In their fourth year of residency, with an affidavit from their director to confirm program completion, OB-GYN residents can choose whether to begin the board certification process by applying to take the ABOG Qualifying Exam, which is a written test. [ 5 ]  If residents pass the Qualifying Exam, demonstrating they possess the knowledge and skills to potentially become certified OB-GYNs, they are then eligible to sit for the oral Certification Exam. [ 5 ]  Prior to the Certification Exam, residents must also gather a list of patient cases they've worked on throughout their residency in order to demonstrate their competence and experience in OB-GYN patient care. [ 2 ]


Residents then sit for the three-hour oral exam at ABOG's test center, and if they pass the exam they become "board certified" OB-GYNs. [ 3 ]  Since 2013 at least 82% of all Certifying Exam examinees have passed. [ 6 ]


This adds up to 11–14 years of education and practical experience. The first 7–9 years are general medical training.


Experienced OB-GYN professionals can seek certifications in sub-specialty areas, including maternal and fetal medicine. See  Fellowship (medicine) .


All doctors must first complete medical school and obtain a  MBBS  or equivalent certification. [ 7 ]  This portion typically takes five years. Following this, they are eligible for provisional registration with the  General Medical Council . They then must complete a two years of foundation training. [ 7 ] [ 8 ]  After the first year of training is complete, trainees are eligible for full registration with the General Medical Council. [ 7 ]  After the foundation training is complete applicants take the Part 1 MRCOG examination [ 9 ]  administered by the  Royal College of Obstetricians and Gynaecologists . There are an additional seven years of training after this, and two more exams (Part 2 and Part 3 MRCOG exams) which adds up to nine years total minimum in training, although some trainees may take longer. [ 10 ]


Examples of subspecialty training available to physicians in the US are:


Of these, only the first four are truly recognized sub-specialties by the Accreditation Council for Graduate Medical Education (ACGME) and the American Board of Obstetrics and Gynecology (ABOG). The other subspecialties are recognized as informal concentrations of practice. To be recognized as a board-certified subspecialist by the  American Board of Obstetrics and Gynecology  or the  American Osteopathic Board of Obstetrics and Gynecology , a practitioner must have completed an  ACGME  or  AOA -accredited residency and obtained a Certificate of Added Qualifications (CAQ) which requires an additional standardized examination. [ 11 ] [ 12 ]


Additionally, physicians of other specialties may become trained in  Advanced Life Support in Obstetrics  (ALSO), a short certification that equips them to better manage emergent OB/GYN situations.


There are many procedures that can be provided to people by OB/GYNs. Some procedures may include: [ 13 ]


The  orgasmic platform  is the  tissues  of the outer third of the  vagina , labeled by  Masters and Johnson .  They swell considerably, and the  pubococcygeus muscle  tightens, reducing the diameter of the opening of the vagina. During orgasm, women experience rhythmic contractions of the orgasmic platform.
The orgasmic platform is brought about through the swelling of the bulbus vestibuli that narrows the vestibulum.
It is actually the narrowing and the extending of the lower 1/3 of the sheath.  [ 1 ]


This  sexuality -related article is a  stub . You can help Wikipedia by  expanding it .


Our Bodies, Ourselves  is a book about  women's health  and  sexuality  produced by the nonprofit organization Our Bodies Ourselves (originally called the Boston Women's Health Book Collective). First published in 1970, it contains information related to many aspects of women's health and sexuality, including: sexual health,  sexual orientation ,  gender identity ,  birth control ,  abortion ,  pregnancy  and  childbirth , violence and abuse, and  menopause . The most recent edition of the book was published in 2011. The book was revolutionary in that it encouraged women to celebrate their sexuality, including chapters on  reproductive rights ,  lesbian sexuality , and  sexual independence . [ 1 ]  Its emphasis on women's active engagement with their actual sexual desires stood in contrast to the societal notion of the role of "women as docile and passive," and "men as active and aggressive" in a sexual relationship. [ 2 ]


The book has been translated and adapted by women's groups around the world and is available in 33 languages. [ 3 ]  Sales for all the books exceed four million copies. [ 4 ]   The New York Times  has called the seminal book "America's best-selling book on all aspects of women's health" and a "feminist classic". [ 5 ]


The health seminar that inspired the booklet was organized in 1969 by  Nancy Miriam Hawley  at Boston's  Emmanuel College . "We weren't encouraged to ask questions, but to depend on the so-called experts," Hawley told  Women's eNews . "Not having a say in our own health care frustrated and angered us. We didn't have the information we needed, so we decided to find it on our own." [ 6 ]  As a result of this goal, the book contained information intended to guide women on "how to maneuver the American health care system, with subsections called 'The Power and Role of Male Doctors,' 'The Profit Motive in Health Care,' 'Women as Health Care Workers,' and 'Hospitals. ' " [ 7 ]


Created during a moment of radical activism in Boston's history,  Our Bodies, Our Selves,  came out of the  Bread and Roses  collective, a radical women's liberation collective started in the 1960s and 1970s. While a short-lived collective it had a lasting impact of the projects that were created from it. [ 8 ]


The original writers of the book stated four main reasons for creating it. First, that personal experiences provide a valuable way to understand one's own body beyond the mere facts that experts can provide, creating an empowering learning experience. Second, this kind of learning meant that they were "better prepared to evaluate the institutions that are supposed to meet our health needs...". Third, the historical lack of self-knowledge about the female body "had had one major consequence – pregnancy" and through greater information, women will have more ability to make proactive choices about when to get pregnant. Fourth, information about one's body is perhaps the most essential kind of education, because "bodies are the physical bases from which we move out into the world". Without this basic information, women are alienated from their own body and necessarily on unequal footing with men. [ 7 ]


The women researched and wrote up the information themselves. Wendy Sanford wrote about  abortion , Jane Pincus and Ruth Bell about  pregnancy , and Paula Doress and  Esther Rome  about  postpartum depression . The 12 feminists then published their research as a 35-cent, 136-page booklet called  Women and Their Bodies , published in 1970 by the New England Free Press. The booklet sold 250,000 copies in New England without any formal advertising. [ 6 ]


As a result of their success, the women formed the non-profit Boston Women's Health Book Collective (which now goes by the name Our Bodies,  Ourselves) and published the first 276-page  Our Bodies, Ourselves  in 1973. The collective published it with the major publisher  Simon & Schuster  only on the condition that they would have complete editorial control and that nonprofit health centers could purchase copies at a significant discount. [ 7 ]  It featured first-person stories from women, and tackled many topics then regarded as  taboo . Since then, over four million copies have been sold. [ 9 ]  It has been considered one of the founding events of the  women's health movement in the United States . [ 10 ]


In 2018, the group announced that due to financial pressures, it would no longer publish new print editions nor have the resources to update its web site with new health information. [ 11 ]  In 2022, the Our Bodies, Ourselves began a collaboration with the  Center for Women's Health and Human Rights at Suffolk University  and launched Our Bodies, Ourselves Today, a new website that selects and features the high quality health and sexuality information on women, girls, and gender-expansive people. [ 12 ]


The Boston Women's Health Book Collective, also known as the Our Bodies, Ourselves Collective, is a feminist group that created  Our Bodies, Ourselves . The collective formed at the peak of the women's movement in Boston.


Twelve women all between the ages of 23 and 39 first attended a workshop entitled "Women and Their Bodies" which allowed the women to discuss together the issues they had surrounding their health. The discussion created a consciousness-raising environment, providing each woman with information that they all deal with when handling issues about their bodies. The strong discussion supplied the women with the necessary tools and ideas that lead to the creation of their book that addressed issues surrounding sexuality and abortion. They put their knowledge into an accessible format that served as a model for women who wanted to learn about themselves, communicate with doctors, and challenge the medical establishment to change and improve the health of women everywhere.


Reproductive justice was at the forefront during the women's liberation, causing much debate over the biological rights of women. The Equal Rights Amendment had a section specifically targeting the important issues about Reproductive justice that combines multiple reproductive rights and issues surrounding family. The strategy of the reproductive justice plank was to establish the necessary rights and access for women to gain control over their bodies. Through the passing of this legislation woman would be granted the ability to have abortions, obtain access to birth control and gain full control over their bodies.


The Boston Collective focused on these ideas to allow women the ability to understand their bodies and themselves as women. During the National Women's Conference, women from all over the country deliberated to determine the exact laws that should be put into place for women's reproductive justice. The Boston Collective work together to teach courses and create books that provide knowledge from women not only in Boston, but women across the nation. These women use their skills and knowledge to provide many women with knowledge about their lives through rhetoric that avoids describing the female reproductive system as passive, unproductive, helpless, or powerless.


The organization has also created two single-topic books.  Our Bodies, Ourselves: Menopause  was published in 2006, [ 13 ]  and  Our Bodies, Ourselves: Pregnancy and Birth  in 2008. [ 14 ]  The Boston Women's Health Book Collective earlier produced  Changing Bodies, Changing Lives: A Book For Teens on Sex and Relationships [ 15 ]  and  The New Ourselves, Growing Older: Women Aging with Knowledge and Power . [ 16 ] [ 17 ]


The first book was a product of the  feminist movement  and could still be said to reflect its values. The personal experiences of women are taken into account and are quoted throughout, while the social and political context of women's health informs the content of the book. The book emphasizes empowerment through information and learning, specifically, information gained through women sharing their personal narratives with each other because "by sharing our responses we can develop a base on which to be critical of what the experts tell us." [ 7 ]


Topics such as  male-to-female  and  female-to-male   transsexualism / transgenderism  are discussed in the most recent edition and considered in a nonjudgmental manner. The writing style of the book tends toward a familiar, inclusive tone, with the authors referring to women and themselves as a collective group.


The collective of women who initiated  Our Bodies, Ourselves  are part of the documentary  She's Beautiful When She's Angry , about the founders of the modern women's movement from 1966 to 1971.


