Unit One.

Reproductive Health
Reproductive health is a state of complete physical, mental and social well-being and not merely the
absence of disease or infirmity, in all matters relating to the reproductive system and to its functions and
processes. Reproductive health implies that people are able to have a satisfying and safe sex life and
that they have the capability to reproduce and the freedom to decide if, when and how often to do so.

Reproductive Rights
Reproductive rights are about the legal right to contraception, abortion, fertility treatment, reproductiv
accesse health, and to information about one's reproductive body. Reproductive rights refer to the
composite of human rights that address matters of sexual and reproductive health. Reproductive rights
are protected through the application of human rights in guidelines, national laws, constitutions, and
regional and international treaties. While reproductive rights are instrumental to achieving population,
health, and development goals, they are also important in themselves as human rights intended to
protect the inherent dignity of the individual. Reproductive rights consist of three broad categories of
rights:

(1) rights to reproductive self-determination,

(2) rights to sexual and reproductive health sevices, information, and education,

(3) rights to equality and nondiscrimination.

Factors influencing reproductive health and right

There are numerous factors that affect SRH issues, namely poor socio-economic, socio-cultural, and
environmental conditions, and inadequate accessibility, availability, and quality of SRH services. Many
lifestyle factors such as the age at which to start a family, nutrition, weight, exercise, psychological
stress, environmental and occupational exposures, and others can have substantial effects on fertility;
lifestyle factors such as cigarette smoking, illicit drug use, and alcohol and caffeine consumption can
negatively influence fertility.

For example, research shows that :Obesity is linked to lower sperm count and quality in men.

Among women with obesity who have polycystic ovary syndrome (PCOS), losing 5% of body weight
greatly improves the likelihood of ovulation and pregnancy.

Being underweight is linked to ovarian dysfunction and infertility in women.

Strenuous physical labor and taking multiple medications are known to reduce sperm count in males.

Excessive exercise is known to affect ovulation and fertility in women.

Research shows that using body-building medications or androgens can affect sperm formation.
Substance use, including smoking tobacco, using other tobacco products, marijuana use, heavy drinking,
and using illegal drugs such as heroin and cocaine reduce fertility in both men and women.

Having high blood pressure changes the shape of sperm, thereby reducing fertility.

The type of underwear a man chooses is not related to his infertility.

Radiation therapy and chemotherapy can cause infertility in females and males. Those who have to
undergo these types of treatments may want to consider fertility preservation.

UNIT TWO

Anatomy & Physiology of the Reproductive System

Puberty Puberty is a period of rapid change in the lives of boys and girls during which the reproductive
systems mature and become capable of reproduction. Puberty ends when mature sperm are formed
or when regular menstrual cycles occur. In girls, the first menstrual period (menarche) occurs 2 to 2
years later (age 11 to 15 years), and pubertal changes typically occur as:

1. Growth spurt

2. Increase in the transverse diameter of the pelvis

3. Breast development

4. Growth of pubic hair

5. Onset of menstruation

6. Growth of axillary hair

7. Vaginal secretions

Female Reproductive System

The female reproductive system consists of external genitalia, internal genitalia, and accessory
structures such as the mammary glands (breasts). External Genitalia The female external genitalia are
collectively called the vulva. They include the mons pubis, labia majora, labia minora, fourchette, clitoris,
vaginal vestibule, and perineum.

Mons pubis The mons pubis (mons veneris) is a pad of fatty tissue covered by coarse skin and hair. It
protects the symphysis pubis and contributes to the rounded contour of the female body. Labia majora
The labia majora are two folds of fatty tissue on each side of the vaginal vestibule. Many small glands
are located on the moist interior surface.
Labia minora The labia minora are two thin, soft folds of tissue that are seen when the labia majora
are separated. Secretions from sebaceous glands in the labia are bactericidal to reduce infection and
lubricate and protect the skin of the vulva.

Fourchette The fourchette is a fold of tissue just below the vagina, where the labia majora and the labia
minora meet. It is also known as the obstetrical perineum.

Clitoris The clitoris is a small, erectile body in the most anterior portion of the labia minora. It is similar
in structure to the penis. Functionally, it is the most erotic, sensitive part of the female genitalia.

Vaginal vestibule The vaginal vestibule is the area seen when the labia minora are separated and
includes five structures: 1. The urethral meatus lies approximately 2 cm below the clitoris. It has a
foldlike appearance with a slit type of opening, and it serves as the exit for urine. 2. Skene ducts
(paraurethral ducts) are located on each side of the urethra and provide lubrication for the urethra and
the vaginal orifice. 3. The vaginal introitus is the division between the external and internal female
genitalia. 4. The hymen is a thin elastic membrane that closes the vagina from the vestibule to various
degrees. 5. The ducts of the Bartholin glands (vulvovaginal glands) provide lubrication for the vaginal
introitus during sexual arousal and are normally not visible.

Perineum The perineum is a strong, muscular area between the vaginal opening and the anus. The
elastic fibers and connective tissue of the perineum allow stretching to permit the birth of the fetus.

Internal Genitalia

The internal genitalia are the vagina, uterus, fallopian tubes, and ovaries.

Vagina The vagina is a tubular structure made of muscle and membranous tissue that connects the
external genitalia to the uterus. An average adult vagina is slightly curved and can range between 7 to
12 cm in length, but everybody is different. The vagina is self-cleansing and during the reproductive
years maintains a normal acidic pH of 4 to 5. The vagina has three functions: 1. Provides a passageway
for sperm to enter the uterus. 2. Allows drainage of menstrual fluids and other secretions. 3. Provides a
passageway for the infant’s birth.

Uterus The uterus (womb) is a hollow muscular organ in which a fertilized ovum is implanted, an
embryo forms, and a fetus develops. It is shaped like an upside-down pear or light bulb. In a mature,
nonpregnant woman, it weighs approximately 60 g and is 7.5 cm long, 5 cm wide, and 1 to 2.5 cm thick.
The uterus lies between the bladder and the rectum above the vagina. The uterus is separated into
three parts: fundus, corpus, and cervix. The fundus (upper part) is broad and flat. The fallopian tubes
enter the uterus on each side of the fundus. The corpus (body) is the middle portion, and it plays an
active role in menstruation and pregnancy. The fundus and the corpus have three distinct layers:

1. The perimetrium is the outermost or serosal layer that envelops the uterus.

2. The myometrium is the middle muscular layer that functions during pregnancy and birth.
3. The endometrium is the inner or mucosal layer that is functional during menstruation and
implantation of the fertilized ovum. It is governed by cyclical hormonal changes.

The cervix (lower part) is narrow and tubular and opens into the upper vagina. The cervix consists of
a cervical canal with an internal opening near the uterine corpus (internal os) and an opening into the
vagina (the external os). The mucosal lining of the cervix has four functions:

1. Lubricates the vagina.

2. Acts as a bacteriostatic agent.

3. Provides an alkaline environment to shelter deposited sperm from the acidic pH of the vagina. 4.
Produces a mucous plug in the cervical canal during pregnancy.

Fallopian tubes The fallopian tubes, also called uterine tubes or oviducts, extend laterally from the
uterus, one to each ovary. They vary in length from 8 to 13.5 cm. Each tube has four sections: 1. The
interstitial portion extends into the uterine cavity and lies within the wall of the uterus. 2. The isthmus is
a narrow area near the uterus. 3. The ampulla is the wider area of the tube and is the usual site of
fertilization. 4. The infundibulum is the funnel-like enlarged distal end of the tube. Fingerlike
projections from the infundibulum, called fimbriae, hover over each ovary and “capture” the ovum
(egg) as it is released by the ovary at ovulation. The four functions of the fallopian tubes are to provide
the following:

1. A passageway in which sperm meet the ovum.

2. The site of fertilization (usually the outer one-third of the tube).

3. A safe, nourishing environment for the ovum or zygote (fertilized ovum).

4. The means of transporting the ovum or zygote to the corpus of the uterus.

Ovaries The ovaries are two almond-shaped glands, each about the size of a walnut. They are located in
the lower abdominal cavity, one on each side of the uterus, and are held in place by ovarian and uterine
ligaments. The ovaries have two functions: 1. Production of hormones, chiefly estrogen and
progesterone. 2. Stimulation of an ovum’s maturation during each menstrual cycle.

Reproductive Cycle and Menstruation

Stages of the Menstrual Cycle Includes: A. The ovarian cycle consists of three phases: follicular
(preovulatory) phase, ovulation, and luteal (postovulatory) phase. B. The uterine cycle has three phases:
menses, proliferative and secretory. The female reproductive cycle consists of regular changes in
secretions of the anterior pituitary gland, the ovary, and the endometrial lining of the uterus. The
anterior pituitary gland, in response to the hypothalamus, secretes follicle-stimulating hormone
(FSH) and luteinizing hormone (LH). FSH stimulates maturation of a follicle in the ovary that contains a
single ovum. Several follicles start maturing during each cycle, but usually only one reaches final
maturity. The maturing ovum and the corpus luteum (the follicle left empty after the ovum is released)
produce increasing amounts of estrogen and progesterone, which leads to enlargement of the
endometrium. A surge in LH stimulates final maturation and the release of an ovum. Approximately 2
days before ovulation, the vaginal secretions increase noticeably. Ovulation occurs when a mature
ovum is released from the follicle about 14 days before the onset of the next menstrual period. The
corpus luteum turns yellow (luteinizing) immediately after ovulation and secretes increasing quantities
of progesterone to prepare the uterine lining for a fertilized ovum. Approximately 12 days after
ovulation, the corpus luteum degenerates if fertilization has not occurred, and progesterone and
estrogen levels decrease. The drop in estrogen and progesterone levels causes the endometrium
to break down, resulting in menstruation. The anterior pituitary gland secretes more FSH and LH,
beginning a new cycle.

Functions of female Reproductive system

functions include producing

•gametes called eggs,

• secreting sex hormones (such as estrogen)

•providing a site for fertilization

•gestating a fetus if fertilization occurs

•giving birth to a baby, and breastfeeding a baby after birth.

