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Androgenic Alopecia

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581. Benign Vulvar Lesions (Treatment)

. Different epithelia, from keratinized squamous epithelium to squamous mucosa, cover the vulva. The labia minora are rich with sebaceous glands but have few sweat glands and no hair follicles. The epithelium of the vestibule is neither pigmented nor keratinized and contains eccrine glands. Benign vulvar disorders are a significant issue for patients. These disorders include vulvar atrophy, benign tumors, hamartomas and cysts, infectious disorders, and nonneoplastic epithelial disorders. [ ] Infectious (...) is evidently a substantial predisposing factor because lesions occur in areas of the skin where sebaceous glands are most active, such as the face, scalp, body folds, and, less commonly, the genitalia. Seborrheic dermatitis is commonly observed in neonates during the early months of life (as a result of sebaceous gland activation by maternal androgens) or after puberty. An association with Pityrosporum yeasts has been noted. Neurologic factors have also been thought to play a role; emotional stress

2014 eMedicine.com

582. Cancer and Rehabilitation (Treatment)

dysfunction or loss of anatomic integrity. Disability refers to functional consequences in relation to self-care and mobility imposed by underlying impairments. Handicap may be defined as a physical condition that interferes with a patient's ability to engage in social, educational, recreational, and vocational pursuits. In essence, handicap compromises patient's full integration into personal relationships and family and societal roles. Introduction Cancer is a group of diseases characterized (...) and shoulder strengthening. Decreased trunk flexion and extension strength also result from the surgery. PT focuses on strengthening exercises and compensatory movements for most patients, particularly for individuals with chronic spinal pain. Other types of reconstruction are associated with discomfort related both to loss of tissue from their respective areas and to the actual surgical procedure. The latissimus dorsi flap procedure is less complicated than other reconstructive procedures, but an implant

2014 eMedicine.com

583. Benign Lesions of the Ovaries (Treatment)

excess (eg, acne, hirsutism, temporal balding, male pattern hair loss, or clitoromegaly) Menstrual irregularities (oligomenorrhea or polymenorrhea) Note that a diagnosis of PCOS does not require multiple ovarian cysts or polycystic ovaries. Ultrasonographic findings suggestive of PCOS commonly include the following: Ovarian enlargement Increased follicle count Stromal echogenicity The ovaries are usually bilaterally enlarged and spherical rather than ovoid in shape. However, 30% of patients with PCOS (...) from all 3 germ layers. Benign teratomas (also known as mature teratomas or dermoid cysts) are likely to contain more of the recognizable organic structures, such as thyroid, bronchial, and central nervous system tissue. [ ] In dermoid cysts, ectodermal structures such as hair, teeth, and skin predominate. Treatment In most instances, simple excision of the solid tumors is adequate therapy, particularly for women of reproductive age. Laparoscopic treatment of benign cystic teratomas of the ovaries

2014 eMedicine.com

584. Erectile Dysfunction (Treatment)

until proven otherwise. ED patients should be assessed and categorized as high-, intermediate-, or low-risk. This stratification can guide management. Risk-factor modification, including lifestyle interventions (eg, exercise and weight loss) is strongly encouraged for ED patients with cardiovascular disease. A study by Gupta et al supports the view that for men with cardiovascular risk factors, modifications in lifestyle along with pharmacotherapy are helpful in improving sexual function (...) with oral PDE5 inhibitors, one of these agents can be combined with an injection of prostaglandin E1 (PGE1; alprostadil). [ ] Gutierrez et al demonstrated that this combination was more effective than either one alone. [ ] The combination of a PDE5 inhibitor with intraurethral PGE1 has also proved successful. Androgens Men who present with diminished libido and ED may be found to have low serum testosterone levels (hypogonadism). Hormone replacement may benefit men with severe hypogonadism and may