Ovarian remnant syndrome [ 1 ]  is a condition that occurs when  ovarian  tissue is left behind following  oophorectomy , causing development of a pelvic mass,  pelvic pain , and occasionally  dyspareunia . [ 2 ]  Ovarian remnant syndrome (ORS) is characterized by the presence of residual ovarian tissue after a woman has had  surgery  to remove one ovary or both ovaries ( oophorectomy ). [ 3 ]


If ovarian hormones are present after the ovaries are removed can be a sign that ovarian tissue still remains. [ 4 ]  Signs and symptoms may include pelvic pain, a pelvic mass, or the absence of  menopause  after oophorectomy. Factors may include pelvic  adhesions  (limiting ability to see the ovary or causing it to adhere to other tissues);  anatomic variations ;  bleeding  during surgery; or poor surgical technique. Treatment is indicated for people with symptoms and typically involves surgery to remove the residual tissue.  Therapy  for those who refuse surgery, cannot have surgery, or do not have a pelvic mass may include hormonal therapy to suppress ovarian function. [ 3 ]


Some women have symptoms consistent with endometriosis, including difficult or  painful intercourse ; urinary symptoms; or bowel symptoms. It is likely that some women with ORS don't have any symptoms, but the rate of this is unknown. In most cases, symptoms occur within the first five years of the oophorectomy, although there are reports of ORS presenting 20 years after the initial surgery. [ 3 ]


The cause of ORS is the unintentional retention of ovarian tissue after the procedure to remove the ovaries. If a woman is receiving hormone replacement therapy, distinguishing from other disease process may be difficult. Other confounding conditions contributing to ORS are thick and profuse pelvic adhesions, inflammation, bleeding after surgery (peri-operative bleeding), and ovaries which are retroperitoneal, can all contribute to the unintentional preservation of ovarian fragments. [ 4 ]


The  risk  of ovarian remnant (ORS) is increased by incomplete removal of the ovary at the time of oophorectomy. Surgical factors that contribute to incomplete removal include those that limit surgical exposure of the ovary, or compromise surgical technique. Factors may include:


Ovarian remnant (ORS) may first be considered in women who have undergone oophorectomy and have suggestive symptoms, the presence of a mass, or evidence of persistent ovarian function (by symptoms or laboratory testing). A history of oophorectomy is required, by definition, to make the diagnosis. Notes regarding the indication for the procedure and the procedure itself should be reviewed and may include prior abdominal or pelvic surgery,  endometriosis , and/or poor surgical visualization. If ORS is possible, pelvic should be performed to evaluate for a pelvic mass.[1]


Surgical exploration and confirmation of possible ovarian tissue is required for the definitive diagnosis of ORS, and treatment by excision of the remnant ovarian tissue may be performed during the same procedure. For women who are not candidates for surgery, a clinical diagnosis can be made based on the symptoms and levels ( follicle-stimulating hormone  and  estradiol , after bilateral oophorectomy) and/or findings consistent with the presence of residual ovarian tissue. [ 3 ]  Laparoscopy and histological assessment can aid in diagnosis. [ 4 ]


Treatment for ovarian remnant  (ORS) is generally indicated for women with suspected ORS who have symptoms (such as  pain); have a pelvic mass; or need or desire complete removal of  to decrease the risk of ovarian  (for example, BRCA  ). The mainstay of treatment is surgery to remove the residual ovarian tissue. Women with ORS with a pelvic mass should have appropriate evaluation for malignancy ( cancer ).  Hormonal therapy  to suppress ovarian function is an alternative treatment for those who refuse surgery, or those who are not candidates for surgery. [ 3 ]  Medications may be used to treat ORS and include GnRH agonists, danazol, or progesterone. [ 4 ]


The incidence of ovarian remnant syndrome is difficult to determine. [ 3 ] [ 4 ]  The available  data  are limited to case reports or to retrospective case series. The best available data are from a study describing the frequency and outcome of laparoscopy in women with chronic pelvic pain and/or a pelvic mass who were found to have ovarian remnants. In 119 women who underwent  hysterectomy  and oophorectomy by  laparoscopy , ovarian remnants were known in 5 and were found during surgery in 21 patients (18%).[2] However, this was a small study and the participants were only symptomatic women. Therefore, it is not known whether the data can be extrapolated to include all women who have undergone oophorectomy. [ 3 ]


Ovarian reserve  is a term that is used to determine the capacity of the  ovary  to provide  egg cells  that are capable of  fertilization  resulting in a healthy and successful  pregnancy . With  advanced maternal age , the number of egg cell that can be successfully recruited for a possible pregnancy declines, constituting a major factor in the inverse correlation between  age and female fertility .


While there is no known method for assessing the ovarian reserve of individual women, [ 1 ]  indirect determination of ovarian reserve is important in the treatment of  infertility . [ 2 ]


The ovary is generally thought of as an egg bank from which the woman draws during her reproductive life. The human ovary contains a population of  primordial follicles . At 18–22 weeks post-conception, the female  ovary  contains its peak number of follicles (about 300,000 in the average case, but individual peak populations range from 35,000 to 2.5 million [ 3 ] ).
p
The size of the initial ovarian reserve is strongly influenced by  genetics . [ 4 ]  Also, elevated  androgen  levels during  prenatal development  have an adverse effect on the early establishment of the ovarian reserve. [ 4 ]


The mitosis starts the 3rd week of embryo intrauterine life and between the 5th and 7th week, there are already about 10.000 oogonias. However, the ovarian reserve is at maximum value in sixth month old embryos. Then this amount is only decreasing, as there is no new synthesis and differentiation. There is a huge decrease before the child is born, being this pool reduced from over 8 million potential oocytes to 2 million. The amount continues decreasing progressively until reaching the age of 30 years old, in which there is a dramatic decrease.


There are about 1 to 2 million oocytes when a woman is born. From them, 400000 oocytes will reach the stage of puberty and only 400 will rise maturation and ovulation. The rest of them reach  atresia , a natural apoptotic process leading to the breakdown of the follicle.


Each  menstrual cycle  one egg cell is released by ovulation. In addition, the remaining follicles that were recruited towards maturation are lost by  atresia . Few if any egg cells are replenished during the reproductive years. However, this loss by the  menstrual cycle  only accounts for approximately up to 10 egg cells per month, thus accounting for only a small fraction of the actual loss of egg cells throughout the lifetime.


One additional contributory mechanism for the decline in the ovarian reserve with age appears to be a decreased  gene expression  of proteins involved in  DNA repair  by  homologous recombination  such as  BRCA1 ,  MRE11 ,  Rad51  and  ATM . [ 5 ]   Homologous recombinational  repair of DNA double-strand breaks mediated by  BRCA1  and  ATM  weakens with age in  oocytes  of humans and other species. [ 6 ]   Women with BRCA1  mutations  have lower ovarian reserves and experience earlier  menopause  than women without these mutations. [ 6 ]


Women who are 35 years or older who have attempted to get pregnant unsuccessfully for 6 months should undergo testing for ovarian reserve. The most commonly used test to assess this ovarian reserve is the  day 3 FSH test . [ 7 ]  This blood test determines the level of  FSH  on cycle day 3. Cycle day 3 is chosen because at this time the  estrogen  level is expected to be low, a critical feature, as FSH levels are subject to a  negative feedback .
Thus any determination of FSH needs to include the corresponding  estradiol  level to indicate that the FSH level was drawn when the estrogen level was low. In a patient with infrequent menstruation, an FSH level and estrogen level could be measured at random and is valid if the estrogen level is low. Generally FSH levels are expected to be below 10  miu /ml in women with reproductive potential (levels of 10-15 miu/ml are considered borderline), however the exact numbers returned will depend on the type of assay used in a particular laboratory.


Although FSH and more recently Inhibin B have been shown to have some correlation with ovarian reserve, it is now well established that anti-Müllerian Hormone or AMH is more useful biochemical test. [ citation needed ]  AMH appears to play a role not only in the selection of the primary follicle but also in the overall process of recruiting preantral follicles. Around fifteen years before menopause, a gradual decrease in AMH levels follows a logarithmic pattern. This decline continues until about five years before menopause, at which point AMH levels reach a notably low point. However, for people with increased AMH due to PCOS that has been adequately managed with diet, exercise, and/or bariatric surgery, fertility improves even when AMH returns to normal levels. [ 8 ]
In particular, an AMH level between 7.14-25 pmol/L indicates a normal ovarian response. In contrast, an AMH level of less than 7.14 pmol/L and an AMH level greater than 25 pmol/L indicate a low ovarian response and a high ovarian response, respectively. High levels however can be present in women with Polycystic Ovarian Syndrome which compromises female fertility and therefore a combination of AMH and a transvaginal ultrasound to count the number of antral follicles is probably the best way to assess ovarian reserve and future fertility. This combination is sometimes referred to as the Biological Body Clock Test. [ citation needed ]


A  clomiphene  challenge test is a variation on this approach. [ 9 ]


Another approach is to examine the ovaries by  gynecologic ultrasonography  and to determine their size as ovaries depleted of egg cells tend to be smaller [ 10 ]  and to examine the number of antral follicles visible by sonography. [ 11 ]


Women with poor ovarian reserve are unlikely to conceive with infertility therapy. Also see  poor ovarian reserve  and  Follicle-stimulating hormone  for treatment options.


The  ovary  (from  Latin    ōvārium  'egg') is a  gonad  in the female  reproductive system  that produces  ova ; [ 1 ]  when released, an ovum travels through the  fallopian tube / oviduct  into the  uterus . There is an ovary on the left and the right side of the body. The ovaries are  endocrine glands , secreting various  hormones  that play a role in the  menstrual cycle  and  fertility . The ovary progresses through many stages beginning in the  prenatal period  through  menopause . [ 2 ]


Each ovary is whitish in color and located alongside the lateral wall of the  uterus  in a region called the  ovarian fossa . The ovarian fossa is the region that is bounded by the  external iliac artery  and in front of the  ureter  and the  internal iliac artery . This area is about 4 cm x 3 cm x 2 cm in size. [ 3 ] [ 4 ]


The ovaries are surrounded by a capsule, and have an outer cortex and an inner medulla. [ 4 ]  The capsule is of dense connective tissue and is known as the  tunica albuginea . [ 5 ]


Usually, ovulation occurs in one of the two ovaries releasing an egg each  menstrual cycle .


The side of the ovary closest to the  fallopian tube  is connected to it by  infundibulopelvic ligament , [ 3 ]  and the other side points downwards attached to the uterus via the  ovarian ligament .


Other structures and tissues of the ovaries include the  hilum .


The ovaries lie within the peritoneal cavity, on either side of the uterus, to which they are attached via a fibrous cord called the  ovarian ligament . The ovaries are uncovered in the  peritoneal cavity  but are tethered to the body wall via the  suspensory ligament of the ovary , which is a posterior extension of the broad ligament of the uterus. The part of the  broad ligament of the uterus  that covers the ovary is known as the  mesovarium . [ 4 ]


The ovarian pedicle is made up part of the  fallopian tube ,  mesovarium , ovarian ligament, and ovarian blood vessels. [ 6 ]


The surface of the ovaries is covered with a membrane consisting of  a lining of   simple cuboidal -to-columnar shaped  mesothelium , [ 7 ]  called the  germinal epithelium .


The outer layer is the  ovarian cortex , consisting of  ovarian follicles  and  stroma  in between them. Included in the follicles are the  cumulus oophorus ,  membrana granulosa  (and the  granulosa cells  inside it),  corona radiata ,  zona pellucida , and  primary oocyte .  Theca of follicle ,  antrum  and  liquor folliculi  are also contained in the follicle. Also in the cortex is the  corpus luteum  derived from the follicles. The innermost layer is the  ovarian medulla . [ 8 ]  It can be hard to distinguish between the cortex and medulla, but follicles are usually not found in the medulla.