Male Reproductive System

The male reproductive system consists of external and internal organs. External Genitalia The penis and
the scrotum, which contains the testes, are the male external genitalia.

Penis The penis consists of the glans and the body. The glans is the rounded, distal end of the penis. It is
visible on a circumcised penis but is hidden by the foreskin on an uncircumcised penis. At the tip of the
glans is an opening called the urethral meatus. The body of the penis contains the urethra (the
passageway for sperm and urine) and erectile tissue (the corpus spongiosum and two corpora
cavernosa). The penis has two functions:

1. Provides a duct to expel urine from the bladder.

2. Deposits sperm in a woman’s vagina to fertilize an ovum.

Scrotum The scrotum is a sac that contains the testes. The scrotum is suspended from the perineum,
keeping the testes away from the body and thereby lowering their temperature, which is
necessary for normal sperm production (spermatogenesis).

Internal Genitalia
The internal genitalia include the testes, vas deferens, prostate, seminal vesicles, ejaculatory ducts,
urethra, and accessory glands.

Testes The testes (testicles) are a pair of oval glands housed in the scrotum. They have two functions:

1. Manufacture male germ cells (spermatozoa or sperm).

2. Secrete male hormones (androgens).

Sperm are made in the convoluted seminiferous tubules that are contained within the testes. Sperm
production begins at puberty and continues throughout the life span of the male. The production
of testosterone, the most abundant male sex hormone, begins with the anterior pituitary gland. Under
the direction of the hypothalamus, the anterior pituitary gland secretes follicle-stimulating hormone
(FSH) and luteinizing hormone (LH). FSH and LH initiate the production of testosterone in the Leydig
cells of the testes.

Testosterone Functions:

1. Increases muscle mass and strength.

2. Promotes growth of long bones.

3. Increases basal metabolic rate.

4. Enhances production of red blood cells.

5. Produces enlargement of vocal cords.

6. Affects the distribution of body hair.

Ducts Each epididymis, one from each testicle, stores the sperm. The sperm may remain in the
epididymis for 2 to 10 days, during which time they mature and then move on to the vas deferens.
The ejaculatory ducts then enter the back of the prostate gland and connect to the upper part of the
urethra, which is in the penis. The urethra transports both urine from the bladder and semen from the
prostate gland to the outside of the body, although not at the same time.

Accessory glands

The accessory glands are the seminal vesicles, the prostate gland, and the bulbourethral glands, also
called Cowper’s glands. The accessory glands have three functions:

1. Nourish the sperm.

2. Protect the sperm from the acidic environment of the woman’s vagina.

3. Enhance the motility (movement) of the sperm.

4. The combined seminal plasma and sperm are called semen. Semen may be secreted during sexual
intercourse before ejaculation.

Process of sperm formation

When a baby boy is born, he has all the parts of his reproductive system in place, but it isn't until
puberty that he is able to reproduce. When puberty begins, usually between the ages of 9 and 15, the
pituitary gland — located near the brain — secretes hormones that stimulate the testicles to produce
testosterone. The production of testosterone brings about many physical changes. Although the timing
of these changes is different for every guy, the stages of puberty generally follow a set sequence:

During the first stage of male puberty, the scrotum and testes grow larger.

Next, the penis becomes longer and the seminal vesicles and prostate gland grow.

Hair begins to grow in the pubic area and later on the face and underarms. During this time, a boy's
voice also deepens. Boys also have a growth spurt during puberty as they reach their adult height and
weight.

Sperm Process

A male who has reached puberty will produce millions of sperm cells every day. Each sperm is extremely
small: only 1/600 of an inch (0.05 millimeters long). Sperm develop in the testicles within a system of
tiny tubes called the seminiferous tubules. At birth, these tubules contain simple round cells. During
puberty, testosterone and other hormones cause these cells to transform into sperm cells. The cells
divide and change until they have a head and short tail, like tadpoles. The head contains genetic
material (genes). The sperm move into the epididymis, where they complete their development.

The sperm then move to the vas deferens (VAS DEF-uh-runz), or sperm duct. The seminal vesicles and
prostate gland make a whitish fluid called seminal fluid, which mixes with sperm to form semen when a
male is sexually stimulated. The penis, which usually hangs limp, becomes hard when a male is sexually
excited. Tissues in the penis fill with blood and it becomes stiff and erect (an erection). The rigidity of the
erect penis makes it easier to insert into the female's vagina during sex. When the erect penis is
stimulated, muscles around the reproductive organs contract and force the semen through the duct
system and urethra. Semen is pushed out of the male's body through his urethra — this process is called
ejaculation. Each time a guy ejaculates, it can contain up to 500 million sperm.

Functions of male reproductive system

•To produce, maintain, and transport sperm (the male reproductive cells) and protective fluid (semen)

•To discharge sperm within the female reproductive tract during sex

•To produce and secrete male sex hormones responsible for maintaining the male reproductive system
 UNIT THREE
Disorders of the reproductive system
Disorder – An illness that disrupts normal physical or mental
functions. A disorder could be defined as a set of problems, which
result in causing significant difficulty, distress, impairment and/or
suffering in a person's daily life.

Menstrual Disorders
There are several types of menstrual disorders. Problems can range
from heavy, painful periods to no periods at all. There are many
variations in menstrual patterns, but in general women should be
concerned when periods come fewer than 21 days or more than 3
months apart, or if they last more than 10 days. Such events may
indicate ovulation problems or other medical conditions.

1. Dysmenorrhea (Painful Cramps)

Dysmenorrhea is severe, frequent cramping during menstruation. Pain
occurs in the lower abdomen but can spread to the lower back and
thighs. Dysmenorrhea is usually referred to as primary or secondary:

•Primary dysmenorrhea. Cramping pain caused by menstruation. The

cramps occur from contractions in the uterus and are usually more
severe during heavy bleeding.

•Secondary dysmenorrhea. Menstrual-related pain that accompanies

another medical or physical condition, such as endometriosis or uterine
fibroids.
2. Menorrhagia (Heavy Bleeding)
Menorrhagia is the medical term for significantly heavier periods.
Menorrhagia can be caused by a number of factors. During a normal
menstrual cycle, the average woman loses about 1 ounce (30 mL) of
blood and changes her sanitary products around 3 to 5 times per day.
With menorrhagia, menstrual flow lasts longer and is heavier than
normal. The bleeding occurs at regular intervals (during periods), but
may last more than 7 days, and menstrual flow soaks more than 5
sanitary products per day or requires product change during the night.
Clot formation is common. Menorrhagia is often accompanied by
dysmenorrhea because passing large clots can cause painful cramping.
Menorrhagia is a type of abnormal uterine bleeding. Other types of
abnormal bleeding are:

3. Metrorrhagia. Also called breakthrough bleeding, refers to

bleeding that occurs at irregular intervals and with variable amounts.
The bleeding occurs between periods or is unrelated to periods.
Spotting or light bleeding between periods is common in girls just
starting menstruation and sometimes during ovulation in young adult
women.

4. Menometrorrhagia. Refers to heavy and prolonged bleeding that

occurs at irregular intervals. Menometrorrhagia combines features of
menorrhagia and metrorrhagia. The bleeding can occur at the time of
menstruation (like menorrhagia) or in between periods (like
metrorrhagia).

5. Dysfunctional uterine bleeding (DUB). A general term for

abnormal uterine bleeding that usually refers to extra or excessive
bleeding caused by hormonal problems, usually lack of ovulation
(anovulation). DUB tends to occurs either when girls begin to
menstruate or when women approach menopause, but it can occur at
any time during a woman's reproductive life. This term is not often
used by most gynecologists.

Other types of abnormal uterine bleeding. Include bleeding after sex

and bleeding after menopause. Postmenopausal bleeding is not normal
and can be a sign of a serious condition.

6. Amenorrhea (Absence of Menstruation)

Amenorrhea is the absence of menstruation. There are two categories:
primary amenorrhea and secondary amenorrhea. These terms refer to
the time when menstruation stops:

•Primary amenorrhea. Occurs when a girl does not begin to menstruate

by age 16. Girls who show no signs of sexual development (breast
development and pubic hair) by age 13 should be evaluated by a
doctor. Any girl who does not have her period by age 15 should be
evaluated for primary amenorrhea.

•Secondary amenorrhea. Occurs when periods that were previously

regular stop for at least 3 months.

7. Oligomenorrhea (Infrequent Menstruation) and

Hypomenorrhea (Light Menstruation)
Oligomenorrhea is a condition in which menstrual cycles are
infrequent, occurring more than 35 days apart. It is very common in
early adolescence and does not usually indicate a medical problem.
Light or scanty flow is also common in the first years after menarche
and before menopause. When girls first menstruate they often do not
have regular cycles for several years. Even healthy cycles in adult
women can vary by a few days from month to month. Periods may
occur every 3 weeks in some women, and every 5 weeks in others. Flow
also varies and can be heavy or light. Skipping a period and then having
a heavy flow may occur; this is most likely due to missed ovulation
rather than a miscarriage.

8. Premenstrual Syndrome (PMS)

Premenstrual syndrome (PMS) is a set of physical, emotional, and
behavioral symptoms that occur during the last week of the luteal
phase (a week before menstruation) in most cycles. The symptoms
typically do not start until at least day 13 in the cycle, and resolve
within 4 days after bleeding begins.

Women may begin to have premenstrual syndrome symptoms at any

time during their reproductive years, but it usually occurs when they
are in their late 20s to early 40s. Once established, the symptoms tend
to remain fairly constant until menopause, although they can vary from
cycle to cycle.

Causes
Many different factors can trigger menstrual disorders, including
hormone imbalances, genetic factors, clotting disorders, and pelvic
diseases.

Causes of Dysmenorrhea (Painful Periods)

Primary dysmenorrhea is caused by prostaglandins, hormone-like

substances that are produced in the uterus and cause the uterine
muscle to contract. Prostaglandins also play a role in the heavy
bleeding that causes dysmenorrhea.