2014 eMedicine.com

585. Menopause (Treatment)

lipoprotein (LDL), and apolipoprotein B levels, in conjunction with loss of the protective effect of high-density lipoprotein (HDL), is characteristic in menopause. [ , , ] With cessation of ovulation, estrogen production by the aromatization of androgens in the ovarian stroma and estrogen production in extragonadal sites (adipose tissue, muscle, liver, bone, bone marrow, fibroblasts, and hair roots) [ ] continue, unopposed by progesterone production by a corpus luteum. Consequently, perimenopausal (...) and menopausal women are often exposed to unopposed estrogen for long periods, and this exposure can lead to endometrial hyperplasia, a precursor of endometrial cancer. Although estradiol levels decrease significantly because of the loss of follicular production with menopause and postmenopause, estrone, which is aromatized from androstenedione from nonfollicular sources, is still produced and is the major source of circulating estrogen in the postmenopausal female. Because most conversion of androgens

2014 eMedicine.com

586. Osteoporosis (Primary) (Treatment)

-dependent loss of protection against hip fracture. [ ] Other oral bisphosphonates include risedronate (Actonel) or risedronate delayed-release (Atelvia), given daily, weekly, or monthly. It is also available as a combination product with calcium as risedronate/calcium carbonate (Actonel with Calcium). Risedronate reduced vertebral fractures by 41% and nonvertebral fractures by 39% over 3 years. Ibandronate (Boniva) is another bisphosphonate that can be given orally once a month. Intravenous (...) bone loss, and data in females with osteoporosis have demonstrated that this agent causes a 35% reduction in the risk of vertebral fractures. It has also been shown to reduce the prevalence of invasive breast cancer. Raloxifene may be most useful in younger postmenopausal women without severe osteoporosis. It has been shown to increase the incidence of deep vein thrombosis, stroke, and hot flashes. In 601 postmenopausal women who had daily therapy with raloxifene, BMD was increased, serum

2014 eMedicine.com

587. Oral Manifestations of Systemic Diseases (Treatment)

Chilblains lupus Discoid lupus/lichen planus overlap Oral ulcers Palate Buccal Tongue OR nasal ulcers, in the absence of other causes, such as vasculitis, Behçet disease, infection (herpesvirus), inflammatory bowel disease, reactive arthritis, and acidic food exposure Nonscarring alopecia (diffuse thinning or hair fragility with visible broken hairs) in the absence of other causes such as alopecia areata, drugs, iron deficiency, and androgenic alopecia Synovitis involving two or more joints (...) ) deficiency Atrophic glossitis with erythema and swelling of the tongue Angular cheilitis Glossodynia Dysphagia Recurrent aphthous stomatitis Schlosser et al, [ ] Kozlak et al [ ] Vitamin B-12 (cobalamin, cyanocobalamin) deficiency Generalized stomatitis Taste disturbance Red, atrophic, beefy, burning tongue with bald appearance due to loss of filiform papillae Recurrent aphthous stomatitis Schlosser et al, [ ] Kozlak et al, [ ] Field et al [ ] Vitamin C (ascorbic acid, L-ascorbic acid, ascorbate

2014 eMedicine.com

588. Osteoporosis (Treatment)

-dependent loss of protection against hip fracture. [ ] Other oral bisphosphonates include risedronate (Actonel) or risedronate delayed-release (Atelvia), given daily, weekly, or monthly. It is also available as a combination product with calcium as risedronate/calcium carbonate (Actonel with Calcium). Risedronate reduced vertebral fractures by 41% and nonvertebral fractures by 39% over 3 years. Ibandronate (Boniva) is another bisphosphonate that can be given orally once a month. Intravenous (...) bone loss, and data in females with osteoporosis have demonstrated that this agent causes a 35% reduction in the risk of vertebral fractures. It has also been shown to reduce the prevalence of invasive breast cancer. Raloxifene may be most useful in younger postmenopausal women without severe osteoporosis. It has been shown to increase the incidence of deep vein thrombosis, stroke, and hot flashes. In 601 postmenopausal women who had daily therapy with raloxifene, BMD was increased, serum

