgery to take away such myomata solely to depart behind an uterus which is unlikely to conceive in future. Danazol administered every day in divided doses ranging from 200�400 mg for 3 months minimizes blood loss and even produce amenorrhea by its antigonadotropin and androgen agonist actions. Mechanism of action is sustained pituitary down regulation and suppression of ovarian function. Prostaglandin synthetase inhibitors-These are used to relieve pain because of related endometriosis or degeneration of the fibroid. Preoperative therapy: It is indeed advantageous to reduce the size and vascularity of fibroid prior to both myomectomy or hysterectomy. While operation shall be technically simpler in broad ligament or cervical fibroid, in myomectomy, there may be little difficulty in enucleation of the tumor from its pseudocapsule. However, with the stoppage of the remedy, the tumor will attain its previous size slowly. However, the ultimate decision as to whether to perform myomectomy or hysterectomy is to be taken following laparotomy. Hysteroscopy: Generally a fibroid of 3�4 cm in diameter or a polyp is resected with a hysteroscope. Complications of hysteroscopic surgery are uterine perforation, fluid overload, hemorrhage and others (see p. Laparoscopy: Subserous and intramural fibroids might be removed laparoscopically (see p. Complications of laparoscopic surgical procedure, contraindications and others are mentioned in Ch 36 (see p. The patients over the age of forty years and in those not desirous of further child are the classic indications. Prophylactic salpingectomy during hysterectomy is an option to forestall ovarian most cancers (see p. Place of vaginal hysterectomy Fibroids with dimension of 10�12 weeks of pregnancy related to uterine prolapse are better dealt by the vaginal route. Uterine arteries are occluded by injecting polyvinyl alcohol particles by way of percutaneous femoral catheterization. Result: Improvement of menorrhagia is noticed in 80� 90% with 60% discount in size. Ligation of bilateral uterine artery gives the same end result as to that of uterine artery embolization. Emergency Surgery the indications for emergency surgical procedure in a fibroid are listed in Table 20. Anterior cervical: Bladder symptoms like frequency or even retention of urine are conspicuous. The precept to be adopted is enucleation adopted by hysterectomy to decrease the injury to the ureter. Vaginal part fibroids: If the tumor is sessile, myomectomy and if pedunculated, polypectomy is completed. Risk factors: Hormone replacement remedy, tamoxifen remedy, diabetes, hypertension, weight problems, and elevated affected person age are the essential threat elements. Pathogenesis Body A part of the thick endometrium tasks into the cavity and finally attains a pedicle. Naked eye look: It reveals a small polyp size of about 1�2 cm, seems reddish and feels gentle. The pedicle might at times be long sufficient to make the polyp protruded from the cervix. Lateral cervical: Vascular obstruction could result in hemorrhoids and edema legs (rare). In pregnancy, it stays asymptomatic however produces insuperable obstruction throughout labor. Fibroids arising from the vaginal part of the cervix might remain asymptomatic during nonpregnant state however produces obstruction throughout labor. If pedunculated, there may be a sensation of something coming down or if infected a foul smelling discharge per vaginam. However, if it protrudes out of the cervix, it feels delicate, slippery and is small in dimension. Predictors of malignancy are: (a) Size >10 mm; (b) Postmenopausal standing, and (c) Abnormal uterine bleeding. Cervical the polyp mainly arises from the endocervix and infrequently from the ectocervix. The stimulus of epithelial overgrowth might be as a result of hyperestrinism, chronic irritation by an infection or localized vascular congestion. Naked eye look: It reveals the polyp of normally small size not often exceeding 1�2 cm, single and red in colour. Microscopically: the stroma consists of fibrous connective tissues with quite a few small blood vessels and occasional cervical glands. Fibroid polyp is almost at all times as a result of extrusion of a submucous fibroid into the uterine cavity. During this process, it attains a pedicle which is usually broad and usually hooked up to the posterior wall. The uterus contracts to expel the polyp out and as a result, the polyp may be pushed out through the cervix to lie even within the vagina. There could also be evidences of necrosis, infection and hemorrhage specially on the tip. The entity is by chance discovered during speculum examination, following hysterosalpingography (filling defect) or hysteroscopy. Symptoms of a cervical polyp Irregular uterine bleeding, either pre or post-menopausal. Note the broad pedicle and scaling down of the cervix Chapter 20 x Benign