Secondary dysmenorrhea can be caused by a number of medical

conditions. Common causes of secondary dysmenorrhea include:

Endometriosis. Endometriosis is a chronic and often progressive

disease that develops when the tissue that lines the uterus
(endometrium) grows onto other areas, such as the ovaries,
peritoneum, bowels, or bladder. It often causes chronic pelvic pain.

Uterine Fibroids.Fibroids are noncancerous growths on the walls of the

uterus. They can cause heavy bleeding during menstruation and
cramping pain.

Other Causes. Pelvic inflammatory disease, ovarian cysts, and ectopic

pregnancy. The intrauterine device (IUD) contraceptive can also cause
secondary dysmenorrhea.

Causes of Menorrhagia (Heavy Bleeding)

There are many possible causes for heavy bleeding:

Hormonal Imbalances. Imbalances in estrogen and progesterone levels

can cause heavy bleeding. Hormonal imbalances are common around
the time of menarche and menopause.

Ovulation Problems. If ovulation does not occur (anovulation), the

body stops producing progesterone, which can cause heavy bleeding.

Uterine Fibroids. Uterine fibroids are a very common cause of heavy

and prolonged bleeding.
Uterine Polyps. Uterine polyps (small benign growths) and other
structural problems or other abnormalities in the uterine cavity may
cause bleeding.

Endometriosis and Adenomyosis. Endometriosis, a condition in which

the cells that line the uterus grow outside of the uterus in other areas,
such as the ovaries, can cause heavy bleeding. Adenomyosis, a related
condition where endometrial tissue develops within the muscle layers
of the uterus, can also cause heavy bleeding and menstrual pain.

Medications and Contraceptives. Certain drugs, including

anticoagulants and anti-inflammatory medications, can cause heavy
bleeding. Problems linked to some birth control methods, such as birth
control pills or intrauterine devices (IUDs) can cause bleeding.

Bleeding Disorders. Bleeding disorders that reduce blood clotting can

cause heavy menstrual bleeding. Most of these disorders have a genetic
basis. Von Willebrand disease is the most common of these bleeding
disorders.

Cancer. Rarely, uterine, ovarian, and cervical cancer can cause

excessive bleeding.

Infection. Infection of the uterus or cervix can cause bleeding.

Pregnancy or Miscarriage. Spotting is very common during the first 20

weeks of pregnancy. Heavier bleeding may also occur. Heavy bleeding
during the first trimester may be a sign of miscarriage or ectopic
pregnancy, but it may also be due to less serious causes that do not
harm the woman or her baby.
Other Medical Conditions. Systemic lupus erythematosus, diabetes,
pelvic inflammatory disorder, cirrhosis, and thyroid disorders can cause
heavy bleeding. Fibroid tumors may not need to be removed if they are
not causing pain, bleeding excessively, or growing rapidly.

Sexual dysfunctions
Sexual dysfunction is when facing significant challenges related to your
ability to experience pleasure or respond sexually.

If you’re having difficulty with sexual activity, getting aroused, or

experiencing pleasure during sexual activity, you might be experiencing
sexual dysfunction.

4 Main categories
There are four main categories of sexual dysfunction:

Desire disorders: characterized by low sexual interest or desire

Arousal disorders: focused on the physical inability to become
sexually aroused

Orgasm disorders: characterized by a delay or absence of orgasms

Pain disorders: marked by physical discomfort and pain during sexual
activity

Sexual disorders that only affect males

•premature or early ejaculation

•erectile disorder
•male hypoactive sexual desire disorder

Sexual disorders that only affect females

•female orgasmic disorder

•female sexual interest/arousal disorder

•genito-pelvic pain/penetration disorder

•Other conditions that overlap

There are also other conditions that sometimes overlap with sexual
dysfunctions:

•exhibitionistic disorder

•fetishistic disorder

•frotteuristic disorder

•sexual masochism and sadism

•transvestic disorder

•voyeuristic disorder

Diagnosis
Before a healthcare professional makes an official diagnosis of sexual
dysfunction, they will look at your physical and mental health history.
They will also ask you questions about your sex life.
For the healthcare professional to make a diagnosis, the problem had
to persist for a minimum of 6 months and occur 75% to 100% of the
time.

A doctor may look for the following symptoms that could suggest a
sexual dysfunction:

difficulty getting aroused

lack of interest in having sex

pain during intercourse

You must be experiencing significant distress about these issues for the
condition to be considered a sexual dysfunction. It’s important to note
that some people are not distressed about not being interested in
having sex. These people would not receive a sexual dysfunction
diagnosis.For example, someone who is asexual does not experience
much sexual attraction or experiences none at all. This is normal and
just as valid as any other shade of sexuality.

Descriptions of each sexual disorder

Delayed ejaculation

Delayed ejaculation occurs when people with a penis have trouble

reaching ejaculation or take a longer time than they would like to
ejaculate. There are physical and psychological factors that may cause
delayed ejaculation, such as a medical condition or fear of intimacy.

Talking with a doctor will help you determine the cause of this
condition and whether medication might help. These might include
drugs that treat physical issues, such as Viagra, or antidepressants for
psychological issues.

Erectile disorder

Erectile disorder is also known as erectile dysfunction. You might have

this condition if you have trouble maintaining an erection throughout
sexual intercourse.

Erectile disorder is common in people with a penis as they get older.

About 30 million people who identify as menTrusted Source in the
United States experience it.

The good news is you can reduce your chances of erectile disorder by
taking steps to maintain your health.

Consider eating healthier meals, limiting your alcohol intake, and

exercising regularly. Your doctor can also prescribe medication to
increase blood flow in your genitals and increase sexual stimulation.

Female orgasmic disorder

Female orgasmic disorder happens when people with a vulva have

difficulty reaching orgasm. There may be biological or psychological
factors influencing this, or both.

If you experience female orgasmic disorder, a healthcare professional

may help you treat the condition with a combination of cognitive
behavioral therapy (CBT) and physical therapy.

Female sexual interest/arousal disorder

The DSM-5 now considers hypoactive sexual interest and female sexual
arousal disorder to be the same condition, called female sexual
interest/arousal disorder.

This condition involves a low level of — or a lack of — sexual

excitement or pleasure. People also have trouble feeling physically
aroused during sex.

Genito-pelvic pain/penetration disorder

This occurs when people with a vagina feel pain during vaginal
intercourse. You might have this disorder if you experience one of the
following symptoms:

pelvic pain during intercourse

pain during penetration

recurring fear or anxiety of possible pain during sex

pelvic muscles that tend to become tense during penetration

Male hypoactive sexual desire disorder

A diagnosis of this disorder means you have little to no interest in

thinking about or having sex. The lack of sexual desire needs to persist
for 6 months and cause

Premature or early ejaculation

Premature or early ejaculation is a disorder where a person with a

penis orgasms and releases semen much sooner than they expect or
want during sex. About 1 in 3 people who are biologically male from
ages 18 to 59 experience this issue, according to experts. The condition
often has a psychological cause, but at times, it can also be biological.
Substance/medication-induced sexual dysfunction

If you’re on medication and having problems with having sex, you may
be experiencing substance/medication-induced sexual dysfunction.

Research reports that using some drugs regularly, such as MDMA,

can cause delayed orgasms and erectile dysfunction.

Heavy alcohol use can reduce sexual arousal in females and suppress
testosterone in males, making it hard to maintain an erection.
Prescribed medications can also produce sexual dysfunction. These can
include antidepressants and blood pressure medication.

Paraphilias

Paraphilias are conditions involving a persistent sexual interest in

inanimate objects or activities that are atypical.

If you have a paraphilic disorder, you not only have a recurring sexual
interest but your interest or behavior causes severe distress

Pedophilic disorder

Pedophilic disorder is a condition where you feel a persistent sexual

attraction toward a minor.

The DSM-5 updated the diagnosis of pedophilia to distinguish it from

pedophilic disorder. Pedophilic disorder involves recurring sexual
thoughts and urges toward a child that impairs your ability to function.
Some people with symptoms of pedophilic disorder may act out their
urges, such as by watching child pornography.

Exhibitionistic disorder
Exhibitionistic disorder is a sexual disorder where you get sexually
aroused by exposing your genitals or acting out sexual acts for a
stranger to see.

Voyeuristic disorder

Voyeuristic disorder is the chronic urge to observe a person naked,

undressing, or engaging in sexual activity without their consent.

Sexual sadism disorder

Sexual sadism disorder is when you enjoy sexual activities involving the
extreme pain, suffering, or humiliation of another person.

Sexual masochism disorder

This is when you receive sexual pleasure from experiencing extreme
pain or suffering.

Frotteuristic disorder
Frotteuristic disorder is when you get sexual pleasure from rubbing
your genitals on an unsuspecting person without their consent.

Fetishism

Fetishism is a condition where your sexual fantasies or activities depend

on using inanimate objects, such as shoes, or nonsexual body parts,
such as feet or hair.

It becomes a disorder when people feel extreme distress over it or the

behavior starts to impair their everyday life.

What is sex addiction?

If you find yourself preoccupied with sexual urges or thoughts, and it’s
impacting your relationships and your ability to function, it might be a
sign of something more serious.

Having an honest conversation with a healthcare professional can help

if you’re experiencing challenging sexual thoughts or behavior.