Follicular cells  are flat epithelial cells that originate from surface epithelium covering the ovary. They are surrounded by  granulosa cells  that have changed from flat to cuboidal and proliferated to produce a stratified epithelium.


The ovary also contains  blood vessels  and  lymphatics . [ 9 ]


At  puberty , the ovary begins to secrete increasing levels of hormones. Secondary sex characteristics begin to develop in response to the hormones. The ovary changes structure and function beginning at puberty. [ 2 ]  Since the ovaries are able to regulate hormones, they also play an important role in pregnancy and  fertility . When egg cells (oocytes) are released from the fallopian tube, a variety of feedback mechanisms stimulate the endocrine system, which cause hormone levels to change. [ 10 ]  These feedback mechanisms are controlled by the hypothalamus and pituitary glands. Messages or signals from the hypothalamus are sent to the pituitary gland. In turn, the pituitary gland releases hormones to the ovaries. From this signaling, the ovaries release their own hormones.


The ovaries are the site of production and periodical release of  egg cells , the female gametes. In the ovaries, the developing egg cells (or  oocytes ) mature in the fluid-filled  follicles . Typically, only one oocyte develops at a time, but others can also mature simultaneously. Follicles are composed of different types and number of cells according to the stage of  their maturation , and their size is indicative of the stage of oocyte development. [ 11 ] : 833


When an oocyte completes its maturation in the ovary, a surge of  luteinizing hormone  is secreted by the  pituitary gland , which stimulates the release of the oocyte through the rupture of the follicle, a process called  ovulation . [ 12 ]  The follicle remains functional and reorganizes into a  corpus luteum , which secretes  progesterone  in order to prepare the  uterus  for an eventual  implantation  of the embryo. [ 11 ] : 839


At maturity, ovaries secrete  estrogen ,  androgen , [ 13 ] [ 14 ]   inhibin , and  progestogen . [ 15 ] [ 16 ] [ 2 ]  In women before menopause, 50% of testosterone is produced by the ovaries and released directly into the blood stream. The other 50% of testosterone in the blood stream is made from conversion of the adrenal pre-androgens ( DHEA and androstenedione) to testosterone in other parts of the body. Estrogen is responsible for the appearance of  secondary sex characteristics  for females at  puberty  and for the maturation and maintenance of the  reproductive organs  in their mature functional state. Progesterone prepares the uterus for pregnancy, and the mammary glands for lactation. Progesterone functions with estrogen by promoting  menstrual cycle  changes in the  endometrium . [ medical citation needed ]


As women age, they experience a decline in reproductive performance leading to  menopause .  This decline is tied to a decline in the number of ovarian follicles. Although about 1 million oocytes are present at birth in the human ovary, only about 500 (about 0.05%) of these ovulate, and the rest do not ovulate.  The decline in ovarian reserve appears to occur at a constantly increasing rate with age, [ 17 ]  and leads to nearly complete exhaustion of the reserve by about age 52.  As ovarian reserve and fertility decline with age, there is also a parallel increase in pregnancy failure and meiotic errors resulting in chromosomally abnormal conceptions. The ovarian reserve and fertility perform optimally around 20–30 years of age. [ 18 ]  Around 45 years of age, the menstrual cycle begins to change and the follicle pool decreases significantly. [ 18 ]   The events that lead to ovarian aging remain unclear. The variability of aging could include environmental factors, lifestyle habits or genetic factors. [ 18 ]


Women with an inherited mutation in the DNA repair gene BRCA1 undergo menopause prematurely, [ 19 ]  suggesting that naturally occurring DNA damages in oocytes are repaired less efficiently in these women, and this inefficiency leads to early reproductive failure.  The BRCA1 protein plays a key role in a type of DNA repair termed homologous recombinational repair that is the only known cellular process that can accurately repair DNA double-strand breaks. Titus et al. [ 20 ]  showed that DNA double-strand breaks accumulate with age in humans and mice in primordial follicles.  Primordial follicles contain oocytes that are at an intermediate (prophase I) stage of meiosis.  Meiosis is the general process in eukaryotic organisms by which germ cells are formed, and it is likely an adaptation for removing DNA damages, especially double-strand breaks, from germ line DNA (see  Meiosis  and  Origin and function of meiosis ). [ 21 ]  Homologous recombinational repair is especially promoted during meiosis.  Titus et al. [ 20 ]  also found that expression of 4 key genes necessary for homologous recombinational repair of DNA double-strand breaks (BRCA1, MRE11, RAD51 and ATM) decline with age in the oocytes of humans and mice.  They hypothesized that DNA double-strand break repair is vital for the maintenance of oocyte reserve and that a decline in efficiency of repair with age plays a key role in ovarian aging. A study identified 290 genetic determinants of ovarian ageing, also found that  DNA damage  response processes are implicated and suggests that possible effects of extending fertility in women would improve bone health, reduce risk of type 2 diabetes and increase the risk of hormone-sensitive cancers. [ 22 ] [ 23 ]


A variety of testing methods can be used in order to determine fertility based on maternal age. Many of these tests measure levels of hormones FSH, and GnrH. Methods such as measuring AMH ( anti-Müllerian hormone ) levels, and AFC (antral follicule count) can predict ovarian aging. AMH levels serve as an indicator of ovarian aging since the quality of ovarian follicles can be determined. [ 24 ]


Ovarian diseases  can be classified as  endocrine disorders  or as a disorders of the  reproductive system . [ medical citation needed ]


If the egg fails to release from the follicle in the ovary an  ovarian cyst  may form. Small ovarian cysts are common in healthy women. Some women have more follicles than usual ( polycystic ovary syndrome ), which inhibits the follicles to grow normally and this will cause cycle irregularities.


the ovaries.


Cryopreservation  of ovarian tissue, often called  ovarian tissue cryopreservation , is of interest to women who want to preserve their reproductive function beyond the natural limit, or whose reproductive potential is threatened by cancer therapy, [ 48 ]  for example in hematologic malignancies or breast cancer. [ 49 ]  The procedure is to take a part of the ovary and carry out slow freezing before storing it in liquid nitrogen whilst therapy is undertaken. Tissue can then be thawed and implanted near the fallopian, either orthotopic (on the natural location) or heterotopic (on the abdominal wall), [ 49 ]  where it starts to produce new eggs, allowing normal conception to take place. [ 50 ]  A study of 60 procedures concluded that ovarian tissue harvesting appears to be safe. [ 49 ]  The ovarian tissue may also be transplanted into mice that are immunocompromised ( SCID mice ) to avoid  graft rejection , and tissue can be harvested later when mature follicles have developed. [ 51 ]


In former centuries, medical authors, for example  Galen , referred to a woman's ovaries as "female testes".


Birds have only one functional ovary (the left), while the other remains vestigial. In mammals including humans, the female ovary is  homologous  to the male  testicle , in that they are both  gonads  and  endocrine glands . Ovaries of some kind are found in the female reproductive system of many invertebrates  that employ  sexual reproduction . However, they develop in a very different way in most invertebrates than they do in vertebrates, and are not truly homologous. [ 52 ]


Many of the features found in human ovaries are common to all vertebrates, including the presence of follicular cells, tunica albuginea, and so on. However, many species produce a far greater number of eggs during their lifetime than do humans, so that,  in fish  and amphibians, there may be hundreds, or even millions of fertile eggs present in the ovary at any given time. In these species, fresh eggs may be developing from the germinal epithelium throughout life. Corpora lutea are found only in mammals, and in some  elasmobranch  fish; in other species, the remnants of the follicle are quickly resorbed by the ovary. In birds, reptiles, and  monotremes , the egg is relatively large, filling the follicle, and distorting the shape of the ovary at maturity. [ 52 ]


Amphibians and reptiles have no ovarian medulla; the central part of the ovary is a hollow,  lymph -filled space. [ 53 ]


The ovary of  teleosts  is also often hollow, but in this case, the eggs are shed into the cavity, which opens into the  oviduct . [ 52 ]  Certain  nematodes  of the genus  Philometra  are parasitic in the ovary of marine fishes and can be spectacular, with females as long as 40 cm (16 in), coiled in the ovary of a fish half this length. [ 54 ]  Although most female vertebrates have two ovaries, this is not the case in all species. In most birds and in  platypuses , the right ovary never matures, so that only the left is functional. (Exceptions include the  kiwi  and some, but not all  raptors , in which both ovaries persist. [ 55 ] [ 56 ] )  In some elasmobranchs, only the right ovary develops fully. In the primitive  jawless fish , and some teleosts, there is only one ovary, formed by the fusion of the paired organs in the embryo. [ 52 ]


Pediatric gynaecology  or  pediatric gynecology [ 1 ]  is the medical practice dealing with the health of the  vagina ,  vulva ,  uterus , and  ovaries  of infants, children, and adolescents. Its counterpart is  pediatric andrology , which deals with medical issues specific to the  penis  and  testes .


The word "gynaecology" comes from the Greek γυνή  gyne . "woman" and  -logia , "study."


Assessment of the external genitalia and  breast development  are often part of routine physical examinations. Physicians also can advise pediatric gynecology patients on anatomy and sexuality.  Assessment can include an examination of the vulva, and rarely involve the introduction of instruments into the vagina. Many young patients prefer to have a parent, usually a mother, in the examination room. Two main positions for examination can be used, depending on the patient's preference and the specific examination being performed, including the frog-leg position (with the head of the examination table raised or lowered), the  lithotomy position  with stirrups, or either of these with a parent holding the child. A hand mirror can be provided to allow the child to participate and to educate the child about their anatomy.  Anesthesia  or  sedation  should only be used when the examination is being performed in an emergency situation; otherwise it is recommended that the clinician see a reluctant child with a gynecologic complaint over several visits to foster trust. [ 2 ]


Examination of the external genitalia should be done by gently moving the labia minora to either side, or gently moving them towards the anterior (front) side of the body to expose the vaginal introitus. [ 2 ]  Routine physical examinations by a pediatrician typically include a visual examination of breasts and vulva; more extensive examinations may be performed by a pediatrician in response to a specific complaint. Rarely, an internal examination may be necessary, and may need to be conducted under anesthesia. Cases where an internal examination may be necessary include vaginal bleeding, retained foreign bodies, and potential tumors. [ 3 ]


There are a number of common pediatric gynecologic conditions and complaints, both pathological and benign.