Lesions of the Uterus 233 Hysterography-to detect the filling defect in a fibroid polyp. Examination beneath anesthesia and exploration of the uterine cavity by curette or ovum or ring forceps might help in prognosis of an uterine polyp. Sound test-to differentiate a fibroid polyp from continual inversion, sound check is completed. Irregular bleeding per vaginam and offensive vaginal discharge are present dated again to the being pregnant events. The chief complaints are: Intermenstrual bleeding, often steady, specifically in fibroid polyp arising from the physique Colicky ache in the lower abdomen due to uterine contraction in an effort to expel the polyp out of the uterine cavity Excessive vaginal discharge which can be offensive Sensation of one thing coming down when the polyp turns into huge distending the vagina It might stay asymptomatic additionally. The causes of recurrence of polyps are: (1) Incomplete removal; (2) Persistence of the cause leading to polyp formation; (3) Malignancy. Endometrial polyps that trigger infertility, postmenopausal bleeding or abnormal uterine bleeding must be eliminated hysteroscopically under direct imaginative and prescient. After the polyp is eliminated, endometrium is curetted to rule out coexisting pathology (5%). The cervix could additionally be patulous and the tip of the polyp is felt or else, the polyp is felt distinctly outside the exterior os. Speculum examination: It reveals the dimensions and color of the polyp which is normally pale; could also be hemorrhagic. Whereas, the attachment of the pedicle to the cervix may be visualized but attachment higher up could additionally be at occasions difficult to locate. Histology Histologically the polyp may be adenomatous (80%), cystic, fibrous, vascular and fibromyomatous. Hysteroscopy-to visualize the uterine polyp and concurrently polypectomy could possibly be done.

Once conversant with the method anxiety buzzfeed 5 mg emsam order, it may be carried out with satisfaction to the patient anxiety lexapro cheap 5 mg emsam overnight delivery. Can be accomplished in conditions contraindicated for laparoscopy Minimal however often not 3�5 days zero anxiety heart rate emsam 5 mg best. Vaginal ligation: Tubectomy through the vaginal route could additionally be accomplished together with vaginal plastic operation or in isolation anxiety job emsam 5 mg cheap visa. The operation is finished within the interval period, concurrent with vaginal termination of being pregnant or 6 weeks following delivery. The tubes are occluded both by a silastic ring (silicone rubber with 5% barium sulfate) devised by Fallope or by Filshie clip is manufactured from titanium lined with silicone rubber. Principal Steps (Single Puncture Technique) Premedication: Pethidine hydrochloride 75�100 mg with phenergan 25 mg and atropine sulfate zero. Local anesthesia: Taking usual aseptic precautions about 10 mL of 1% lignocaine hydrochloride is to be infiltrated at the puncture site (just beneath the umbilicus) down up to the peritoneum. An uterine manipulator is launched by way of the cervical canal for manipulation for visualization of tubes and uterus at a later step. The stomach is inflated with about 2 liters of gasoline (carbon dioxide or nitrous oxide or room air or oxygen). Introduction of the trocar and laparoscope with ring loaded applicator: Two silastic rings are loaded one after the opposite on the applicator with the help of a loader and pusher. The trocar with cannula is launched via the incision previously made with a twisting motion. The ring loaded applicator approaches one aspect of the tube and grasps at the junction of the proximal and middle third of the tube. It is safe, has wider applicability, is less expensive and has received a much less failure price in comparison with laparoscopic sterilization. However, for a quick turn over in an organized mass camp, laparoscopic sterilization provides a promising success Table 30. Hazards of Tubal Sterilization Immediate: these are related to common anesthesia and to the actual method used in sterilization. Pelvic pain, menorrhagia together with cystic ovaries represent a postligation syndrome. Failure rates of laparoscopic sterilization depend upon the person method (electrocoagulation- unipolar zero. Mortality following tubal sterilization is estimated to be 72 per one hundred,000 for all methods. Laparoscopic procedures carried the mortality rate of 5�10 per one hundred,000 compared to 7 per one hundred,000 for puerperal ligations. Couple must understand the permanency of the procedure, its occasional failure price, the dangers and unwanted side effects, and its alternatives. Reversal of vasectomy with restoration of vasa patency is feasible up to 90% of cases. Hysteroscopic methods of sterilization embody insertion of quinacrine pellet and essure (microcoil). Apart from standard