Gender dysphoria

Gender dysphoria is a feeling of distress you experience when your sex

assigned at birth does not match your gender identity. Not every
person who is transgender or gender diverse will experience gender
dysphoria

INFERTILITY
Infertility is a condition where you can’t get pregnant after one
year of trying to conceive. Infertility is a condition of your
reproductive system that causes people to be unable to get
pregnant (conceive). Infertility can affect anyone and has many
causes.
What are the types of infertility?
Primary infertility: You’ve never been pregnant and can’t
conceive after one year (or six months if you’re 35 or older) of
regular, unprotected sexual intercourse.
Secondary infertility: You can’t get pregnant again after having
at least one successful pregnancy.
Unexplained infertility: Fertility testing hasn’t found a reason
that a person or couple is unable to get pregnant.
How common is infertility?
Infertility affects men and people assigned male at birth
(AMAB) and women and people assigned female (AFAB) at birth
equally. Infertility is very common. In the United States, 1 in 5
women between 15 and 49 years old struggle with primary
infertility and about 1 in 20 women struggle with secondary
infertility. Approximately 48 million couples live with infertility
around the world.
SYMPTOMS AND CAUSES
The main sign of infertility is being unable to get pregnant after
six months or one year of regular, unprotected sex. You may
not have any other symptoms. But some people may show
physical symptoms such as:
•Pelvic or abdominal pain.
•Irregular vaginal bleeding, irregular periods or no periods.
•Penile disorders or issues with ejaculation.
Causes of infertility
While causes of infertility vary, studies show that:
•33% of infertility involves the partner with a uterus and
ovaries.
•33% of infertility involves the partner with a penis and
testicles.
•33% of infertility involves both partners or is unexplained.
•Twenty-five percent of infertile couples have more than one
factor that contributes to their infertility.
Some causes of infertility affect just one partner, while others
affect both partners.

Risk factors for infertility include:

•Age, particularly being in your late 30s or 40s. For men, age
begins affecting fertility closer to 50.
•Eating disorders, including anorexia nervosa and bulimia.
•Excessive alcohol consumption.
•Exposure to environmental toxins, such as chemicals, lead and
pesticides.
•Over-exercising.
•Radiation therapy or chemotherapy.
•Sexually transmitted infections (STIs).
•Smoking and using tobacco products. (This behavior plays a
role in about 13% to 15% of infertility cases.)
•Substance abuse.
•Having obesity or being underweight.
•Abnormalities of the hormone-producing centers of the brain
(hypothalamus or pituitary).
•Chronic conditions and diseases.
Infertility causes for women and people assigned female at
birth
•Ovulation disorders are the most common cause of infertility
in people with ovaries. Ovulation is the process in which your
ovary releases an egg to meet sperm for fertilization. These
factors can contribute to female infertility:
Endometriosis.
Structural abnormalities of your vagina, uterus or fallopian
tubes.
Autoimmune conditions like celiac disease or lupus.
Kidney disease.
Pelvic inflammatory disease (PID).
Hypothalamic and pituitary gland disorders.
Polycystic ovary syndrome (PCOS).
Primary ovarian insufficiency or poor egg quality.
Sickle cell anemia.
Uterine fibroids or uterine polyps.
Thyroid disease.
Prior surgical sterilization (tubal ligation or salpingectomy).
Genetic or chromosomal disorders.
Sexual dysfunction.
Surgical or congenital absence of your ovaries.
Infrequent or absent menstrual periods.
Infertility causes for men and people assigned male at birth
The most common cause of male infertility involves problems
with the shape, movement (motility) or amount (low sperm
count) of sperm.
Other causes of male infertility include:
_Enlarged veins (varicocele) in your scrotum, the sac that holds
your testicles.
_Genetic disorders, such as cystic fibrosis.
_Chromosomal disorders, such as Klinefelter syndrome.
_High heat exposure to your testicles from tight clothing,
frequent use of hot tubs and saunas, and holding laptops or
heating pads on or near your testes.
_Injury to your scrotum or testicles.
_Low testosterone (hypogonadism).
_Misuse of anabolic steroids.
_Sexual dysfunction, such as erectile dysfunction,
anejaculation, premature ejaculation or retrograde ejaculation.
_Undescended testicles.
_Previous chemotherapy or radiation therapy.
_Surgical or congenital absence of testes.
_Prior surgical sterilization (vasectomy).

female infertility diagnoses

These tests can help diagnose or rule out problems:
Pelvic exam: to check for structural problems or signs of
disease.
Blood test: A blood test can check hormone levels to see if
hormonal imbalance is a factor or if you’re ovulating.
Transvaginal ultrasound: inserts an ultrasound wand into the
vagina to look for issues with reproductive system.
Hysteroscopy: the provider inserts a thin, lighted tube
(hysteroscope) into the vagina to examine the uterus.
Saline sonohysterogram (SIS): fills the uterus with saline
(sterilized salt water) and conducts a transvaginal ultrasound.
Sono hysterosalpingogram (HSG): the provider fills the
fallopian tubes with saline and air bubbles during an SIS
procedure to check for tubal blockages.
X-ray hysterosalpingogram (HSG): X-rays capture an injectable
dye as it travels through your fallopian tubes. This test looks for
blockages.
Laparoscopy: Your provider inserts a laparoscope (thin tube
with a camera) into a small abdominal incision. It helps identify
problems like endometriosis, uterine fibroids and scar tissue.
Male infertility diagnoses
Diagnosing infertility in people with a penis typically involves
making sure a person ejaculates healthy sperm. Most fertility
tests look for problems with sperm.
These tests can help diagnose or rule out problems:
Semen analysis: This test checks for low sperm count and poor
sperm mobility. Some people need a needle biopsy to remove
sperm from their testicles for testing.
Blood test: A blood test can check thyroid and other hormone
levels. Genetic blood tests look for chromosomal abnormalities.
Scrotal ultrasound: An ultrasound of your scrotum identifies
varicoceles or other testicular problems.

MANAGEMENT AND TREATMENT

Treatment for infertility depends mostly on the cause and your
goals. Your age, how long you’ve been trying to conceive and
your personal preferences are factors in deciding on a
treatment. Sometimes, one person needs treatment, but other
times, treatment involves both partners.
In most cases, people and couples with infertility have a high
chance of pregnancy. Things like medication, surgery or
assisted reproductive technology (ART) can help. Often, lifestyle
changes or improving the frequency and timing of intercourse
can improve your chances of pregnancy. Treatment can also
include a combination of methods.
Infertility treatment in women
Treatments for infertility in women and people assigned female
at birth include:
1. Lifestyle modification: Gaining or losing weight, stopping
smoking or using drugs, and improving other health conditions
can improve your chance of pregnancy.
2. Medications: Fertility drugs stimulate your ovaries to ovulate
more eggs, which increases your chance of getting pregnant.
3. Surgery: Surgery can open blocked fallopian tubes and
remove polyps, fibroids or scar tissue.
Providers may make suggestions on how to improve your
odds of conceiving. These may include things like:
_Tracking ovulation through basal body temperature, using a
fertility tracking app and noting the texture of the cervical
mucus.
_Using a home ovulation kit, a kit you can purchase at the drug
store or online to help predict ovulation.
Infertility treatment for men
•Medications: Medications can raise testosterone or other
hormone levels. There are also drugs for erectile dysfunction to
help you maintain an erection during sex.
•Surgery: Some men need surgery to open blockages in the
tubes that carry sperm or to repair structural problems.
Varicocele surgery can make sperm healthier and improve the
odds of conception.
common fertility treatments
Some couples need more help conceiving using assisted
reproductive technology (ART). ART is any fertility treatment
that involves a healthcare provider handling the sperm or egg.
To increase pregnancy odds, you can take medications to
stimulate ovulation before trying one of these options:
In vitro fertilization (IVF): IVF involves retrieving eggs from your
ovary, then placing them with sperm in a lab dish. The sperm
fertilizes the eggs. A provider transfers one to three of the
fertilized eggs (embryos) into your uterus.
Intracytoplasmic sperm injection (ICSI): This procedure may be
performed during the IVF process. An embryologist injects a
single sperm directly into each egg. Then, a provider transfers
one to three of the embryos into your uterus.
Intrauterine insemination (IUI): A healthcare provider uses a
long, thin tube to place sperm directly into your uterus. IUI is
sometimes called artificial insemination.
Assisted hatching: A process that involves opening the outer
layer of an embryo to make it easier for it to implant in your
uterine lining.
Third-party ART: Couples may use donor eggs, donor sperm or
donor embryos. Some couples need a gestational carrier or
surrogate.
Complications of treatment
Complications of infertility treatment include:
_Higher chance of multiples (twins, triplets or more): Producing
multiple eggs and transferring more than one embryo increases
your risk of becoming pregnant with more than one fetus.
Complications such as miscarriage, premature birth, low birth
weight, neonatal death, and long-term health complications are
more common in people pregnant with multiple fetuses.
Ovarian hyperstimulation syndrome (OHSS): A condition that
causes painful and swollen ovaries as a result of fertility
medications. It can become serious and require immediate
medical attention.
Ectopic pregnancy: IVF has an increased risk of ectopic
pregnancy.
Failed cycles: A failed cycle is when you go through infertility
treatment and it doesn’t end in pregnancy.
Can infertility be cured?
Yes, but it depends on the cause. In 85% to 90% of cases,
lifestyle modification, medication, ART or surgery can treat
infertility and allow a person to conceive.
PREVENTION
How can I prevent infertility?
You can take these steps to protect your fertility, especially
while trying to conceive:
Eat a well-balanced diet and maintain a weight that’s healthy
for you.
Don’t smoke, misuse drugs or drink alcohol.
Get treated for STIs.
Limit exposure to environmental toxins.
Stay physically active, but don’t overdo exercise.
Don’t delay conception until an advanced age.
Undergo fertility preservation procedures (freezing eggs or
sperm).
PROGNOSIS
Approximately 9 out of 10 couples get pregnant after
undergoing fertility treatments. Success rates vary depending
on the cause of infertility, the couple’s ages and other factors.
Infertility has emotional, physical, financial and psychological
side effects. Don’t forget to practice self-care and be patient
with yourself and your partner throughout the process.
Infertility isn’t easy, so surround yourself with supportive
people or consider joining an online support group. Sometimes,
sharing your feelings with people who understand what you’re
going through can be helpful.
UNIT FOUR. Abortion
Abortion is the termination of pregnancy or expulsion of the
fetus either spontaneously or by induction before it reaches
viability i.e before 20 weeks of gestation in developed country
and 28 weeks of gestation in developing country.
Between 10 and 15% of all pregnancies terminate as
spontaneous abortions, and a further 10-60% are terminated
by an inducedabortion. The majority of spontaneous abortions
occur between the 8th and 12th weeks of pregnancy.