A pediatric gynecologist can care for children with a number of  intersex  conditions, including  Swyer syndrome  (46,XY  karyotype ). [ 2 ]


Amenorrhea, the lack of a  menstrual period , may indicate a congenital anomaly of the reproductive tract. Typically obvious on an external visual examination of a child's vulva,  imperforate hymen  is the presence of a  hymen  that completely covers the introitus. Other anomalies that can cause amenorrhea include  Müllerian agenesis  affecting the uterus, cervix, and/or vagina;  obstructed uterine horn ;  OHVIRA syndrome ; and the presence of a transverse  vaginal septum . OHVIRA and uterine horn obstruction can also cause increasingly painful menstruation ( dysmenorrhea ) in the months following  menarche . [ 3 ]


Vaginal bleeding not associated with menarche may be cause for concern in a child. In the first few days of life, some amount of vaginal bleeding is normal, prompted by the drop in transplacental hormones. Causes of vaginal bleeding in children include trauma, condyloma acuminata, lichen sclerosus, vulvovaginitis, tumors, urethral prolapse, precocious puberty, exogenous hormone exposure, and retained foreign body. Most causes can be diagnosed with a visual examination of the vulva and a careful medical history, but some may require vaginoscopy or a speculum exam. [ 3 ]


Vulvovaginitis in children may be "nonspecific", or caused by irritation with no known infectious cause, or infectious, caused by a pathogenic organism. Nonspecific vulvovaginitis may be triggered by fecal contamination, sexual abuse, chronic diseases,  foreign bodies , nonestrogenized epithelium, chemical irritants,  eczema ,  seborrhea , or immunodeficiency. It is treated with topical steroids; antibiotics may be given in cases where itching has resulted in a secondary infection. [ 3 ]


Infectious vulvovaginitis can be caused by  group A beta-hemolytic  Streptococcus  (7–20% of cases),  Haemophilus influenzae ,  Streptococcus pneumoniae ,  Staphylococcus aureus ,  Shigella ,  Yersinia , or common STI organisms ( Neisseria gonorrhoeae ,  Chlamydia trachomatis ,  Trichomonas vaginalis ,  herpes simplex virus , and  human papillomavirus ) .  Symptoms and treatment of infectious vulvovaginitis vary depending on the organism causing it.  Shigella  infections of the reproductive tract usually coexist with infectious of the gastrointestinal tract and cause mucous, purulent discharge. They are treated with  trimethoprim-sulfamethoxazole .  Streptococcus  infections cause similar symptoms to nonspecific vulvovaginitis and are treated with  amoxicillin . STI-associated vulvovaginitis may be caused by sexual abuse or  vertical transmission , and are treated and diagnosed like adult infections. [ 3 ]


Vulvitis, inflammation of the vulva, can have a variety of etiologies in children and adolescents, including  allergic dermatitis ,  contact dermatitis ,  lichen sclerosus , and infections with bacteria, fungi, and parasites. Dermatitis in infants is commonly caused by a soiled diaper being left on for an extended period of time. Increasing the frequency of diaper changes and topical application of  emollients  are sufficient to resolve most cases. Dermatitis of the vulva in older children is usually caused by exposure to an irritant (e.g. scented products that come into contact with the vulva, laundry detergent, soaps, etc.) and is treated with preventing exposure and encouraging  sitz baths  with  baking soda  as the vulvar skin heals. Other treatment options for vulvar dermatitis include oral  hydroxyzine hydrochloride  or topical  hydrocortisone . [ 3 ]


Lichen sclerosus is another common cause of vulvitis in children, and it often affects an hourglass or figure eight-shaped area of skin around the anus and vulva. Symptoms of a mild case include skin fissures, loss of skin pigment ( hypopigmentation ), skin atrophy, a parchment-like texture to the skin, dysuria, itching, discomfort, and excoriation. In more severe cases, the vulva may become discolored, developing dark purple bruising ( ecchymosis ), bleeding, scarring, attenuation of the labia minora, and fissures and bleeding affecting the posterior  fourchette . Its cause is unknown, but likely genetic or autoimmune, and it is unconnected to malignancy in children. If the skin changes are not obvious on visual inspection, a biopsy of the skin may be performed to acquire an exact diagnosis. Treatment for vulvar lichen sclerosis may consist of  topical hydrocortisone  in mild cases, or stronger topical steroids (e.g.  clobetasol propionate ). Preliminary studies show that 75% of cases do not resolve with puberty. [ 3 ]


Organisms responsible for vulvitis in children include pinworms ( Enterobius vermicularis ),  Candida  yeast, and  group A hemolytic  Streptococcus . Though pinworms mainly affect the perianal area, they can cause itching and irritation to the vulva as well. Pinworms are treated with  albendazole . Vulvar  Candida   infections  are uncommon in children, and generally occur in infants after antibiotic therapy, and in children with  diabetes  or  immunodeficiency .  Candida  infections cause a red raised vulvar rash with satellite lesions and clear borders, and are diagnosed by microscopically examining a sample treated with potassium hydroxide for hyphae. They are treated with topical  butoconazole ,  clotrimazole , or  miconazole .  Streptococcus  infections are characterized by a dark red discoloration of the vulva and introitus, and cause pain, itching, bleeding, and dysuria. They are treated with antibiotics. [ 3 ]


An abnormal mass in a child's developing breast or early development of breast tissue may prompt concern. Neonates can have small breast buds at birth or white discharge (witches' milk), caused by exposure to transplacental hormones in utero. These phenomena are not pathological and typically disappear over the first weeks to months of life. Accessory nipples ( polythelia ) occur in 1% of children along the  embryonic milk line  and are benign in most cases. They may be removed surgically if they develop glandular tissue and cause pain, have discharge, or develop fibroadenomas. [ 3 ]


Some asymmetric breast growth is normal in early adolescence, but asymmetry may be caused by trauma,  fibroadenoma , or cysts. Most non-pathological asymmetry resolves spontaneously by the end of puberty; if it does not, surgical intervention is possible. Some adolescents may develop tuberous breasts, wherein the normal fat and glandular tissue grows directly away from the chest due to the adherence of breast fascia to the underlying muscle.  Hormone replacement therapy  or  oral contraceptives  are used to encourage outward growth of the breast base.  Hypertrophy of breast tissue  may or may not be a problem for an individual adolescent; back pain,  kyphosis , shoulder pain, and psychologic distress may be cause for  breast reduction surgery  after development is complete. On the opposite end of the spectrum, breast tissue may not develop for a variety of reasons. The most common cause is low levels of estrogen ( hypoestrogenism ), which may result from chronic disease, radiation or chemotherapy,  Poland syndrome , extreme physical activity, or  gonadal dysgenesis .  Amastia , which occurs when a child is born without glandular breast tissue, is rare. [ 3 ]


More than 99% of breast masses in children and adolescents are benign, and include fibrocystic breast changes, cysts, fibroadenomas, lymph nodes, and abscesses. Fibroadenomas make up 68–94% of all pediatric breast masses, and can be simply observed to ensure their stability, or excised if they are symptomatic, large, and/or enlarging. [ 3 ]


Mastitis, infection of the breast tissue, occurs most commonly in neonates and children over 10, though it is rare overall in children. Most often caused by  S. aureus , mastitis in children is caused by a variety of factors, including trauma, nipple piercing, lactation and/or pregnancy, or shaving periareolar hair. The development of abscesses from mastitis is more common in children than in adults. [ 3 ]


Precocious puberty occurs when children younger than 8 experience changes indicative of  puberty , including development of  breast buds  (thelarche),  pubic hair , and a  growth spurt . Thelarche before 8 is considered abnormal. Though not all precocious puberty has a specific pathological cause, it may indicate a serious medical problem and is thoroughly evaluated. In most cases, the cause of precocious puberty cannot be identified. " Central precocious puberty " or "true precocious puberty" stems from early activation of the  hypothalamic-pituitary-ovarian axis . It occurs in 1 in 5,000 to 1 in 10,000 people and can be caused by a lesion in the central nervous system or  have no apparent cause . "Peripheral precocious puberty" or "GnRH independent precocious puberty" does not involve the hypothalamic-pituitary-ovarian axis, instead, it involves other sources of hormones. The causes of peripheral precocious puberty include adrenal or ovarian tumors, congenital adrenal hyperplasia, and exogenous hormone exposure. [ 3 ]


Premature development of breast tissue is not necessarily indicative of precocious puberty; if it occurs without a corresponding growth spurt and with normal bone age, it does not represent pubertal development. It is associated with low birthweight and slightly elevated estradiol. Most premature breast development regresses spontaneously, and monitoring for other signs of precocious puberty is usually the only necessary management. [ 3 ]


Labial adhesion is a fusion between the labia minora that may be small and posterior – and generally asymptomatic – or may involve the entire labia and seal off the vaginal introitus entirely. It is generally only treated when it causes urinary symptoms; otherwise it normally resolves when the vaginal mucosa becomes estrogenized at the onset of puberty. Treatments include topical application of estrogens or  betamethasone  with gentle traction on the labia, followed with  vitamin A ,  vitamin D , and/or  petroleum jelly  to prevent re-adhesion. The labia may be separated manually with  local anesthesia  or surgically under  general anesthesia  (in a procedure called  introitoplasty ) if topical treatment is unsuccessful. This is followed with estrogen treatment to prevent recurrence. [ 3 ]


Ovarian masses in children are typically cystic, but 1% are malignant ovarian cancers. 30–70% of neonates with ovaries have cysts; they are caused by transplacental hormones  in utero  or by the postnatal spike in  gonadotropins . Neonatal ovarian cysts usually affect one ovary, do not cause symptoms, are classed as simple, and disappear by the age of 4 months. In rare cases, neonatal ovarian cysts may result in  ovarian torsion ,  autoamputation  of the ovary,  intracystic hemorrhage ,  rupture , and compression of surrounding organs. Cysts smaller than 5 centimeters in diameter may be monitored with ultrasonography; larger cysts are more likely to cause complications are either drained by percutaneous aspiration or surgically removed. [ 3 ]


In older children, cystic ovarian masses may cause a visible change in body shape, chronic pain, and precocious puberty; complications with these cysts cause acute, severe abdominal pain.  Transabdominal ultrasonography  can be used to diagnose and image pediatric ovarian cysts, because transvaginal probes are not recommended for use in children. Complex cysts are likely to be  benign mature cystic teratoma , whereas the most common malignancies in this age group are malignant germ cell tumors and  epithelial ovarian cancer . [ 3 ]


Common pediatric gynecologic complaints include  vaginal discharge , pre- menarche  bleeding,  itching , and accounts of  sexual abuse . [ 2 ]


A mass in the inguinal area may be a  hernia  or may be a testis in an intersex child. [ 2 ]


The  vaginal mucosa  in prepubertal children is markedly different from that of postpubertal adolescents; it is thin and red colored. [ 2 ]


In neonates, the uterus is spade-shaped, contains fluid 25% of the time, and often has a visible  endometrial stripe . This is normal and due to the hormones that have passed to the neonate across the  placenta . The shape of the uterus is influenced by the anteroposterior diameter of the  cervix , which is larger than the  fundus  at this age. By premenarchal age, the uterus is tubular, because the fundus and the cervix are the same diameter. The  ovaries  are small in neonates and grow throughout childhood to a volume of 2–4 cubic centimeters. On  vaginoscopy , the prepubertal cervix is usually level with the proximal vagina. [ 3 ]


During puberty, the vaginal mucosa becomes  estrogenized  and becomes a dull pink color and gains moisture. [ 2 ]   Secondary sex characteristics  develop under the influence of estrogen on the  hypothalamic-pituitary-gonadal axis , typically between the ages of 8 and 13. These characteristics include breast buds, pubic hair, and accelerated growth. Higher body mass index is correlated with earlier puberty. [ 3 ]


Pelvic compression syndrome  is characterized by intermittent or persisting pain in the  abdomen , which is  exacerbated  by abdominal pressure. A swelling of the  veins  in the valveless  pampiniform plexus  causes it.