or mini-lap belly methodology, laparoscopic sterilization is very popular and efficient (see p. The objective is achieved by mechanical gadgets or by chemical means which produce sperm immobilization, or by combined means. Inner ring is inserted at the apex of the vagina and the outer ring stays outside. Male - Condom Female - Condom, diaphragm, cervical cap � Chemical (Vaginal contraceptives) Creams - Delfen (nonoxynol-9, 12. Polyurethane condoms are thinner and appropriate to those that are sensitive to latex rubber. The distance between the tip of the middle finger placed in the posterior fornix and the point over the finger beneath the symphysis pubis gives the approximate diameter of the diaphragm. Ill fitting and unintentional displacement throughout intercourse enhance the failure fee. Usually, they contain surfactants like nonoxynol�9, octoxynol or benzalkonium chloride. The cream or jelly is launched excessive in the vagina with the help of the applicator soon before coitus. Foam tablets (1�2) are to be launched high in the vagina a minimal of 5 minutes prior to intercourse. There could also be occasional native allergic manifestations both in the vagina or vulva. Spermicide-Microbicide combination help the natural protection maintaining the acidic pH and act as antimicrobial also. The brokers containing surfactant, destroy the sperm membrane and likewise the outer envelops of the virus and bacteria. It releases spermicide throughout coitus, absorbs ejaculate and blocks the entrance to the cervical canal. The technique relies on identification of the fertile interval of a cycle and to abstain from sexual intercourse throughout that interval. The strategies to decide the approximate time of ovulation and the fertile interval include- (a) recording of previous menstrual cycles (calendar rhythm) (b) noting the basal physique temperature chart (temperature rhythm) and (c) noting excessive mucoid vaginal discharge (mucus rhythm). The users of the calendar method obtain the period of abstinence from Vaginal Contraceptive Sponge (Today) It is made of polyurethane impregnated with 1 g of nonoxynol-9 as a spermicide. The first unsafe day is obtained by subtracting 20 days from the length of the shortest cycle and final unsafe day by deducting 10 days from the longest cycle. Users of temperature rhythm require abstinence till the third day of the rise of temperature. Users of mucus rhythm require abstinence on all days of noticeable mucus and for 3 days thereafter. It requires adequate self-control by the person so that withdrawal of penis preceed ejaculation. When the women is full breastfeeding, a contraceptive methodology should be used in the 3rd postpartum month and with partial or no breastfeeding, she should use it within the 3rd postpartum week. The particular person ought to have the freedom to choose any of the presently out there well-tested technique, which can even vary at every section in her reproductive life. Important elements for the selection of any contraceptive technique for a person are-relative security, effectiveness, unwanted aspect effects, and willingness to use the tactic accurately and persistently. Acceptability is probably essentially the most critical factor within the effectiveness of a contraceptive technique. Reversal is extra likely to achieve success after laparoscopic clips in comparison with laparotomy procedures. To cease future pregnancies: the decision to advise everlasting sterilization ought to be judiciously given specially to the underprivileged women in the face of excessive perinatal and toddler mortality rate. Low dose pills may be continued until menopause (with monitoring) within the low-risk group. Barrier strategies and vaginal spermicides can be utilized both as a major or again up technique. They ought to use condom with spermicides or use another contraceptive technique along side condom. Adolescent Girls Low dose mixed drugs are best for the sexually lively adolescents. It is a nonsteroidal compound with potent antiestrogenic and weak-estrogenic properties. It is prevented in polycystic ovarian illness, with liver and kidney ailments, and in tuberculosis. Postabortal the contraceptive practice ought to be began soon following the abortion process is accomplished. Postpartum Nonlactating Lactating Nonlactating Contraceptive apply should be began after 3 weeks. Lactating In absolutely lactating girls (5�6 feeds and spending about 60 minutes in 24 hours), the contraceptive follow may be safely withheld for 10 weeks postpartum. Transdermal patch: Nestorone (newer progestin): When used as a cream to the skin supplies efficient contraception. Patch delivers one hundred fifty Pg of norelgestromin (progestin) and 20 Pg ethinylestradiol every day. Drawbacks: Patch detachment, pores and skin reaction and excessive failure in overweight girls (> 90 kg).