5.1.1 Causes of Abortion

The causes of abortioncan conveniently be divided into three
groups -ova-fetal, maternal and paternal.
In the early weeks (0 to 10) of pregnancy, when most abortions
occur, ova-fetal factors pre dominant, but in the latter weeks
(11 to 19) maternal factors become more common and the
fetus is often born fresh and apparently normal, although too
immature to survive.
Fetal causes
Chromosomal abnormality or disease of the fertilized ovum
may account for 60% of spontaneous, first trimester abortions.
Malformation of the trophoblast and poor implantation of the
blastocyst may result in placental separation with consequent
hypoxia and impaired embryonic development.
Maternal cause
Disease acquired during pregnancy such as rubella or influenza,
especially if they are accompanied by acute fever, interfere
with transplacental oxygenation and may precipitate abortion.
Chronic disorders, e.g renal disease accompanied by
hypertension, may have a similar effect.
Drugs large doses of any drug are poisonous and should be
avoided
ABO incompatibility between mother and embryo may result
in abortion.
Local disorders of the genital tract
- A retroverted uterus which is unable to rise out of the pelvis
may occasionally predispose to abortion.
- Developmental defects such as a bicornuate uterus and
myomas
- Cervical incompetence
Paternal causes
Since the paternal spermatozoon gives to the ovum half of its
chromosomes, defects may result in abortions, particularly if
both partners share many common HLA antigen sites.
Risk factors for spontaneous abortion include:
Classifications of Abortion
Abortion can either be spontaneous or induced. Spontaneous
abortion often referred to as miscarriage, describes the
termination of pregnancy without action taken by the woman
or any other person whereas Induced abortion referred to a
deliberate interference with the
pregnancy for the sake of terminating it.
Spontaneous abortion
Spontaneous abortion is non-induced embryonic or fetal death
or passage of products of conception before 20 weeks
gestation.
Sign and symptoms- many mothers will speak of a period of
uneasiness prior to the onset of specific sign and symptoms.
Vaginal bleeding is generally the earliest sign of an impending
abortion. The bleeding may consist of a bloodstained discharge,
brown spotting or a bright red loss, which may be variable in
amount. Pain is usually felt in a central position, low in the
abdomen, and is intermittent in character due to uterine
contractions. This may be accompanied by backache.

Threatened Abortion
. Threatened abortion is vaginal bleeding without cervical
dilation occurring before 20 weeks of gestation and indicating
that spontaneous abortion may occur in a woman with a
confirmed viable intrauterine pregnancy. Diagnosis is by clinical
criteria and ultrasonography.

Manifestations
- The bleeding is not usually severe
- The cervical os is found to be closed & no effect
- Uterine cramping and pain; occasionally lower abdominal pain
and backache.
- The membrane remains intact and no tissue is passed.
Treatments: is usually expectant observation for threatened
abortion and, if spontaneous abortion has occurred or appears
unavoidable, observation or uterine evacuation. It is essential
that the mother is encouraged to rest in bed with the minimum
of disturbance. A mild sedative may be prescribed to aid
relaxation and analgesia may be given for pain.
All loss per vagina should be observed and recorded.
Vital signs should be taken and recorded appropriately
After the bleeding, a speculum examination is performed to
exclude local lesions and to note the state of the cervical os.
48 hours after the bleeding ceases, the mother can commence
gentle ambulation and if in hospital, she may return home.
Outcomes of threatened abortion
- 70-80% of all mothers diagnosed as having threatened
abortion in the first trimester will continue with their
pregnancies to term.
Missed abortion
This is the term applied to the fetus which is died and is
retained with its placenta in the uterus. Early ultrasonic scan
may identify missed abortion before the mother experiences
any symptoms.
 - Pain and bleeding may cease but the mother may experience
a residual brown vaginal discharge as having an odour of
decaying matter and it can be offensive and distressing.
- All other physiological signs of pregnancy will regress, uterine
enlargement will cease and a pregnancy test will prove
negative.
Manifestation
• Uterus stops increasing in size
• There may be decrease in uterine size
• Early signs of pregnancy disappear

• Usually no accompanying vaginal bleed

• No uterine cramp
• Closed cervix
Treatment: Some obstetricians prefer not to treat a missed
abortion actively as the dead conceptus will be expelled
eventually.
Alternatively prostaglandin E2 may be given to induce expulsion
in conjunction with i.v
oxytocin or a vacuum aspiration of the uterine contents may be
performed.
Blood coagulation disorders may develop in cases of missed
abortion which persists for over 6-8 weeks.
Inevitable Abortion
When it is impossible for the pregnancy to continue it is termed
as inevitable abortion. Profuse vaginal bleeding which suggests
that a large section of the placenta has separated from the
uterine wall. The abdominal pain becomes more acute and
rhythmic in character. The membranes may have ruptured and
amniotic fluid will be seen. Alternatively the fetal sac and its
contents, and possibly the placenta, will protrude through the
dilating cervical os. Bleeding and uterine contractions will
continue and all or part of the conceptus will be expelled
vaginally.
Complete Abortion
A complete abortion is more likely to occur prior to the 8th
week of pregnancy and constitutes the expulsion of the
embryo, placenta and intact membranes. There is relief from
pain and the bleeding usually stops.
Incomplete Abortion
When the products of conception are only partially evacuated
during abortion, the abortion is incomplete. This usually occurs
in the second trimester. Bleeding is profuse but the abdominal
pain and back ache may cease.
The cervix will be soft and purplish in colour and will be partly
closed. Prolonged retention of the tissues predisposes the
woman to infection and immediate medical intervention is
needed.
Treatment: Specific treatment prior to the 12th week will
include the administration of ergometrine 0.5mg i.m to expel
the uterine contents and reduce bleeding from the placental
site followed by evacuation of any tissue retained. The latter
procedure is carried out under general anaesthesia.
After 12 week an oxytocin infusion will be administered using a
pump. A dose of ergometrine will be given on completion of
surgery. Uterine aspiration is commonly used but where this is
not available the uterus will be evacuated digitally or by
dilatation and curettage.
Recurrent Pregnancy Loss (Recurrent or Habitual Abortion)
This term is applied when a mother has had at least two
consecutive spontaneous abortions. The risk of further abortion
increases with each successive aborted pregnancy. The majority
of mothers who encounter this problem will lose their babies in
the early weeks of pregnancy. If a pregnancy continues
following a mid- trimester threatened abortion there is a
greater risk of preterm labour. Determining the cause may
require extensive evaluation of both parents. Some causes can
be treated.
Causes of recurrent pregnancy loss may be maternal, fetal, or
placental
Common maternal causes include:
•Uterine or cervical abnormalities (eg, polyps, myomas,
adhesions, cervical insufficiency)
•Maternal (or paternal) chromosomal abnormalities
•Overt and poorly controlled chronic disorders (e.g.
hypothyroidism, hyperthyroidism, diabetes mellitus,
hypertension), Chronic renal disorders
Placental causes include: pre-existing chronic disorders that are
poorly controlled (eg, SLE, chronic hypertension).
Fetal causes are usually Chromosomal or genetic
abnormalities and Anatomic malformations
Chromosomal abnormalities may cause 50% of recurrent
pregnancy losses; losses due to chromosomal abnormalities are
more common during early pregnancy.

Diagnosis
Clinical evaluation
Tests to identify the cause
The diagnosis of recurrent pregnancy loss is clinical.
Evaluation for recurrent pregnancy loss should include the following to help determine the
cause:
Genetic evaluation (karyotyping) of both parents and any products of conception as clinically
indicated to exclude possible genetic causes
Screening for acquired thrombotic disorders
Thyroid-stimulating hormone
Diabetes
Hysterosalpingography or sonohysterography to check for structural uterine abnormalities
Treatment
Treatment of the cause if possible
Some causes of recurrent pregnancy loss can be treated. If the cause cannot be identified, the
chance of a live birth in the next pregnancy is 35 to 85%.

Induced Abortion
 Therapeutic abortion
Legal termination of pregnancy is a therapeutic procedure carried out under the acts of abortion. It is
important to provide adequate counselling and support prior to and following the operation. Many
mothers do not make the decision to have a pregnancy terminated without some inner conflict. There
are religious, psychological, social and cultural factors, which affect the woman's decision.

Important considerations are her economic and marital status, the health and wellbeing of existing
children in the family and the presence of an abnormal fetus. A few may be advised on health grounds
to discontinue the pregnancy.

In the United Kingdom the 1967 Abortion act made the following provisions: Two registered
medical practitioners should be of the opinion that the pregnancy should be terminated.
- The continuance of the pregnancy would involve a risk to the life of the pregnant woman or of injury to
her physical and mental health.
- The continuance of the pregnancy would be detrimental to the health and well-being of the
existing children in the family.
- There is a substantial risk that the child when born would suffer from such physical or mental
abnormalities as to be seriously handicapped.

Methods of therapeutic abortion

• Before the 12th week of pregnancy vacuum aspiration is the chosen method of termination
of pregnancy as there is less blood loss. Alternatively dilatation and curettage may be performed.
•After the 12th week, a prostaglandin preparation will be used either intra or extra amniotically to
produce abortion within 48 hours.
•All terminations performed after 8 weeks gestation should be carried out in hospital where
resuscitation facilities are available.
Criminal abortion
A criminal abortion is one performed in contravention of legal abortion. Such procedures are illegal and
are punishable by imprisonment. The abortion is attempted by an unqualified, inexpert person. Injuries
to the birth canal and pelvic organs can occur if implements are inserted. It is usually the subsequent
bleeding which causes a mother to seek professional help and care should be given as for threatened
abortion until medical assistance arrives.
Septic abortion
Infection may occur following any abortion. It may be associated with incomplete abortion but is more
commonly found after an induced abortion. The infection may be limited to the decidual lining of the
uterus but virulent organisms may cause the infection to spread and involve the myometrium, fallopian
tubes

Symptoms and signs

Complaining of feeling unwell, Headache and nausea accompanied by sweating and shivering
On examination, the woman looks flushed, her skin will be hot to the touch and it may be clammy.
Spiking pyrexia in excess of 380C
Steadily rising pulse
After 12th week of pregnancy abdominal examination will identify tenderness of the uterus,
which will be bulky and soft in texture. The vaginal discharge will have an offensive odour and may be
pinkish in colour,

Specific investigations will include vaginal and cervical swabs, full blood culture and haematological
investigations.
Treatment
Amoxycillin 500 mg three times daily and metronidazole 200mg 6hourly is the treatment of
choice until bacteriological results are obtained, after which the antibiotic treatment will be
more appropriately prescribed.
Dilatation and curettage will be performed preferably after the acute infection subsides.