While  varicocele  is the diagnostic term for swelling in the valveless venous distribution of the male  pampiniform plexus , this  embryological  structure, common to males and females, is often incidentally noted to be swollen during  laparoscopic  examinations in both  symptomatic  and  asymptomatic  females. [ 1 ]  Diagnosis of female varicocele, properly called pelvic compression syndrome, should be expected to be as frequent as male varicocele (15% of healthy asymptomatic men, which are thought to develop primarily during puberty and prevalence increases approximately 10% per decade of life  [ 2 ] ).


While one may expect the female to have an equal  prevalence  of pelvic compression syndrome due to the identical  embryological  origin of the valveless  pampiniform plexus , this condition is thought to be underdiagnosed due to the broad differential of the pain pattern:  unilateral or bilateral  pain, dull to sharp, constant to intermittent pain worsening with any increase in  abdominal pressure . [ 3 ]


Physical exam has a specificity of 77% and sensitivity of nearly 94% when the patient is noted to be tender over  adnexa  during physical examination with a history of postcoital pain for differentiating  pelvic congestion syndrome  from other  pathologies  of pelvic origin. [ 4 ]


Confirmatory imaging requires  ultrasound  while performing a  Valsalva maneuver , while the gold standard remains  ovarian  and iliac  catheter   venography  showing veins 5-10mm in diameter during the Valsalva maneuver.


Complete resolution of symptoms after  menopause  indicates the influence of hormones on  pelvic congestion syndrome .  Estrogen  is a venous dilator and can thus produce the venous dilation implicated in the  pathophysiology  of the PCS. [ 3 ]


Pelvic massage  was a  gynecological  treatment first recorded as being used by doctors in the 19th century. An early practitioner was the  Swedish  Major  Thure Brandt  (1819–1895), whose method was described in the  New York Medical Journal [ 1 ]  and the  Journal of the American Medical Association . [ 2 ]


Brandt had been developing his method since the 1860s, and after having a breakthrough in 1886, the method was disseminated in the  Baltic Sea  region,  Germany , and to the world, including to the  United States . [ 3 ]


The method was based upon an old holistic theory of women's  physiology : the  uterus  was seen as a hub of network of nerves in the female body from which illness was disseminated throughout the body, especially if the  uterus was somehow displaced . The pelvic massage restored the uterus to its proper place and thus the typical women's complaints, like headaches, backaches, fatigue, depression and such, were cured. [ 4 ]
The doctor or therapist put his or her finger in the  vagina  of the patient and simultaneously massaged the uterus from the outside with the other hand. [ 5 ]  Sometimes the massage was actually carried out by a female assistant of the male physician or physiotherapist, but her participation in the process was usually not mentioned in medical writings and the male practitioner was cited as the sole expert on the method instead. [ 6 ]


Contrary to what  Rachel Maines  claimed in her book  The Technology of Orgasm , [ 7 ]  many practitioners of this massage were aware of the possibility of a sexual stimulation during the procedure and, like the Finnish physician Georg Asp (1834–1901), [ 8 ]  made it clear that the sexual excitation shall be circumvented and the  clitoris  studiously avoided. [ 9 ]


The pelvic massage disappeared from gynecology during the 1920s. [ 10 ]  One important reason to that was the influence of early  psychoanalysis : the locus of women's pathological issues was moved from the uterus to the neurotic brain, and they were now seen as psychological, not physiological ailments. [ 11 ]


The  Pelvic Organ Prolapse Quantifications System  ( POP-Q ) is a system for assessing the degree of  prolapse  of pelvic organs to help standardize diagnosing, comparing, documenting, and sharing of clinical findings. [ 1 ] [ 2 ]  This assessment is the most frequently used [ 3 ] [ 4 ]  among research publications related to  pelvic organ prolapse . [ 4 ]


When assessed using the POP-Q, the prevalence of pelvic organ prolapse is estimated to be up to 50% while diagnosis by symptoms has a prevalence of 3–6%. [ 2 ]  Some advocate that the system of assessment be modified. [ 5 ]


The POP-Q was developed in 1996, it quantifies the descent of pelvic organs into the  vagina . [ 3 ] [ 6 ] [ 2 ]  The POP-Q provides reliable description of the support of the anterior, posterior and apical vaginal wall. It uses objective and precise distance measurements to the reference point, the  hymen .  Cystocele  and prolapse of the vagina from other causes is staged using POP-Q criteria and can range from good support (no descent into the vagina) reported as a POP-Q stage 0 or I to a POP-Q score of IV, which includes prolapse beyond the hymen. It also used to quantify the movement of other structures into the vaginal  lumen  and their descent. [ 6 ] [ 2 ]


The POP-Q assessment tool measures nine points in the vagina. The hymen is the reference point to which the other points are compared. The prolapsed organs are measured in centimeters to the hymen. The measurements are taken when the  Valsalva maneuver  is performed while The woman is in the dorsal lithotomy position. [ 7 ] [ 3 ]  The anatomical landmarks used are anterior vaginal wall,  cervix , hymen,  perineal body , total vaginal length, posterior vaginal wall and  posterior fornix . [ 8 ]  A three-by-three centimeter grid is used to record the proximal and distal numbers. The information on the grid is translated to the appropriate stage of prolapse. [ 3 ]


This system of assessing pelvic organ prolapse is China's most commonly used grading system. [ 9 ]


Other assessment tools are abailable to determine the impact of pelvic floor prolapse. These are Pelvic Floor Impact Questionnaire (PFIQ), The Pelvic Floor Distress Inventory (PFDI) and the shorter forms PFIQ-7 and PFDI-20. [ 7 ]


The evaluation of pelvic organ prolapse includes other diagnostic tests in addition to the POP-Q. These can be: [ 3 ]


In the US, greater than 200,000 surgeries are performed each year for pelvic organ prolapse. Examples of pelvic organ prolapse are  cystocele ,  rectocele ,  urethrocele ,  enterocele  and  sigmoidocele . Cystocele is the most common. [ 10 ] [ 2 ]


The Porges or Severity prolapse assessment system was proposed in 1963. [ 11 ]  In 1972,  the Baden–Walker Halfway Scoring System  was developed and is the second most used system. [ 11 ] [ 1 ]  In 1980, the Beecham system was developed. The POP was developed in 1996. [ 11 ]


Pelvic pain  is  pain  in the area of the  pelvis .  Acute pain  is more common than  chronic pain . [ 2 ]  If the pain lasts for more than six months, it is deemed to be chronic pelvic pain. [ 3 ] [ 4 ]  It can affect both the male and female pelvis.


Common causes in include:  endometriosis  in women,  bowel adhesions ,  irritable bowel syndrome , and  interstitial cystitis . [ 5 ] [ 6 ]   The cause may also be a number of poorly understood conditions that may represent abnormal psychoneuromuscular function.


The role of the nervous system in the genesis and moderation of pain is explored. [ 7 ]  The importance of psychological factors is discussed, both as a primary cause of pain and as a factor which affects the pain experience. As with other chronic syndromes, the biopsychosocial model offers a way of integrating physical causes of pain with psychological and social factors. [ 8 ]


Pelvic pain is a general term that may have many causes, listed below.


The subcategorical term  urologic chronic pelvic pain syndrome  (UCPPS)  is an umbrella term adopted for use in research into  urologic  pain syndromes associated with the male and female pelvis. [ 9 ]  UCPPS specifically refers to  chronic prostatitis/chronic pelvic pain syndrome  (CP/CPPS) in men and  interstitial cystitis  or painful bladder syndrome (IC/PBS) in women. [ 10 ]


Genital  pain  and pelvic pain can arise from a variety of conditions, crimes,  trauma , medical treatments, physical diseases,  mental illness  and infections.


Many different conditions can cause female pelvic pain including:


The absence of visible pathology in chronic pain syndromes should not form the basis for either seeking psychological explanations or questioning the reality of the patient’s pain. [ 14 ]  Instead it is essential to approach the complexity of chronic pain from a psychophysiological perspective which recognises the importance of the mind-body interaction. Some of the mechanisms by which the  limbic system  impacts on pain, and in particular myofascial pain, have been clarified by research findings in neurology and psychophysiology. [ 15 ]


In chronic pelvic pain, there are no standard diagnostic tests in males; diagnosis is by exclusion of other disease entities. [ 16 ]


Nerve blocks aimed at the  pudendal nerve ,  superior hypogastric plexus  and  ganglion of impar  have shown to be effective for treating certain types of pelvic pain that do not respond to conservative treatment. [ 17 ]


Neuromodulation has been explored as a potential treatment option for some time.  Traditional spinal cord stimulation, also known as dorsal column stimulation has been inconsistent in treating pelvic pain:  there is a high failure rate with these traditional systems due to the inability to affect all of the painful areas and there remains to be consensus on where the optimal location of the spinal cord this treatment should be aimed. [ 18 ]   As the innervation of the pelvic region is from the sacral nerve roots, previous treatments have been aimed at this region; however pain pathways seem to elude treatment solely directed at the level of the spinal cord (perhaps via the sympathetic nervous system) [ 19 ]  leading to failures. Spinal cord stimulation aimed at the mid- to high-thoracic region of the spinal cord have produced some positive results. [ 20 ]   A newer form of spinal cord stimulation called dorsal root ganglion stimulation (DRG) has shown a great deal of promise for treating pelvic pain due to its ability to affect multiple parts of the nervous system simultaneously - it is particularly effective in patients with "known cause" (i.e. post surgical pain, endometriosis, pudendal neuralgia, etc.). [ 21 ] [ 22 ]


There are a number of "alternative" therapies that have been offered for pelvic pain based on the notion that they are "non-invasive" however they are not supported by evidenced-based medicine.   Diazepam  ( Valium ) suppositories are an older therapy that was offered to patients with pelvic pain based on the belief that by delivering the medication in closer proximity to the area of pain that a greater effect would be gained. [ 18 ]   However, this hypothesis has been disproven due to the fact that  benzodiazepines  work on the  GABA receptor  which is present within the central nervous system and do not work locally - therefore, regardless of the route of administration of the medication, it will still need to travel to the central nervous system to work so it is no more or less effective being given "closer" to the area of discomfort. [ 23 ]  Moreover, benzodiazepines have not been shown to be effective for pelvic pain and should only be used with extreme caution due to the potential for addiction.  Similarly, hydrodissection is another treatment that has been suggested for pelvic pain despite the fact that there is no evidence whatsoever to substantiate its use. [ 24 ]   Proponents suggest the therapy is able to "move" adjacent tissue away from a potentially  compressed nerve  by injecting small amounts of fluid under ultrasound guidance; however this premise is incorrect due to the fact that  in vivo  tissue will nearly always absorb foreign fluid and return to its original orientation in a matter of minutes to days.