2014 eMedicine.com

589. Osteoporosis (Secondary) (Treatment)

-dependent loss of protection against hip fracture. [ ] Other oral bisphosphonates include risedronate (Actonel) or risedronate delayed-release (Atelvia), given daily, weekly, or monthly. It is also available as a combination product with calcium as risedronate/calcium carbonate (Actonel with Calcium). Risedronate reduced vertebral fractures by 41% and nonvertebral fractures by 39% over 3 years. Ibandronate (Boniva) is another bisphosphonate that can be given orally once a month. Intravenous (...) bone loss, and data in females with osteoporosis have demonstrated that this agent causes a 35% reduction in the risk of vertebral fractures. It has also been shown to reduce the prevalence of invasive breast cancer. Raloxifene may be most useful in younger postmenopausal women without severe osteoporosis. It has been shown to increase the incidence of deep vein thrombosis, stroke, and hot flashes. In 601 postmenopausal women who had daily therapy with raloxifene, BMD was increased, serum

2014 eMedicine.com

590. Psychosocial and Environmental Pregnancy Risks (Treatment)

in the child when the pregnant woman's exposures result in maternal hair concentrations between approximately 5 ppm for subtle developmental changes to a range of 10-20 ppm for clinically obvious changes such as delayed walking. A study in Quebec showed that elevated levels of MeHg in umbilical cord blood were associated with cognitive deficits in the A-not-B test in 11 month olds; this indicates a decreased working memory and reflects poorly on early development of executive function. [ ] Intervention (...) for the protection of public health. The committee also supported the use of the benchmark dose level to estimate the reference dose, with the preferred benchmark dose level at 58 parts per billion of mercury in cord blood or 12 parts per million of mercury in hair. Working environments should have a mercury vapor level below 0.01 mg/m 3 . No safe level of mercury in any form has been documented. Women should consider limiting fish intake to no more than 350 g/wk (about two 6-ounce servings) preconceptually

2014 eMedicine.com

591. Prostate Cancer: External Beam Radiation Therapy (Treatment)

uncommon, given the frequent use of high-energy photon beams (≥ 10 MV). Skin irritation is common in patients with a fair complexion; however, early intervention can limit progression to either dry or moist desquamation. Hair loss in the irradiated field (epilation) is commonly seen. Small intestine Radiation therapy can cause changes to the epithelial lining of the small intestine. Absorption and transit can be impaired. Patients may experience more frequent bowel movements or less well formed stools (...) in the management of primary central nervous system tumors and viscera-based malignancies. Hypofractionated radiotherapy In this form of therapy, radiation is delivered from an accelerator, with the equipment mounted to a computer-guided robotic arm; because the machine is capable of treating the target at angles that are not possible with conventional rotation-based equipment, it yields the theoretical advantage of conforming the dose more closely to the target organ’s shape Radiotherapy and androgen ablation

2014 eMedicine.com

592. Prostate Cancer: Management of Localized Disease (Treatment)

surveillance has not been shown. Newer therapies, such as proton-beam radiation and high-intensity focused ultrasound are being used, but long-term survival and complication rates have not been presented in well-done studies. For locally advanced prostate cancer, radiation therapy along with androgen ablation is generally recommended, although radical prostatectomy may be an appropriate alternative to radiation therapy in some cases. A combination of external radiation, brachytherapy, and hormone therapy (...) the following: Conventional radiation therapy Three-dimensional (3-D) conformal radiation therapy Intensity-modulated radiation therapy Temporary and permanent brachytherapy Proton-beam radiation Stereotactically guided radiation Hormone therapy for prostate cancer is also known as androgen deprivation therapy (ADT). It may consist of surgical castration (orchiectomy) or medical castration. Agents used for medical castration include luteinizing hormone–releasing hormone (LHRH) analogues or antagonists