General management of abortion

•The woman with abortion must be admitted to gynaecological ward for close
observation and treatment
•History taking to obtain possible aetiological factors together with details of bleeding, pain and
products of conception expelled
•Perform a full physical examination
•Check and record vital signs i.e. temperature, pulse, respiration and blood pressure
•Observe aseptic technique when performing vaginal examinations
•Provide pads to observe severity of blood loss
•Put up intravenous fluids if the woman is bleeding severely i.e. normal saline, ringers lactate
•Check PCV, grouping and cross matching and arrange for blood donor as the case may be.
•Give antibiotics to treat infection in case of septic abortion

•Manual Vacuum Aspiration (MVA) is the method of choice for the management of incomplete or
inevitable abortion for gestation of 14 weeks or less, because it has fewer complications compared to
curettage
Complications of Abortion
• Acute Complications
Incomplete abortion
Sepsis
Haemorrhage
Uterine Perforation
Bowel injury
• Long-term Complications
Chronic pelvic pain
Pelvic inflammatory disease
Tubal blockage and secondary infertility
Ectopic pregnancy
Increased risk of spontaneous abortion or premature delivery in subsequent pregnancies
Counseling for family planning.

Birth spacing and postpartum family planning

Family planning is about deciding how many children you choose to have and when you want to have
them (timing of pregnancies and birth spacing). The recommended interval before attempting the next
pregnancy is at least 24 months in order to reduce risks to the mother and infant. A woman can become
pregnant within several weeks after birth if she has sexual relations and if she is not breastfeeding
exclusively. It is important that as a health worker you discuss the importance of family planning and
birth spacing, and help couples in choosing the contraceptive method that is right for them.

The role of family planning counselling is to support a woman and her partner in choosing the method of
family planning that best suits them and to support them in solving any problems that may arise with
the selected method. During late pregnancy, after giving birth and after an abortion, it is important that
the woman or the couple receives and discusses correct and appropriate information so that they can
choose a method which best meets their needs. If a woman, preferably with her partner, is able to make
an informed choice, she is more likely to be satisfied with the method chosen and continue its use.

THE HEALTH BENEFITS OF BIRTH SPACING AND FAMILY PLANNING

•Delaying having children can give people the opportunity to complete education or further studies

•Waiting to become pregnant at least 24 months after birth can lead to health benefits for the mother
and baby.

•Spacing births allows the mother to recover physically and emotionally before she gets pregnant again,
and faces the demands of pregnancy, birth and breastfeeding.

•Limiting the number of children in a family means more resources for each child and more time for the
parents to dedicate to each child.

•Family planning can also help couples in a sexual relationship not to be worried about the woman
getting pregnant.

•STIs including HIV/AIDS can also be prevented with correct and consistent use of condoms.

•Younger women (adolescents) can delay pregnancy until their bodies are mature and they are ready in
terms of their life course.

•Older women (over 35) can prevent unwanted pregnancies that are often risky for their health and can
lead to complications for both mothers and infants.

When to counsel on birth spacing

You should begin discussing family planning during pregnancy, particularly during the third trimester,
after birth and in the immediate postpartum period. Pregnant women need to know that if they are not
exclusively breastfeeding they can get pregnant as soon as four weeks after the birth of their baby, even
if they have not yet started their menstrual cycle. Several methods of family planning can be started
immediately after birth, but others may need to be delayed if the woman is breastfeeding.

If the woman wants female sterilization or an Intrauterine Device (IUD) inserted immediately after
childbirth, she should inform her birth attendant and plan to give birth in a health facility.

Advise women about the benefits of using breastfeeding as a family planning choice, known as the
Lactational Amenorrhoea Method (LAM). LAM provides protection when the following three
requirements are met:

_the woman is exclusively breastfeeding a baby, day and night during the first six months after birth and
her menstrual periods have not returned.

Counselling a woman on family planning after an abortion

When advising a woman how to care for herself after an abortion. remember that it is important to
discuss the use of a family planning method to prevent another unwanted pregnancy. Explain that she
can become pregnant as soon as two weeks after an abortion if she begins to have sexual relations. A
woman who has recently experienced an induced or spontaneous abortion should wait at least six
months before another pregnancy to reduce risks to her health and to her future baby. You can support
her and her partner in choosing a method that meets their needs:

If she has no post-abortion complications or infection, she can safely use any family planning method,
and can start all methods immediately post-abortion (except for the natural calendar method, when she
should wait for 3 months).

If an infection is present or suspected, advise her to avoid intercourse until the infection is ruled out or
fully treated. Delay female sterilization and IUD insertion until an infection is fully treated, but offer
other methods to use in the meantime.

For IUD insertion or female sterilization after a second trimester abortion, the provider may need special
training because of the changed uterine size and the position of the fallopian tubes.

If she thinks she could be at risk of getting STI/HIV, she should use a condom in all sexual relations.

It may also be helpful to explain emergency contraception, and offer her emergency contraceptive pills
to take home in case she needs them.

Male partner

The partner should be encouraged to take part in family planning counselling sessions, especially if the
chosen method involves his cooperation, for example, condoms or natural methods. In some places
research has shown that family planning method use is more successful when partners choose and
agree upon a method together. First, ask the woman whether she would be happy for her partner to be
involved. In some cases women may feel more comfortable if their partners are not present or if their
partners are counselled on their own and/or by a male counsellor.

Family planning counselling — the BRAIDED approach

The acronym BRAIDED can help you remember what to talk about when you counsel clients on specific
methods. It stands for:

B Benefits of the method

R Risks of the method, including consequences of method failure

A Alternatives to the method (including abstinence and no method)

I Inquiries about the method (individual’s right and responsibility to ask)

D Decision to withdraw from using the method, without penalty

E Explanation of the method chosen

D Documentation of the session for your own records.

Steps in family planning counselling: the GATHER approach

When you counsel a new client in your village about family planning, you should follow a step-by-step
process. GATHER is an acronym that will help you remember the 6 basic steps for family planning
counselling. It is important to know that not every new client in your village needs all the steps — you
need to use the GATHER approach sensitively so that it is appropriate to each client’s need. Within your
community you may need to give more attention to one step than another.

Family planning counselling — the GATHER approach

G Greet the client respectfully.

A Ask them about their family planning needs.

T Tell them about different contraceptive options and methods.

H Help them to make decisions about choices of methods.

E Explain and demonstrate how to use the methods.

R Return/refer; schedule and carry out a return visit and follow up.

Unit five menopause

Menopause is diagnosed once a woman’s menstrual periods have stopped altogether for 12 months. It’s
a natural part of the aging process that’s caused by the depletion of the hormones estrogen, follicle-
stimulating hormone (FSH), testosterone and progestogen. At the start of menopause, the ovaries stop
functioning correctly so that neither ovulation nor menstruation occur and there’s a sharp decline in the
hormones produced. Once menopause has finished, a woman can no longer have any children.

Some factors can lead to the early onset of menopause, such as if a woman has had her uterus or
ovaries removed. Other behaviour can lead to a deficiency in hormone levels, which speeds up the
process. This can include having a poor diet, drinking excessively or suffering from obesity.

For people with ovaries, having a period is a fact of life, but so too is losing it. Menopause is a normal
part of aging and natural transition all females experience. It occurs when the ovaries stop producing
eggs and the reproductive hormones decline — marking the end of menstruation and fertility. For most
females, menopause begins between the ages of 40 and 55. However, it can start earlier for individuals
who experience premature ovarian failure or have surgical removal of both ovaries at a young age.

But while menopause is a natural process, the changes to your body and mood may feel anything but
normal. The experience of menopause varies greatly amongst individuals. Some may barely notice any
symptoms, while others may experience all of them.

Menopause is divided into three basic stages:

perimenopause, menopause, and postmenopause. During this time, the ovaries begin to atrophy which
causes a decline in the production of the hormones that stimulate the menstrual cycle; estrogen and
progesterone. Additionally, as females age there is a natural decline in the number of eggs in the
ovaries. As a result, fertility declines. The transition from perimenopause to menopause to post-
menopause usually lasts seven years or longer.

Perimenopause/Premenopause

The perimenopause or pre-menopause stage occurs about three to five years before menopause. The
age at which females experience this stage can vary greatly. Most females begin to experience
symptoms in their mid to late forties. It is rare to notice symptoms prior to age 40.

During this stage, your estrogen and progesterone levels begin to fluctuate. You may begin to
experience mood changes, irregular menstrual cycles and other menopausal symptoms. During this
stage, it’s still possible to get pregnant, so continuing a form of birth control is important.

Menopause

Menopause is defined as the absence of menses for 12 straight months without other causes, such as
illness, medication or pregnancy. Once you reach menopause, you can no longer achieve pregnancy. The
average age of menopause is 51, but the age can vary greatly. Some enter this stage in their mid-forties
and others not until mid-fifties.
Post-menopause

The post-menopause stage signals the end of your reproductive years. While your ovaries produce low
levels of estrogen and progesterone, you no longer will ovulate or menstruate.