Vibrators  have also been found to be effective at addressing Pelvic Pain. [ 25 ] [ 26 ]  Sometimes described as a massager, the vibrator is used on the body to produce  sexual stimulation . Examples of FDA registered vibrators for sexual arousal disorder include  MysteryVibe's  Crescendo [ 25 ] [ 27 ] [ 28 ]  and Intimate Rose's Pelvic Wand.


Many women will benefit from a consultation with a physical therapist, a trial of anti-inflammatory medications, hormonal therapy, or even neurological agents.  A  hysterectomy  is sometimes performed however this should only be explored as a last resort given the fact that it is often not effective in treating neuropathic pain. [ 29 ]


Most women, at some time in their lives, experience pelvic pain. As girls enter puberty, pelvic or abdominal pain becomes a frequent complaint.
Chronic pelvic pain is a common condition with rate of  dysmenorrhoea  between 16.8 and 81%,  dyspareunia  between 8-21.8%, and noncyclical pain between 2.1 and 24%. [ 30 ]


According to the  CDC , Chronic pelvic pain (CPP) accounted for approximately 9% of all visits to gynecologists in 2007. [ 31 ]  In addition, CPP is the reason for 20-30% of all laparoscopies in adults. [ 32 ]  Pelvic girth pain is frequent during pregnancy. [ 33 ]


Issues have been found in current procedures for the treatment of chronic pelvic pain (CPP). These relate primarily with regard to the conceptual dichotomy between an ‘organic’ genesis of pain, where the presence of tissue damage is presumed, and a ‘psychogenic’ origin, where pain occurs despite a lack of damage to tissue. [ 34 ]  CPP literature in medicine and psychiatry reflects a paradigm where  unproblematically observable ‘organic’ processes are causally and sequentially explained, despite evidence in favour of a possible model which accounts for the “complex role played by meaning and consciousness” in the experience of pain. [ 34 ]  While in the literature of causal mechanisms reference is made to ‘subjective’ aspects of pain, current models do not provide a means through which these aspects may be accessed or understood. [ 34 ]  Without interpretive or ‘subjective’ approaches to the pain experienced by patients, medical understandings of CPP are fixed within ‘organic’ sequences of the “purely object” body conceptually separated from the patient. [ 34 ]  Despite the prevalence of this wider understanding of the biological genesis of pain, alternate diagnosis and treatments of CPP in multidisciplinary settings have shown high success rates for people for whom ‘organic’ pathology has been unhelpful. [ 34 ]


A  perineal dilator  is an inflatable balloon-like device sometimes used to create a functional vagina in women with  vaginal agenesis .  The device, usually made out of  silicone , is inserted into the  vagina  and inflated. [ 1 ] [ 2 ]


This article related to  medical equipment  is a  stub . You can help Wikipedia by  expanding it .


Perineology  is a speciality dealing with the functional troubles of the three axes ( urological ,  gynaecological  and  coloproctological ) of the female  perineum . [ 1 ]  The perineologist takes a  holistic approach , using defect-specific and mini-invasive treatments.


The word perineology represents a  neologism . It was invented for the occasion of the 1st International Symposium on Perineology, held in  Venice  in 1990 to reflect an integrated view of the anatomy, physiology and pathology of the pelvic floor. [ 2 ]  It was popularized by the Italian journal Rivista Italiana di Colon-Proctologia. [ 3 ]


Some physicians in France and Italy prefer to use the broader term “pelviperineology”, which reflect a broader multidisciplinary approach to all the aspects of the management of the pelvic floor. [ 4 ]


In 2010, an International Society for Pelviperineology was formed. [ 5 ]


A  polyp  is an abnormal growth of  tissue  projecting from a  mucous membrane . If it is attached to the surface by a narrow elongated  stalk , it is said to be  pedunculated ; if it is attached without a stalk, it is said to be  sessile .


Polyps are commonly found in the  colon ,  stomach ,  nose ,  ear ,  sinus(es) ,  urinary bladder , and  uterus . They may also occur elsewhere in the body where there are mucous membranes, including the  cervix ,  vocal folds , and  small intestine . Some polyps are tumors ( neoplasms ) and others are non-neoplastic, for example  hyperplastic  or  dysplastic , which are benign. The neoplastic ones are usually  benign , although some can be  pre-malignant , or concurrent with a malignancy.


The name is of ancient origin, in use in English from about 1400 for a  nasal polyp , from Latin  polypus  through Greek. [ 1 ]  The animal of similar appearance called  polyp  is attested from 1742, although the word was earlier used for an  octopus .


Relative incidences by location:


[ 7 ] [ 8 ]


While colon polyps are not commonly associated with symptoms, occasionally they may cause  rectal bleeding , and on rare occasions  pain ,  diarrhea  or  constipation . [ 9 ]  They are a concern because of the potential for  colon cancer  being present microscopically, and the risk of  benign  colon polyps becoming  malignant  over time. [ 10 ]  Since most polyps are  asymptomatic , they are usually discovered at the time of colon cancer screening. Common screening methods are  occult blood test ,  colonoscopy  with a modern flexible  endoscope ,  sigmoidoscopy  (usually with the older rigid endoscope),  lower gastrointestinal series  (barium enema),  digital rectal examination  (DRE),  virtual colonoscopy  or Cologuard. [ 11 ]


The polyps are routinely removed at the time of colonoscopy, either with a wire loop known as a polypectomy snare (first description by P. Deyhle, Germany, 1970), [ 12 ]  or with biopsy  forceps .  If an  adenomatous  polyp is found, it must be removed, since such a polyp is pre-cancerous and has a propensity to become cancerous. For certainty, all polyps which are found by any  diagnostic modality , are removed by a colonoscopy. Although colon cancer is usually not found in polyps smaller than 2.5 cm, all polyps found are removed since their removal reduces the likelihood of future colon cancer. When adenomatous polyps are removed, a repeat colonoscopy is usually performed three to five years later. [ citation needed ]


Most colon polyps can be categorized as sporadic.


Adenomatous polyps , or adenomas, are polyps that grow on the lining of the colon and which carry a high risk of  cancer . The adenomatous polyp is considered  pre-malignant , i.e., likely to develop into  colon cancer . [ 14 ]  The other types of polyps that can occur in the colon are  hyperplastic  and inflammatory polyps, which are unlikely to develop into  colorectal cancer . [ 15 ]


About 5% of people aged 60 will have at least one adenomatous polyp of 1 cm diameter or greater. [ 16 ]  Multiple adenomatous polyps often result from  familial polyposis coli  or  familial adenomatous polyposis , a condition that carries a very high risk of colon cancer. [ 13 ]


Adenomas constitute approximately 10% of digestive polyps. Most polyps (approximately 90%) are small, usually less than 1 cm in diameter, and have a small potential for malignancy. The remaining 10% of adenomas are larger than 1 cm and approach a 10% chance of containing invasive cancer. [ 17 ]


There are three types of adenomatous polyp:


The risks of progression to colorectal cancer increase if the polyp is larger than 1 cm and contains a higher percentage of  villous  component. Also, the shape of the polyps is related to the risk of progression into carcinoma. Polyps that are  pedunculated  (with a stalk) are usually less dangerous than sessile polyps (flat polyps). Sessile polyps have a shorter pathway for migration of invasive cells from the tumor into submucosal and more distant structures, and they are also more difficult to remove and ascertain. Sessile polyps larger than 2 cm usually contain villous features, have a higher malignant potential, and tend to recur following colonoscopic polypectomy. [ 18 ]


Although polyps do not carry significant risk of  colon cancer , tubular adenomatous polyps may become cancerous when they grow larger. Larger tubular adenomatous polyps have an increased risk of malignancy when larger because then they develop more villous components and may become  sessile . [ 19 ]


It is estimated that an individual whose parents have been diagnosed with an adenomatous polyp has a 50% greater chance to develop colon cancer than individuals with no  family history  of colonic polyps. [ 20 ]  As of 2019 [update]  there is no way to establish the risks of colon polyps of patients with a family history of them. Overall, nearly 6% of the population, regardless of family history, is at risk of developing colon cancer. [ citation needed ]


Screening for colonic polyps as well as preventing them has become an important part of the management of the condition. Medical societies have established guidelines for colorectal screening in order to prevent adenomatous polyps and to minimize the chances of developing colon cancer. It is believed that some changes in the diet might be helpful in preventing polyps from occurring, but there is no other way to prevent the polyps from developing into cancerous growths than detecting and removing them. [ citation needed ]


Colon polyps as they grow can sometimes cause bleeding within the  intestine , which can be detected by an occult blood test. According to  American Cancer Society  guidelines, people over 50 should have an annual  occult blood test. People in their 50s are recommended to have flexible sigmoidoscopies performed once every 3 to 5 years to detect any abnormal growth which could be an adenomatous polyp. If adenomatous polyps are detected during this procedure, a  colonoscopy  is recommended. Medical societies recommend colonoscopies every ten years starting at age 50 as a necessary screening practice for colon cancer. [ 11 ] [ 21 ]  The screening provides an accurate image of the intestine and also allows the removal of the polyp, if found.