Primary: the following pointers are prescribed: Psychodynamic remedy: Main causes of worry are removed anxiety symptoms keyed up buy emsam 5 mg online. Behavioral remedy: Dilatation of the vaginal introitus digitally followed by introduction of gradually increasing measurement of the dilators is to be accomplished anxiety 300 purchase emsam 5 mg without prescription. Plastic vaginal trainers (pseudopenises) with graduated sizes may help her to take away her worry anxiety disorder symptoms 5 mg emsam purchase overnight delivery. Vaginal dilators: Daily introduction of the dilators (pseudopenises) for 1�2 weeks and to keep it inside for 10�15 minutes is enough before she is allowed to try coital act anxiety symptoms 6 year molars emsam 5 mg without a prescription. Dyspareunia Definition Dyspareunia means that the coital act is difficult and or painful. Violence towards ladies may be battering, sexual assault, incest, physical trauma or elder abuse. Patients should be informed accordingly for the support and likewise for the community resources. Etiology Male Female Male causes the next male elements are responsible: x Impotence x Premature ejaculation x Congenital anatomic defect of the penis x Lack of technique of coital act. Female causes Depending upon the positioning of ache, the dyspareunia could also be either: Superficial or entrance Vaginal Deep. Superficial: Any lesion of the decrease part of the labia minora or across the fourchette could additionally be responsible. However, some tumors are frequent in a Vaginal: Burning ache alongside the barrel of vagina either throughout or following intercourse is the presenting grievance. Full Bladder It is an axiom that prior to gynecologic examination, bladder must be saved empty. Not solely full bladder may be confused with some abdominopelvic pathology but empty bladder ensures better evaluation of pelvic findings on bimanual examination. Features of a full bladder Strictly suprapubic, might even attain up to the umbilicus Cystic or tense cystic Margins-ill-defined Tendency of urge for micturition on stress Disappears after catheterization. Pseudocyesis Usually present in women having problem of infertility or approaching menopause with an intense need to have a baby. The confusion is accentuated with a history of oligomenorrhea, conception occurring during lactational amenorrhea or illegal being pregnant. In reality, amenorrhea throughout childbearing period with a lump within the decrease abdomen should be provisionally identified as pregnancy unless proved in any other case. Surgical management: Besides these as described above, all need some type of surgical therapy (cyst aspiration, laparoscopy, and laparotomy). Cyst aspiration for cytologic examination to differentiate benign from malignant tumors is completed. Cystectomy for younger ladies and oophorectomy for postmenopausal ladies is beneficial. Such women ought to be recommended preoperatively that a full staging laparotomy could additionally be needed if proof of malignancy is seen. Evaluation of an Adnexal Mass Clinical (bimanual pelvic) examination for its measurement, shape, consistency, mobility, and tenderness. Transvaginal ultrasonography-whether the cyst is easy or advanced, inner echoes, nodularity. Management of an Adnexal Mass Whenever any adnexal mass is diagnosed the management will depend mainly on-(i) Nature of the mass. The excess regular secretion happens during puberty, menstrual cycle (around ovulation and premenstrual), pregnancy and sexual excitement. Improvement of basic health, sympathetic angle in the course of ailments, local hygiene and appropriate remedy for the local ailments are enough to treatment the state. Local pores and skin lesions, vaginal discharge, allergy, intestinal worms or diabetes are a few of the necessary causes. About one-third of the circumstances are because of pelvic malignancy, the most common being uterine Table 34. Apart from routine use of gynecological examination, the special investigations embody cytology, transvaginal sonography, fractional curettage, hysteroscopic analysis and/or laparoscopy. Pain arising from the pelvic organs is often localized to not the organ but referred to the skin space provided by the identical spinal nerve Table 34. The fundamental mechanism of acute pain is due to irritation of the peritoneum by both blood or an infection. Management in circumstances of definite diagnosis includes either immediate laparotomy or establishment of medical therapy. Laparoscopy is finished each for diagnostic and therapeutic functions as "one-stop" procedure. In the absence of particular pathology, medical administration of pain must be tried first. Minimal surgery consists of laser remedy in pelvic endometriosis and adhesiolysis endoscopically. The pain arises from the ovaries (preserved during hysterectomy) because of pressure inside the rising follicle or as a end result of periovarian adhesions. The persistent pelvic ache in ovarian remnant syndrome is as a outcome of of the remnant of ovarian cortical tissue, left behind unintendedly following a tough oophorectomy. The ache in prolapse subsides when the affected person is at relaxation and aggravates on