Once you enter the post-menopause stage, you’re in it for the rest of your life. You may continue to
have the same symptoms you experienced during the perimenopause and menopause stages for many
years after your final menstrual cycle. Fortunately, these symptoms tend to dissipate over time.
However, females in this stage are at an increased risk of heart disease and osteoporosis due to the
decrease in estrogen.

symptoms of menopause

All women experience menopause and it’s quite a sudden process, leading to a number of symptoms as
the body responds to the fast changes. These can include:

•Hot flushes

•Night sweats

•Mood swings

•nsomnia or sleep disturbances

•Elevated heart rate

•Mood changes, such as irritability, depression or anxiety

•Vaginal dryness or discomfort during intercourse

•Urinary incontinence or frequent urination

•Decreased libido e.t.c

•Nausea

•Weight gain

•Brain fog

•Hair loss

•A lack of energy

Andropause
Andropause is a gradual condition in men that’s caused by a decrease in testosterone levels. Not all men
are affected by andropause, which is one of the reasons it’s not widely known. The levels of
testosterone – which is the hormone that creates muscle mass, hair on the face and body and causes a
man’s voice to deepen – reduce very slowly, such as by 1% to 2% each year. Unlike menopause in
women, andropause in men doesn’t cause infertility.

Symptoms Of Andropause

Despite the gradual onset and effects of andropause, there are various symptoms that men can suffer
from, including:

•Erectile dysfunction

•Weight gain

•Hair loss

•Night sweats

•Reduced muscle mass

•Depression

•Anxiety

•Mood swings

•Hot flushes

•A low libido

•Brain fog

•A lack of energy

Treatment

Menopause requires no medical treatment. Instead, treatments focus on relieving the signs and
symptoms and preventing or managing chronic conditions that may occur with aging.
Treatments may include:

✓Hormone therapy. Estrogen therapy is the most effective treatment option for relieving
menopausal hot flashes. If you still have your uterus, you'll need progestin in addition to
estrogen. Estrogen also helps prevent bone loss. Long-term use of hormone therapy may have
some cardiovascular and breast cancer risks, but starting hormones around the time of
menopause has shown benefits for some women.

√Vaginal estrogen. To relieve vaginal dryness, estrogen can be administered directly to the
vagina using a vaginal cream, tablet or ring. This treatment releases just a small amount of
estrogen, which is absorbed by the vaginal tissues. It can help relieve vaginal dryness,
discomfort with intercourse and some urinary symptoms.

√Low-dose antidepressants. Certain antidepressants related to the class of drugs called

selective serotonin reuptake inhibitors (SSRIs) may decrease menopausal hot flashes. A low-
dose antidepressant for management of hot flashes may be useful for women who can't take
estrogen for health reasons or for women who need an antidepressant for a mood disorder.

√Gabapentin (Gralise, Horizant, Neurontin). Gabapentin is approved to treat seizures, but it

has also been shown to help reduce hot flashes. This drug is useful in women who can't use
estrogen therapy and in those who also have nighttime hot flashes.

√Clonidine (Catapres, Kapvay). Clonidine, a pill or patch typically used to treat high blood
pressure, might provide some relief from hot flashes.

√Fezolinetant (Veozah). This medicine is a hormone-free option for treating menopause

hot flashes. It works by blocking a pathway in the brain that helps regulate body temperature.

√Medications to prevent or treat osteoporosis. Depending on individual needs, doctors

may recommend medication to prevent or treat osteoporosis. Several medications are available
that help reduce bone loss and risk of fractures. doctor might Lifestyle and home
remedies
Fortunately, many of the signs and symptoms associated with menopause are temporary. Take
these steps to help reduce or prevent their effects:

_Cool hot flashes. Dress in layers, have a cold glass of water or go somewhere cooler. Try to
pinpoint what triggers your hot flashes. For many women, triggers may include hot beverages,
caffeine, spicy foods, alcohol, stress, hot weather and even a warm room.

_Decrease vaginal discomfort. Try an over-the-counter, water-based vaginal lubricant

(Astroglide, K-Y jelly, Sliquid, others) or a silicone-based lubricant or moisturizer (Replens, K-Y
Liquibeads, Sliquid, others).

_Get enough sleep. Avoid caffeine, which can make it hard to get to sleep, and avoid drinking
too much alcohol, which can interrupt sleep. Exercise during the day, although not right before
bedtime. If hot flashes disturb your sleep, you may need to find a way to manage them before
you can get adequate rest.
Practice relaxation techniques. Techniques such as deep breathing, paced breathing, guided
imagery, massage and progressive muscle relaxation may help with menopausal symptoms. You
can find a number of books and online offerings that show different relaxation exercises.

Strengthen your pelvic floor. Pelvic floor muscle exercises, called Kegel exercises, can improve
some forms of urinary incontinence.

Eat a balanced diet. Include a of fruits, vegetables and whole grains. Limit saturated fats,
oils and sugars.

Don't smoke. Smoking increases your risk of heart disease, stroke, osteoporosis, cancer and a
range of other health problems. It may also increase hot flashes and bring on earlier
menopause.

Exercise regularly. Get regular physical activity or exercise on most days to help protect against
heart disease, diabetes, osteoporosis and other conditions associated with aging.

Unit 6: Female genital mutilation/ Cutting

Female genital mutilation (FGM) is a traditional harmful practice that involves the partial or total
removal of external female genitalia or other injury to female genital organs for non-medical reasons. It
is estimated that more than 200 million girls and women alive today have undergone female genital
mutilation in the countries where the practice is concentrated. In addition, every year an estimated 3
million girls are at risk of undergoing female genital mutilation, the majority of whom are cut before
they turn 15 years old.

FGM has no health benefits. It can lead to immediate health risks, as well as long-term complications to
women’s physical, mental and sexual health and well-being.

The practice is recognized internationally as a violation of human rights of girls and women and as an
extreme form of gender discrimination, reflecting deep-rooted inequality between the sexes. As it is
practiced on young girls without consent, it is a violation of the rights of children. FGM also violates a
person's rights to health, security and physical integrity, the right to be free from torture and cruel,
inhuman or degrading treatment, and the right to life when the procedure results in death. As part of
the Sustainable Development Goals, the global community has set a target to abandon the practice of
female genital mutilation by the year 2030.

Types of FGM

The World Health Organisation has classified FGM into four different types

Type I – Clitoridectomy
Partial or total removal of the clitoris (a small, sensitive and erectile part of the female genitals) and/or
the prepuce (the clitoral hood or fold of skin surrounding the clitoris).

Type II – Excision

Partial or total removal of the clitoris and the inner labia, with or without excision of the outer labia (the
labia are the ‘lips’ that surround the vagina).

Type III – Infibulation

Narrowing of the vaginal opening by creating a covering seal. The seal is formed by cutting and
repositioning the inner or outer labia, with or without removal of the clitoris..

Type IV – Other

All other harmful procedures to the female genitalia for non-medical purposes, eg, pricking, piercing,
incising, scraping and cauterising (burning) the genital area..

What are the health consequences of FGM?

•Death

•Severe pain and shock

•Broken limbs from being held down

•Injury to adjacent tissues

•Urine retention

•Increased risk of HIV and AIDS

•Uterus, vaginal and pelvic infections

•Cysts and neuromas

•Increased risk of fistula

•Complications in childbirth

•Depression and post-natal depression

•Psychosexual problems

•Pregnancy and childbirth

•Sexual dysfunction

•Difficulties in menstruation
•Trauma and flashbacks

•Infertility

How should recent FGM be managed?

Healthcare professionals should be vigilant and aware of the clinical signs and symptoms of recent FGM,
which include pain, haemorrhage, infection and urinary retention. [New 2015] Examination findings
should be accurately recorded in the clinical records. Some type 4 FGM, where a small incision or cut is
made adjacent to or on the clitoris, can leave few, if any, visible signs when healed. Consideration
should be given to photographic documentation of the findings at acute presentation. [New 2015]
Legal and regulatory procedures must be followed. all women and girls with acute or recent FGM
require police and social services referral.
How should FGM be managed in gynaecological practice?
Women may be referred by their general practitioner (GP) to a hospital gynaecology clinic. The referral
should be directed to FGM services, if available, or to the designated consultant obstetrician and/or
gynaecologist responsible for the care of women and girls with FGM. Women should be able to self-
refer. [New 2015] All children with FGM or suspected FGM should be seen within child safeguarding
services.

Medicalized FGM/C
Medicalization is the situation in which health care professionals carry out FGM/C, whether in a health
facility or at home or elsewhere, often using surgical tools, anesthetics, and antiseptics in the hope of
mitigating immediate complications. This term also applies to performing re-infibulation, re-closure of
female external genitalia of women who had been de-infibulated to allow for sexual intercourse,
delivery, and/or related gynecologic procedures by doctors or nurse-midwives. It may also include
situations in which medical professionals administer painkillers or anesthestics, while cutting is done by
the traditional excisor. In countries where health systems are overburdened and experience shortages
of health professionals, FGM/C may also be performed by employees who have no formal medical
training or clinical knowledge, such as apprentices or community health extension workers. This pseudo-
medicalization can involve the use of surgical tools, pain killers, and antiseptics, and thus may appear to
patients to be provided by trained health professionals. Hence, self-reported survey data on medicalized
cutting may conflate these two very different groups.

Health care providers who perform female genital mutilation are violating girls’ and women’s right to
life, right to physical integrity and right to health. They are also violating the fundamental medical
mandate to “do no harm,” and it represents a threat to efforts to eliminate the practice.

Here are 7 lessons from a community Plan International is working with in Mali on how to end this
harmful custom for good:

Education and counseling of FGM/C

1. Challenge the discriminatory reasons fgm is practised

Among the discriminatory reasons FGM is practised is a perceived need to control female sexuality.“The
purpose of female genital cutting is to ensure that a girl behaves properly, saves her virginity until she
gets married and then stays faithful to her husband.” says Alima, 70.

2. Change traditions with the support of older generations

“In the past, grandmothers used to tell fairy tales and fables containing concealed life lessons. But
nowadays children just don’t want to know. Similarly, grandmothers were the ones who provided sexual
education. We’ve lost that role too, but I think it should be reinstated.” says Ma,

3. Educate girls on their right to decide what happens to their body

“More and more children are going to school and learning to think for themselves,” says Sanaba. “No
child who is well informed and able to stand up for himself or herself wants the practice of genital
cutting to continue. I think women of my age should support teenage girls.”

4. Speak out about the risks and realities of FGM

FGM has lasting physical and mental consequences that need to be discussed so that girls and women
no longer have to suffer in silence.