Once an adenomatous polyp is identified during colonoscopy, there are several methods of removal, including using a snare or a heating device. [ 22 ]  Colonoscopies are preferred over sigmoidoscopies because they allow the examination of the entire colon and can detect polyps in the upper colon, where more than half of polyps occur. [ citation needed ]


It has been statistically demonstrated that screening programs are effective in reducing the number of deaths caused by colon cancer due to adenomatous polyps. The risk of complications associated with colonoscopies is approximately 0.35 percent, compared to a lifetime risk of developing colon cancer of around 6 percent. [ 23 ]  As there is a small likelihood of recurrence, surveillance after polyp removal is recommended. [ citation needed ]


An endometrial polyp or uterine polyp is a polyp or  lesion  in the lining of the uterus ( endometrium ) that takes up space within the uterine cavity. Commonly occurring, they are experienced by up to 10% of women. [ 24 ]  They may have a large flat base ( sessile ) or be attached to the uterus by an elongated  pedicle  ( pedunculated ). [ 24 ] [ 25 ]  Pedunculated polyps are more common than sessile ones. [ 26 ]  They range in size from a few millimeters to several centimeters. [ 25 ]  If pedunculated, they can protrude through the  cervix  into the  vagina . [ 24 ] [ 27 ]  Small blood vessels may be present in polyps, particularly large ones. [ 24 ]


A cervical polyp is a common  benign  polyp or  tumor  on the surface of the  cervical canal . [ 28 ]  They can cause irregular  menstrual  bleeding or increased pain but often show no symptoms. [ 29 ]


Nasal polyps are polypoidal masses arising mainly from the  mucous membranes  of the nose and  paranasal sinuses . They are overgrowths of the mucosa that frequently accompany  allergic   rhinitis . They are freely movable and nontender. [ citation needed ]


Polyps on the vocal folds can take on many different forms, and can sometimes result from vocal abuse, although this is not always the cause.  They can occur on one or both vocal folds, and appear as swelling, a bump (similar to a nodule), a stalk-like growth, or a blister-like lesion.  Most polyps are larger than nodules, which are more similar to callouses on the vocal folds. Polyps and nodules can exhibit similar symptoms including hoarseness or breathiness, "rough" or "scratchy" voice, harshness in vocal quality, shooting pain from ear to ear, sensation of having "a lump in the back of the throat", neck pain, decreased pitch range in the voice, and vocal and bodily fatigue. [ citation needed ]


If an individual experiences symptoms for more than 2 to 3 weeks, they should see a physician.  For a diagnosis, a thorough evaluation of the voice should include a physical examination, preferably by an otolaryngologist (ear, nose, and throat doctor) who specializes in voice, a voice evaluation with a speech-language pathologist (SLP), a neurological examination (in certain cases)
The qualities of the voice that will be evaluated include quality, pitch, loudness, and ability to sustain voicing.  In some cases, an instrumental examination may be performed with an endoscope into the mouth or nose; this gives a clear look at the vocal folds and larynx in general.  In addition to this, a stroboscope (flashing light) may be used to observe the movement of the vocal folds during speech. [ citation needed ]


Polyps may be treated with medical, surgical, or behavioral intervention.  Surgical intervention involves removing the polyp from the vocal fold.  This approach is only used when the growth(s) are very large or have existed for an extended amount of time.  In children, surgical intervention is rare.  Existing medical problems may be treated in an effort to reduce the strain and negative impact on the vocal cords.  This could include treatment for gastrointestinal reflux disease, allergies, and thyroid problems.  Intervention to stop smoking and reduce stress may also be needed.  Most people receive behavioral intervention, or vocal therapy, from an SLP.  This might involve teaching good vocal hygiene, and reducing or stopping vocal abuse behaviors.  Direct voice treatments may be used to alter pitch, loudness, or breathe support to promote good voicing. [ citation needed ]


Porphyromonas gingivalis  belongs to the  phylum   Bacteroidota  and is a  nonmotile ,  Gram-negative , rod-shaped,  anaerobic ,  pathogenic   bacterium . It forms black colonies on  blood agar .


It is found in the oral cavity, where it is implicated in  periodontal disease , [ 1 ]  as well as in the upper  gastrointestinal tract , the  respiratory tract , and the  colon . It has been isolated from women with  bacterial vaginosis . [ 2 ]


Collagen  degradation observed in chronic periodontal disease results in part from the  collagenase  enzymes of this  species . It has been shown in an  in vitro  study that  P. gingivalis  can invade  human   gingival   fibroblasts  and can survive in the presence of  antibiotics . [ 3 ]   P. gingivalis  invades gingival  epithelial   cells  in high numbers, in which case both bacteria and epithelial cells survive for extended periods of time. High levels of specific antibodies can be detected in patients harboring  P. gingivalis .


P. gingivalis  infection has been linked to  Alzheimer's disease [ 4 ]  and  rheumatoid arthritis . It contains the enzyme  peptidyl-arginine deiminase , which is involved in  citrullination . [ 5 ]  Patients with  rheumatoid arthritis  have increased incidence of periodontal disease; [ 6 ]  antibodies against the bacterium are significantly more common in these patients. [ 7 ]


P. gingivalis  is divided into K- serotypes  based upon  capsular   antigenicity  of the various types. [ 8 ]


The genome of  P. gingivalis  was described in 2003 revealing 1,990  open reading frames  (i.e. protein-coding sequences), encoded by 2,343,479 bp, with an average G+C content of 48.3%. [ 9 ]  An estimated 463 genes are  essential . [ 10 ]


Arg-gingipain (Rgp) and lys-gingipain (Kgp) are  endopeptidase  enzymes secreted by  P. gingivalis.  These  gingipains  serve many functions for the organism, contributing to its survival and virulence. [ 11 ]


Arg-gingipains have been found to play a key role in the collection of nutrients for  P. gingivalis  survival. Rgp degrades large peptides of the host organism to provide the bacterium with an abundant nitrogen and carbon source from human serum albumin. [ 12 ]   P. gingivalis  can also degrade  transferrin  within host cells which provides the organism with an abundant iron source needed to perform multiple cellular functions. [ 13 ]


The gingipains are also responsible for a number of necessary functions related to host invasion and colonization. Rgp gingipains are necessary for adhesion and invasion as they processed precursor proteins of long fimbriae. [ 13 ]  The  P. gingivalis  genes encoding RgpA, Kgp, and hemagglutinin A (HagA) were strongly expressed after incubation with  T. denticola . The hemagglutinin adhesion domain-containing proteins act to increase adhesive capacities of  P. gingivalis  with other bacterial species. [ 14 ]  They are also associated with coordinating the integrity of the biofilm in the developing and maturation phase. [ 15 ]  Lys- gingipains (Kgp) can bind to immobilized matrix proteins  fibrinogen  and  fibronectin  and may have a role in host colonization. [ 16 ]


Gingipains also have the ability to degrade multiple signals of the host immune response. They have the ability to cleave subclass 1 and 3  IgG antibodies [ 17 ]  as well as proinflammatory  cytokines  such as IL-1β, IL-2, IL-6, TNF-α and IL-8 in regions of high  P. gingivalis  concentration, [ 18 ]  impairing host immune response function. Rgp can inhibit IL-2 accumulation in  T-cells , which enables it to evade the host adaptive immune response, by modulating T-cell communication and proliferation. [ 19 ]


Gingipains are key factors in tissue damage symptoms of  periodontitis , which results from the degradation of  matrix metalloproteins ,  collagen , and  fibronectin . [ 13 ]  Degradation of these substrates interferes with interactions between host cells and the  extracellular matrix , therefore impeding wound healing and causing destruction of periodontal tissues. [ 13 ]  Rgp is responsible for eliciting the host inflammatory response via the p38α  MAPK  transduction pathway. This response likely contributes to the inflammatory nature of periodontitis and is involved in tissue and bone destruction. [ 12 ]


Gingipains have been associated with  Alzheimer's disease  (AD). Gingipains were discovered from  TMAs  of patients exhibiting AD brain pathology. Both RgpB and Kgp were discovered from  hippocampus  and  cerebral cortex  of AD patients and were found to be associated with  tau  load, a marker for AD pathology and  ubiquitin , which accumulates in tau tangles and  amyloid beta  plaques in AD brain.  P. gingivalis  16S rRNA was also discovered in the cerebral cortex and  csf  of AD brains. Pretreatment with gingipain inhibitors protected neuron cell degradation caused by administration of gingipains in murine model. [ 4 ]


The encapsulated strain of  P. gingivalis  is much more virulent than the nonencapsulated strain in a mouse abscess model. [ 20 ]  The capsule is a capsular polysaccharide and when present down regulates  cytokine  production especially proinflammatory  cytokines  IL-1β, IL-6, IL-8, and  TNF-α , indicating host evasion responses. [ 18 ] [ 20 ]  However, other studies have found the capsular polysaccharide to elicit host immune responses like  neutrophil  migration and dose and time dependent expression of cell migration  chemokines  like MCP-1, KC, MIP-2 and RANTES in capsular polysaccharide-challenged murine peritoneal macrophages. These conditions are likely to contribute to the inflammatory lesions observed in  periodontitis . [ 21 ]


Vaccines made from capsular polysaccharide of  P. gingivalis  apparently impair oral bone loss in murine models. These vaccines have been able to elicit potent immune responses such as increased  IgM  and  IgG  responses that recognize whole  P. gingivalis  organisms. [ 22 ]


Fimbriae  are appendages involved in cellular attachment and greatly contribute to virulence and are found on many Gram-negative and some Gram-positive bacteria. [ citation needed ]


P. gingivalis  virulence is heavily associated with fimbriae as they have been characterized to be key factors in adhesion, invasion, and colonization. Fimbriae are also responsible for invasion of membrane vesicles into host cells. [ 13 ]  They were found to bind to cellular α5β1  integrins , which mediated adherence and impaired the homeostatic controls of host cells. [ 23 ]  Fimbriae were also found to be associated with modulating β2 integrin adhesive activity for uptake by  monocytes  using the  CD14 / TLR2 / PI3K  signaling complex, which may contribute to intracellular evasion tactics by  P. gingivalis . [ 24 ]   P. gingivalis  has long fimbriae, short fimbriae, and accessory components, each of which have distinct functions. [ 15 ]


Long fimbriae (FimA), also known as major fimbriae, are long, peritrichous, filamentous components. [ 25 ]  They have a role in initial attachment and organization of biofilms, as they act as adhesins that mediate invasion and colonization of host cells contributing to  P. gingivalis  virulence. [ 15 ]


Short fimbriae (Mfa1), also known as minor fimbriae, have distinct roles from long fimbriae and are characterized to be essential for cell-cell auto aggregation and recruitment for  microcolony  formation. [ 25 ]  Short fimbriae are involved in cell-cell adhesion with other dental commensals. It was found to coadhere and develop biofilm in conjunction with  Streptococcus gordonii  by interaction with SspB streptococcal surface polypeptide. [ 26 ]  This interaction may be essential in the invasion of dentinal tubules by  P. gingivalis . [ 27 ]


Fim C, D, and E accessory components associate with the main FimA protein and have a role in binding with matrix proteins and interaction with CXC-chemokine receptor 4. Loss of function experiments have confirmed that  P. gingivalis  mutants deficient for Fim C, D, or E have drastically attenuated virulence. [ 28 ]


P. gingivalis  has many ways of evading host immune responses which affects its virulence. It does this by using a combination of gingipain proteases, a capsular polysaccharide, induction of host cell proliferation, and the cleavage of chemokines responsible for neutrophil recruitment. [ 17 ] [ 29 ]


Virulent  P. gingivalis  further modulates leukocyte recruitment by proteolysis of  cytokines  and  chemokines  that are secreted by the host cells. The arg-gingipain and lys-gingipains are responsible for this proteolysis. In a study using a mouse model,  P. gingivalis  was specifically found to down-regulate  IL-8  induction, causing delayed  neutrophil  recruitment. Prevention of neutrophil recruitment may inhibit the clearance of the bacterium from the site of infection allowing for colonization. [ 29 ]   P. gingivalis  is able to evade opsonophagocytosis from  granulocytes  by using Gingipain K (Kgp) to cleave  IgG  1 and 3. This further modulates immune response by impairing signaling. [ 17 ]  Other studies have found that  P. gingivalis  can subvert the  complement  pathway through C5αR and C3αR, which modulates the killing capacity of leukocytes, allowing for uncontrolled bacterial growth. [ 29 ] [ 30 ] [ 31 ]   P. gingivalis  was also found to inhibit pro inflammatory and antimicrobial responses in human monocytes and mouse macrophages by fimbrial binding to CXCR4, inducing  PKA  signaling and inhibiting  TLR-2 -mediated immune response. [ 32 ]