standing. Mammography along with physical examination is to be carried out yearly from the age of forty and earlier in excessive danger group. Irrespective of mammographic findings, presence of any suspicious mass suggests biopsy. Purulent discharge is as a result of of an infection and serous or sticky discharge is due to fibrocystic illness. Full bladder ought to be excluded first in the differential prognosis of abdominopelvic lump; similarly, being pregnant has to be excluded in childbearing period no matter the standing of the ladies Table 34. Pregnancy is the commonest trigger for a woman in reproductive age and for a postmenopausal lady genital malignancy must be excluded. Adnexal mass may be as a end result of the pathology of (A) Ovary (neoplasm, cyst, endometrioma, or tubo-ovarian mass), (B) Uterine (myoma), (C) Tubal (hydrosalpinx, ectopic pregnancy), (D) Gastrointestinal (appendicular mass) or genitourinary, (pelvic kidney) (see p. Evaluation and administration have to think about the character of the mass and age of the girl (see p. Clinical examination, imaging research, tumor markers and the genetic markers (see p. Hypertrichosis: It connotes excessive development of nonsexual (fetal lanugo type) hair in normal location. Hyperandrogenism: It is a state of increased serum androgen stage with or with none organic impact of hyperandrogenemia. Virilism: It is outlined because the presence of any a quantity of of the following features-deepening of the voice, temporal balding, amenorrhea, increased muscle mass, enlargement of clitoris (clitoromegaly) and breast atrophy. Approximately, 50% of testosterone arises from peripheral conversion of prohormones, predominantly androstenedione. The principal sites of peripheral conversion are pores and skin, muscle, fats, liver, and lungs. The adrenal glands (zona reticularis and zona fasciculata) and ovaries (theca, stroma, and granulosa) contribute approximately equal amounts (25%) to the circulatory ranges of testosterone. The sources of androgens in normal female are schematically depicted in Flowchart 34. About 19% is bound loosely with albumin and solely 1% of the testosterone remains free which is biologically energetic. Oriental girls have less variety of hair follicles per unit space of pores and skin compared to a Caucasian woman. Ferriman-Gallwey (1981) scoring system was developed to quantify the diploma of hirsutism. Abnormal hair distribution is assessed in 9 physique areas and is scored from zero to 4. Hyperstimulation of the sebaceous glands leads first to oily pores and skin and subsequent infection ends in zits. The pores and skin and hair follicle play an energetic position in serving as goal organs for the androgens and in addition in producing androgens from circulatory prohormones. Once the black terminal hair is produced, the modifications persist even in the absence of a unbroken androgen excess. This latter phenomenon explains continued development even if the initiating testosterone source has been removed.

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The numerous etiological elements related to vulvar ulcers are given within the Table 18 anxiety medication list cheap emsam 5 mg visa. Treatment Oral remedy with methotrexate anxiety meme trusted emsam 5 mg, cyclosporine could additionally be utilized in resistant cases anxiety kava buy 5 mg emsam with amex. The vulvar ulceration could also be intensive and abandoning dense scar after therapeutic anxiety symptoms checklist emsam 5 mg buy discount. Dermatologic problems: (i) Contact dermatitis- because of brokers which might be domestically irritant. Acanthosis nigricans: the attribute skin changes are thickened, hyperpigmented and velvety areas over the labia majora and perianal region. Correction of basic pathology and extended topical antifungal remedy clears the an infection. It is an inflammatory response of the vulva following infections of the bowel or decrease genital tract. Nutritional deficiencies of vitamin B12, folic acid, iron and zinc have been found to be related. Sebaceous cyst: these are often a quantity of and are formed by accumulation of the sebaceous material as a result of occlusion of the ducts. Cyst of the canal of Nuck: Part of the processus vaginalis, which accompanied the round ligament and got obliterated prior to birth might persist to form a cyst. Inguinolabial hernia: When the entire processus vaginalis stays patent, there may be herniation of the stomach contents along the tract. The hernia could also be restricted to the inguinal canal or could lengthen as much as the anterior part of the labium majus. One should take heed to the entity as informal surgical incision on labial swelling might cause inadvertent harm to the gut. Vulvar varicosities: these are met predominantly during pregnancy and subside following delivery. If these fails, treatment by injecting sclerosing fluids or excessive ligature of the lengthy saphenous vein may be of help. Elephantiasis vulva: It is mainly because of consequence of lymphatic obstruction by microfilaria (filariasis). Plastic surgery could additionally be tried to restore the traditional anatomy along with antifilarial therapy. Hydradenoma: Hydradenoma arises from the sweat gland within the vulva, normally positioned within the anterior a half of the labia majora (38%). It is a benign lesion but its reddish look and complicated adenomatous sample on histology could additionally be confused with adenocarcinoma. Its presence is restricted only during reproductive period and becomes enlarged and tender during menstruation. Treatment is surgical excision and confirmation by biopsy (endometrial glands and stroma with hemosiderin-laden macrophages). Alternative histogenesis is embryonic remnants or occlusion of pilosebaceous ducts of sweat glands. The vaginal epithelial inclusion (epidermoid) cysts come up from the epithelium buried beneath the mucosa during healing from a traumatic harm following childbirth or surgical procedure. They are usually situated in the lower-third of the vagina on the posterior or posterolateral wall. Patient might have related other continual pain problems (irritable bowel, interstitial cystitis). Psychosexual counseling, biofeedback and bodily remedy are wanted for some circumstances. Vulvar vestibulitis syndrome is a condition of hyperesthesia (allodynia), pain without any painful stimuli. It is characterised by pain across the ducts of Bartholin gland and the introitus. Improvement of vulvar local hygiene, control of infective brokers and allergens, food regimen modification (low oxalate) are the preliminary steps. Psychological tricyclic antidepressants, gabapentin, biofeedback, behavioral treatment and even surgical procedure (vestibulectomy, perineoplasty, laser vaporization) have been tried. Infection, irritation, trauma (scratching), autoimmune, allergy (atopic), nutritional (deficiency of folic acid, vitamin B12, riboflavin, or achlorhydria) are implicated. Diagnosis of vulvar epithelial disorders wants details of history, symptoms, including sexual historical past. Women with lichen sclerosus or planus should be investigated for autoimmune circumstances (p. Multiple biopsies are to be taken from the sky blue areas left behind after applying 1% aqueous toluidine blue and washed off with 1% acetic acid. Considering the chance, local vulvectomy is justified specifically when associated with atypia (see p. Psychosexual counseling, behavioral therapy, tricyclic antidepressants (amitriptyline) are helpful. Vulvar vestibulitis syndrome-may be a generalized or focal painful situation of unknown etiology. Topical brokers (steroids, antifungal creams), vestibulectomy, behavioral therapy, have been tried. When the estrogen level is excessive, it strikes out so that the columnar epithelium extends onto the vaginal portion of the cervix replacing the squamous epithelium. Infection: the role of infection as the primary explanation for ectopy has been discarded. However, persistent cervicitis could additionally be associated or else the an infection could supervene on an ectopy due to the fragile columnar epithelium which is extra weak to trauma and an infection. Etiology Congenital Acquired Congenital At delivery, in about one-third of instances, the columnar epithelium of the endocervix extends past the external os. This condition persists just for a few days until the level of estrogen derived from the mother falls. Pathogenesis In the lively part of ectopy, the squamocolumnar junction moves out from the os. The columnar epithelium of the endocervix maintains its continuity while covering the ectocervix changing the squamous epithelium. The replaced epithelium is usually arranged in a single layer (flat type) or may be so hyperplastic as to fold inwards to accommodate within the increased area-a follicular ectopy. Underneath the epithelium, there are evidences of round cell infiltration and glandular proliferation. The columnar epithelium is less resistant to infection than the squamous epithelium. During the method of therapeutic, the squamocolumnar junction progressively moves up in the path of the exterior os. The squamous epithelium grows beneath the columnar epithelium till it reaches at or close to to its unique place at the exterior os. Alternatively, the replacement is probably by squamous metaplasia of the columnar cells. The chance of squamous metaplasia of the reserve cells is also likely (details in Ch 23). During the method, the squamous epithelium might hinder the mouth of the underlying glands (normally not current in ectocervix) pent up secretion retention cyst nabothian follicle. This strategy of substitute by the squamous epithelium is called epidermidization. Management Guidelines: All cases should be subjected to cytological examination from the cervical smear to exclude dysplasia or malignancy (see p. Symptomatic instances Detected during pregnancy and early puerperium, the therapy should be withheld for a minimal of 12 weeks postpartum. All the methods employed are primarily based on the precept of destruction of the columnar epithelium to be adopted by its healing by the squamous epithelium. It may be mucopurulent, offensive and irritant in presence of an infection; may be even blood-stained as a outcome of premenstrual congestion. Associated cervicitis might produce backache, pelvic pain and at occasions, infertility.