2014 eMedicine.com

593. Prostate Cancer: Nutrition (Treatment)

, cholesterol and blood glucose levels, and weight/waist size, and arguably could impact prostate cancer incidence. The patient's personal preferences and likelihood of adherence should help guide the decision of which pattern to follow. This is especially relevant when discussing weight loss and obesity. Obesity Obesity is one of the strongest dietary/lifestyle factors associated with prostate cancer. Numerous studies have shown that obese men have a greater risk of developing more aggressive prostate (...) the ability of standard biopsies to detect cancer at an earlier stage. Also, with increasing prostate size comes increased secretion of prostate-specific antigen (PSA) from non-cancerous prostate tissue, thus providing a more potentially confusing picture for the clinician and patient. If preventing weight gain could reduce prostate enlargement in some men, that alone could provide substantial clinical benefits. Some of the best data to support an ideal weight loss diet also can be derived from

2014 eMedicine.com

594. Interstitial Laser Coagulation of the Prostate (Treatment)

surveillance has not been shown. Newer therapies, such as proton-beam radiation and high-intensity focused ultrasound are being used, but long-term survival and complication rates have not been presented in well-done studies. For locally advanced prostate cancer, radiation therapy along with androgen ablation is generally recommended, although radical prostatectomy may be an appropriate alternative to radiation therapy in some cases. A combination of external radiation, brachytherapy, and hormone therapy (...) the following: Conventional radiation therapy Three-dimensional (3-D) conformal radiation therapy Intensity-modulated radiation therapy Temporary and permanent brachytherapy Proton-beam radiation Stereotactically guided radiation Hormone therapy for prostate cancer is also known as androgen deprivation therapy (ADT). It may consist of surgical castration (orchiectomy) or medical castration. Agents used for medical castration include luteinizing hormone–releasing hormone (LHRH) analogues or antagonists

2014 eMedicine.com

595. Kennedy Disease (Treatment)

neuronopathy, with special reference to the loss of small neurons in the intermediate zone. J Neurol . 1994 Feb. 241(4):196-203. . Li M, Sobue G, Doyu M, et al. Primary sensory neurons in X-linked recessive bulbospinal neuropathy: histopathology and androgen receptor gene expression. Muscle Nerve . 1995 Mar. 18(3):301-8. . Thurtell MJ, Pioro EP, Leigh RJ. Abnormal eye movements in Kennedy disease. Neurology . 2009 Apr 28. 72(17):1528-30. . . Rocchi C, Greco V, Urbani A, Di Giorgio A, Priori M, Massa R (...) Treatment & Management Updated: Jun 08, 2016 Author: Paul E Barkhaus, MD, FAAN, FAANEM; Chief Editor: Nicholas Lorenzo, MD, MHA, CPE Share Email Print Feedback Close Sections Sections Kennedy Disease Treatment Medical Care No proven, effective treatment of Kennedy disease (KD) is available. However, the androgen-dependent nature of the disease is the rationale for use of anti-androgens, which have been shown to improve some aspects of the disease manifestations in patients. The following is the summary

2014 eMedicine.com

596. Infertility (Treatment)

with a history of irregular menstrual cycles that fluctuate from 35 days to 2-5 months, sometimes associated with a history of dysfunctional uterine bleeding or prolonged periods of breakthrough bleeding. Patients may have symptoms of hyperandrogenism, acne, hirsutism, and baldness. Obesity is frequently associated and aggravates the prognosis. Although these patients are not sterile, their fertility is decreased, and the obstetrical outcome is poor because of an increased risk of pregnancy loss. Many (...) Excessive exercise Inadequate diet associated with extreme weight loss or gain Advanced age Evaluation of infertility Infertility is a problem that involves both partners. Diagnostic testing is unnecessary if the couple has not attempted to conceive for at least 1 year, unless the woman is age 35 years or older, or if they have a history of a male factor infertility, endometriosis, a tubal factor, diethylstilbestrol (DES) exposure, pelvic inflammatory disease, or pelvic surgery. A complete infertility