Once in the host cells,  P. gingivalis  is capable of inhibiting  apoptosis  by modulating the  JAK/Stat  pathway that controls mitochondrial apoptotic pathways. [ 33 ] [ 15 ]  A proliferative phenotype may be beneficial to the bacterium as it provides nutrients, impairs host cell signaling, and compromises the integrity of the epithelial cell layer, allowing for  invasion and colonization. [ 15 ]


P. gingivalis  plays an important role in the onset of chronic adult periodontitis. [ 34 ]  Though it is found in low abundance in the oral cavity, it causes a microbial shift of the oral cavity, allowing for uncontrolled growth of the  commensal  microbial community. This leads to periodontitis through the disruption of the host tissue homeostasis and adaptive immune response. [ 35 ]  After using laser capture microdissection plus qRT-PCR to detect  P. gingivalis  in human biopsies, colocalization of  P. gingivalis  with CD4+ T cells was observed. [ 36 ]  However, the infection mechanism of T cells by  P. gingivalis  remains unknown. [ citation needed ]


P. gingivalis  has been associated with increasing the virulence of other commensal bacteria in both  in vivo  and  in vitro  experiments.  P. gingivalis  outer membrane vesicles  were found to be necessary for the invasion of epithelial cells of  Tannerella forsythia . [ 37 ]   P. gingivalis  short fimbriae were found to be necessary for coculture biofilm formation with  Streptococcus gordonii . [ 26 ]  Interproximal and horizontal alveolar bone loss in mouse models are seen in coinfections involving  P. gingivalis  and  Treponema denticola . [ 38 ]  The role of  P. gingivalis  in periodontitis is studied using specific pathogen-free mouse models of periodontal infections. In these models,  P. gingivalis  inoculation causes significant bone loss, which is a significant characteristic of the disease. In contrast, germ free mice inoculated with a  P. gingivalis  monoinfection incur no bone loss, indicating that  P. gingivalis  alone cannot induce periodontitis. [ 29 ]


While  P. gingivalis  is a part of the typical microbiotic ecosystem of the oral cavity in humans, it can also become pathogenic is provided with sufficient opportunity. When this occurs, the resultant infection is known as  gingivitis  or  periodontitis .


Periodontal disease, which an infection of the gum tissue driven primarily by  P. gingivalis , has been theorized to be linked with other systemic diseases, including  Alzheimer’s ,  atherosclerosis  and other  cardiovascular diseases . Though there exists no scientific consensus on the mechanism by which these disease processes are linked, evidence for the connection between periodontal disease and cardiovascular diseases including atherosclerosis has been found in both statistical study of human populations, [ 39 ]  and  in vivo  studies using a mouse model. [ 40 ]


It is thought that periodontitis is linked to cardiovascular disease due to  inflammation  pathways, which the two pathologies have in common. The inflammation pathway of periodontitis is such that as the infection grows, bacteria, including  P. gingivalis  are targeted by neutrophils and natural killer immune cells. These cells phagocytize the bacteria, while simultaneously  cytokine  molecules in the area lead to a proinflammatory environment. This proinflammatory environment is also rich in intercellular signaling molecules including  tumor necrosis factor-alpha ,  interleukins  ( interleukin 1 ,  interleukin 4 ,  interleukin 10 ),  interferons  and  transforming growth factor beta . These molecules recruit more enzymes and transcription factors, which then in turn recruit more immune cells, forming a positive feedback loop which can make the immune response, and therefore the inflammation become chronic and systemic. Chronic inflammation of gum tissue can lead to a loss of this tissue and of bone tissue as well. The inflammation upregulates production of  RANKL , an intercellular signaling molecule that promotes bone tissue dissolution, leading to a gradual loss of bony tissue.  P. gingivalis  infection is also thought to lead to oxidative stress. Both chronic systemic inflammation and oxidative stress are factors associated with the onset of cardiovascular disease, and are proposed mechanisms by which periodontal disease may, if it indeed is causationally linked to cardiovascular disease, accelerate the disease process of a cardiovascular disease. [ 41 ]


While invasive  P. gingivalis  is associated with various forms of cardiovascular disease, including  stroke ,  coronary artery disease ,  atrial fibrillation , and  heart failure , the best evidence of a direct causational link is between invasive  P. gingivalis  (periodontal disease) and atherosclerosis. In vivo and in vitro animal models have found that the fimbriae of  P. gingivalis  promote host cell entry and  atherothrombotic lesion  formation once the bacteria enter the bloodstream, such as through lesions in the mouth.  P. gingivalis  has been shown to accelerate the atherosclerosis disease pathway in mice, as well as being found in human atherosclerotic plaque lesions. [ 42 ]


Postcoital bleeding  (PCB) is non- menstrual   vaginal bleeding  that occurs during or after  sexual intercourse . [ 1 ]  Though some causes are with associated pain, it is typically painless and frequently associated with  intermenstrual bleeding . [ 2 ] [ 3 ]


The bleeding can be from the uterus, cervix, vagina and other tissue or organs located near the vagina. [ 4 ]  Postcoital bleeding can be one of the first indications of cervical cancer. [ 5 ] [ 6 ]  There are other reasons why vaginal bleeding may occur after intercourse. Some women will bleed after intercourse for the first time but others will not. The hymen may bleed if it is stretched since it is thin tissue. Other activities may have an effect on the vagina such as sports and tampon use. [ 7 ]  Postcoital bleeding may stop without treatment. [ 8 ]  In some instances, postcoital bleeding may resemble menstrual irregularities. [ 9 ]  Postcoital bleeding may occur throughout pregnancy. The presence of cervical polyps may result in postcoital bleeding during pregnancy because the tissue of the polyps is more easily damaged. [ 10 ]  Postcoital bleeding can be due to trauma after consensual and non-consensual sexual intercourse. [ 11 ] [ 4 ]


A diagnosis to determine the cause will include obtaining a medical history and assessing the symptoms. Treatment is not always necessary. [ 12 ]


Vaginal bleeding after sex is a symptom that can indicate:


Bleeding from hemorrhoids and vulvar lesions can be mistaken for postcoital bleeding. [ 4 ]  Post coital bleeding can occur with discharge, itching, or irritation. This may be due to  Trichomonas  or  Candida . [ 13 ]  A lack of estrogen can make vaginal tissue thinner and more susceptible to bleeding. Some have proposed that  birth control pills  may cause postcoital bleeding. [ 6 ]


Risk factors for developing postcoital bleeding are: low estrogen levels, rape and 'rough sex'. [ 4 ]


Tests and detailed examination are used to determine the cause of the bleeding:


A  referral  may be made to a specialist. [ 12 ] [ 16 ]  Imaging may not be necessary. Cryotherapy has been used but is not recommended. [ 4 ]


Postcoital bleeding rarely is associated with gynecological cancer in young women and its incidence is projected to drop due to the widespread  immunizations  against  HPV . Postcoital bleeding has been most studied in women in the US.  In a large Taiwanese study, the overall incidence of postcoital bleeding was found to be 39-59  per 100,000 women. Those with postcoital bleeding had a higher risk of  cervical dysplasia  and  cervical cancer .  Benign  causes of postcoital bleeding were associated with  cervical erosion , ectropion,  vaginitis  and vulvovaginitis. Other associations were noted such as the presence of  leukoplakia  of the cervix, an  intrauterine contraceptive device ,  cervical polyps ,  cervicitis ,  menopause ,  dyspareunia , and  vulvodynia . [ 17 ]   In Scotland approximately 1 in 600 women aged 20–24 experience unexplained bleeding. [ 6 ]  A study of African women found that trauma from consensual sexual intercourse was a cause of postcoital bleeding in young women. [ 3 ]


Hymenorrhaphy  is a controversial procedure to surgically repair a damaged hymen, thus restoring the appearance of virginity:


"From a Western-ethics perspective, the life-saving potential of the procedure is weighed against the role of the surgeon in directly assisting in a deception and in indirectly promoting cultural practices of sexual inequality. From an Islamic bioethical vantage point, jurists offer two opinions. The first is that the surgery is always impermissible. The second is that although the surgery is generally impermissible, it can become licit when the risks of not having postcoital bleeding harm are sufficiently great." [ 18 ]


Prevotella intermedia  (formerly  Bacteroides intermedius ) is a  gram-negative ,  obligate anaerobic   pathogenic  bacterium involved in periodontal infections, including  gingivitis  and  periodontitis , and often found in  acute necrotizing ulcerative gingivitis . It is commonly isolated from  dental abscesses , where obligate anaerobes predominate.


Prevotella intermedia  is thought to be more prevalent in patients with  noma .
 [ 1 ]


Prevotella intermedia  use  steroid hormones  as growth factors, so their numbers are higher in pregnant women. [ citation needed ]  It has also been isolated from women with  bacterial vaginosis . [ 2 ]


This  Bacteroidota -related article is a  stub . You can help Wikipedia by  expanding it .


Psychoneuroendocrinology  is the clinical study of  hormone  fluctuations and their relationship to  human behavior .  It may be viewed from the perspective of  psychiatry , where in certain  mood disorders , there are associated  neuroendocrine  or hormonal changes affecting the brain.  It may also be viewed from the perspective of  endocrinology , where certain  endocrine disorders  can be associated with negative health outcomes and  psychiatric illness . Brain dysfunctions associated with the hypothalamus-pituitary-adrenal axis  HPA axis  can affect the endocrine system, which in turn can result in physiological and psychological symptoms. This complex blend of psychiatry, psychology, neurology, biochemistry, and endocrinology is needed to comprehensively understand and treat symptoms related to the brain, endocrine system (hormones), and psychological health. (see  neurobiological brain disorder ).


The  Quilligan Scholars  award, named after one of the founding fathers of  Maternal-Fetal Medicine , Dr. Edward J. Quilligan, is a prestigious title in the field of Maternal-Fetal Medicine granted by the  Society for Maternal-Fetal Medicine  and The Pregnancy Foundation to a select group of promising residents [ 1 ]  in  obstetrics and gynaecology  who exhibit unparalleled potential to become future leaders [ 1 ]  in the field of  perinatology .


The purpose of the Quilligan Scholars Program is to identify future leaders in  Perinatology  early in their training and to offer them recognition, guidance, and educational opportunities to foster their careers. These individuals traditionally  exhibit leadership, commitment, and interest in teaching, research, or public policy. Some of the activities provided by the program include paid attendance to the  SMFM  annual meeting, the provision of special courses and experiences, and the granting of personal mentorship from current leaders in the field of  Maternal-fetal Medicine . [ 2 ]