2014 eMedicine.com

597. Polycystic Ovarian Syndrome (Treatment)

2 diabetes mellitus, consider treatment with oral antihyperglycemic drugs, such as metformin. Metformin can also be considered in other women with PCOS who are insulin resistant and therefore at risk of developing cardiovascular disease, even women without type 2 diabetes. Clinical trials have shown that metformin can effectively reduce androgen levels, improve insulin sensitivity, and facilitate weight loss in patients with PCOS as early as adolescence. [ , , , ] One study concluded (...) growth factor-1 (IGF-1) levels also decrease. In patients with PCOS who are obese, weight loss is associated with a reduction of hirsutism and a return of ovulatory cycles in 30% of women, thereby improving pregnancy rates, as well as improving glucose tolerance and lipid levels. [ , ] The Androgen Excess and Polycystic Ovary Syndrome Society recommends lifestyle management as the primary therapy for metabolic complications in overweight and obese women with PCOS. [ ] A moderate amount of daily

2014 eMedicine.com

598. Pituitary Disease and Pregnancy (Treatment)

of symptomatic growth during pregnancy, after the bromocriptine is discontinued. Re-initiation of bromocriptine is the preferred treatment for pregnant women with prolactinomas who become symptomatic. Most cases quickly show a regression of symptoms (headache) and signs (visual field changes) of tumor enlargement, and the bromocriptine re-administration to date appears to be safe. Given the risks of fetal loss associated with surgery, restarting bromocriptine may be preferable if tumor enlargement occurs (...) of glucocorticoid action by progesterone, autonomous ACTH and CRH secretion by the placenta, and enhanced vasopressin (AVP) secretion (see Vasopressin: Diabetes Insipidus). Cushing disease in pregnancy Up to 75% of women with Cushing disease have oligomenorrhea or amenorrhea due to cortisol- and androgen-induced gonadotropin suppression, or a polycystic ovary – like syndrome. Therefore, pregnancy is rare in patients with pre-existing Cushing disease. Fewer than 70 cases of Cushing disease occurring

2014 eMedicine.com

599. Penile Prosthesis Implantation (Treatment)

prior to penile prosthesis implantation. In the authors' experience, patients in whom conservative treatments have failed tend to be more satisfied with their choice of surgical intervention. In patients with hypogonadism, long-term androgen replacement can obviate the need for penile implant surgery. Oral or depot testosterone can be administered, and, if sufficient to maintain testosterone level, transdermal patches may be prescribed. At least an annual (PSA) test should be performed because men (...) the scrotal approach in the ability to place the reservoir under direct vision. However, in the eyes of the authors and many others, the disadvantages undermine this one advantage. These disadvantages include possible damage to the dorsal penile nerves with accompanying sensory loss, limited exposure of the corpora, and inability to fixate the scrotal pump via this approach. The authors prefer the penoscrotal approach because it provides very good exposure to the corporal bodies, allows for concomitant

2014 eMedicine.com

600. Preimplantation Genetic Diagnosis (Treatment)

abnormality and late pregnancy termination (after positive prenatal diagnosis). Primary candidates for PGD These include the following: Couples with a family history of X-linked disorders (Couples with a family history of X-linked disease have a 25% risk of having an affected embryo [half of male embryos].) Couples with chromosome translocations, which can cause implantation failure, recurrent pregnancy loss, or mental or physical problems in offspring [ ] Carriers of autosomal recessive diseases (...) for Preimplantation Genetic Screening Most early pregnancy losses can be attributed to aneuploidy. Because only chromosomally normal embryos are transferred into the uterus, the risk of first and second trimester loss is markedly reduced. At present, no specific list of indications for preimplantation genetic screening (PGS) is available. Primary candidates for PGS can include the following: Women of advanced maternal age Couples with history of recurrent pregnancy loss Couples with repeated IVF failure Male

2014 eMedicine.com

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