5. Spread understanding that religion does not demand FGM

“People don’t seem to be able to distinguish between religion and traditional practices. They tend to see
them as one and the same thing.”

6. Tackle the secrecy that allows cutting to continue

“In the old days, genital cutting was an initiation rite for girls, to prepare them for their future. The
whole community would participate. But nowadays it’s become more controversial and it usually takes
place discreetly at home. And the girls who are cut are getting younger and younger. This is because the
younger a girl is, the less likely she’ll be to discuss it with her friends,” says Fatoumata.

7. Keep pushing for fgm to be banned

Djaminatou, a village educator trained by Plan International suggests that grassroots support for an end
to FGM will lead to an official ban.

“Cutting, is a violation of children’s rights: the right to physical integrity, the right to good health and the
freedom to make your own choices. It even violates a child’s right to be educated. If the wound
becomes infected because the cutter uses an unsterilised knife, for example, the girl will fall ill and be
unable to attend school.

Legislation
Penalties

The VAPP Act establishes the following criminal penalties for violation: The performance of FGM or
engagement of another to perform FGM carries a punishment of imprisonment not exceeding four years
or a fine not exceeding 200,000.00 Naira (US$554.808), or both.
 Attempting to perform FGM or engaging another to perform FGM carries a punishment of
imprisonment not exceeding two years or to a fine not exceeding 100,000.00 Naira (US$277.309), or
both.

 Anyone who incites, aids, abets, or counsels another person to perform FGM or engage another to
perform FGM is liable on conviction to a term of imprisonment not exceeding two years or to a fine not
exceeding 100,000.00 Naira (US$277.3010), or both.

Some individual states set out their own penalties for FGM. For example:
 Cross Rivers state – The Girl-Child Marriages and Female Circumcision (Prohibition) Law (2000),
Section 4 sets out that any person who performs FGM, offers herself for FGM, coerces, entices or
induces another to undergo FGM or allows any female who is either a daughter or ward to undergo FGM
is liable on conviction to a fine of not less than 10,000 Naira (US$27.7011) or to imprisonment not
exceeding two years for a first offender (and to imprisonment not exceeding three years without an
option of fine for each subsequent offence).
 Ebonyi state – Following introduction of the VAPP Act, it brought in a five-year prison sentence for
anyone who carries out FGM.
 Edo state – The Prohibition of Female Genital Mutilation Law (1999) sets out the penalty for
performing FGM as not less than three years’ imprisonment or a fine of not less than 3,000 Naira
(US$8.3012) or both.13
 Rivers state – The Child Rights Act (2009), Section 25 sets out that any person who directly or
indirectly causes a female child to be subjected to FGM is liable on conviction to a fine not exceeding
50,000 Naira (US$138.6014) or imprisonment for a term of one year, or both. In addition:
Punishments for medical malpractice under the Medical Act (2004), Section 16(2) include being struck
off the relevant professional register or suspension from practice for a period not exceeding six months.
A person who commits an offence regarding the removal of tissue under the National Health Act 2014
will be punished under Section 48(3)(a) with a fine of 1,000,000 Naira (US$2,77315) or imprisonment of
not less than two years, or both.

Other Harmful practice related to female reproductive system

1• Early marriage: Early marriage is associated with many health and social consequences. These
include:

Early pregnancy, which may lead to nutritional deficiencies for the mother and child Increased risk of
death due to pregnancy-related causes

Risks to baby include premature birth, low birth weight (reflecting poor nutritional status), fetal loss, and
neonatal mortality (death of the newborn within the first 28 days of life)
•Vaginal tear and fistula

•Sexual abuse

•Young married girls are less likely to participate in decision making.

2.Marriage by abduction: Marriage by abduction is the unlawful carrying away of a woman for marriage.
It is a form of sexual violence against the woman. The would-be abductor forms a group of intimate
friends and relatives to kidnap the girl without the slightest clue or information being given to the girl’s
family, relatives or friends. In some cases abduction is followed by rape.

3.Honour based violence or honor killings, where relatives, including fathers or brothers, kill girls in the
name of family ’honor’, for example, for having sex outside marriage, or refusing an arranged marriage.

Other types of gender based violence are any form of unwanted sexual contact (sexual abuse or
harassment), or even violence within a relationship or marriage.

4. Polygamy is a common practice in Nigeria. It is a form of marriage in which a person marries more
than one spouse. Polygyny (from Greek words: poly = many; gyny = woman) refers to a polygamy in
which a man has two or more wives.

5. Breast ironing Breast ironing, sometimes referred to as breast flattening, is a harmful practice that
generally involves the repetitive pounding, pressing, ironing, rubbing, or massaging of a pubescent girl’s
breasts, often using hard or heated objects, in order to attempt to stop or delay them from growing or
developing, make them flatter, or make them disappear. The practice can include the use of a variety of
objects, such as heated grinding stones, cast-iron pans, ladles, hammers, wooden pestles or spatulas,
spoons, brooms, or electric irons. Other objects that may be utilized include pits of black fruits, coconut
shells, plantain peels, and certain leaves or plants (which are believed to possess medicinal or healing
qualities). Breast ironing may also involve tightly wrapping or tying bandages, elastic compresses, cloths,
or belts around young girls’ chests.

Dangers of breasts ironing

Breast ironing is very painful. But apart from the immediate pains experienced by victims, the practice
can cause serious physical issues such as abscess, a painful collection of pus that develops under the
skin; cysts: fluid-filled lumps under the skin that can develop into abscesses, itching, constant pain,
burns due to the heated objects used, tissue damage.It can also cause infection, discharge of milk,
breasts becoming significantly different in shapes or sizes, fever, scarring, mastitis, an inflammation of
breast tissue, complete disappearance of one or both breasts, difficulty breastfeeding and an increased
likelihood of breast cancer.

Unit 7: Cancer
 Cancer refers to any one of a large number of diseases characterized by the development of abnormal
cells that divide uncontrollably and have the ability to infiltrate and destroy normal body tissue. Cancer
often has the ability to spread throughout your body.

Cancer is the second-leading cause of death in the world. But survival rates are improving for many
types of cancer, thanks to improvements in cancer screening, treatment and prevention.

Types of cancer of the representative organs

Reproductive cancers are cancers that occur in the reproductive organs. These are cancers in
the breast, cervix, uterus, vulva, endometrium or ovaries. Reproductive cancers can also be
found in the prostate, testicles and penis.

When cancer starts in a woman's reproductive organs, it is called gynecologic cancer. The five
main types of gynecologic cancer are: cervical, ovarian, uterine, vaginal, and vulvar. (A sixth
type of gynecologic cancer is the very rare fallopian tube cancer.)

Symptoms
Signs and symptoms caused by cancer will vary depending on what part of the body is affected.
Some general signs and symptoms associated with, but not specific to, cancer, include:

•Fatigue

•Lump or area of thickening that can be felt under the skin

•Weight changes, including unintended loss or gain

•Skin changes, such as yellowing, darkening or redness of the skin, sores that won't heal, or
changes to existing moles

•Changes in bowel or bladder habits

•Persistent cough or trouble breathing

•Difficulty swallowing

•Hoarseness

•Persistent indigestion or discomfort after eating

•Persistent, unexplained muscle or joint pain

•Persistent, unexplained fevers or night sweats

•Unexplained bleeding or bruising

Causes
Cancer is caused by changes (mutations) to the DNA within cells. The DNA inside a cell is
packaged into a large number of individual genes, each of which contains a set of instructions
telling the cell what functions to perform, as well as how to grow and divide. Errors in the
instructions can cause the cell to stop its normal function and may allow a cell to become
cancerous.

Types of Treatment
Gynecologic cancers are treated in several ways. It depends on the kind of cancer and how far it
has spread. Treatments may include surgery, chemotherapy, and radiation. Women with a
gynecologic cancer often get more than one kind of treatment.

Surgery: Doctors remove cancer tissue in an operation.

Chemotherapy: Using special medicines to shrink or kill the cancer. The drugs can be pills you
take or medicines given in your veins, or sometimes both.

Radiation: Using high-energy rays (similar to X-rays) to kill the cancer.

Risk factors
the majority of cancers occur in people who don't have any known risk factors. Factors known
to increase your risk of cancer include:

_Age

Cancer can take decades to develop. That's why most people diagnosed with cancer are 65 or
older. While it's more common in older adults, cancer isn't exclusively an adult disease —
cancer can be diagnosed at any age.

_Habits

Certain lifestyle choices are known to increase your risk of cancer. Smoking, drinking more than
one drink a day for women and up to two drinks a day for men, excessive exposure to the sun
or frequent blistering sunburns, being obese, and having unsafe sex can contribute to cancer.

_ Family history

Only a small portion of cancers are due to an inherited condition. If cancer is common in your
family, it's possible that mutations are being passed from one generation to the next.

_Health conditions
Some chronic health conditions, such as ulcerative colitis, can markedly increase the risk of
developing certain cancers.

_Environment

The environment around you may contain harmful chemicals that can increase the risk of
cancer. Even if you don't smoke, you might inhale secondhand smoke if you go where people
are smoking or if you live with someone who smokes. Chemicals in the home or workplace,
such as asbestos and benzene, also are associated with an increased risk of cancer.

Complications

Cancer and its treatment can cause several complications, including:

Pain. Pain can be caused by cancer or by cancer treatment, though not all cancer is painful.

Fatigue. Fatigue in people with cancer has many causes, but it can often be managed.

Difficulty breathing.

Nausea. Certain cancers and cancer treatments can cause nausea.

Diarrhea or constipation. Cancer and cancer treatment can affect your bowels and cause
diarrhea or constipation.

Weight loss. Cancer and cancer treatment may cause weight loss. Cancer steals food from
normal cells and deprives them of nutrients.

Chemical changes in your body. Cancer can upset the normal chemical balance in your body
and increase your risk of serious complications. Signs and symptoms of chemical imbalances
might include excessive thirst, frequent urination, constipation and confusion.

Brain and nervous system problems. Cancer can press on nearby nerves and cause pain and loss
of function of one part of your body. Cancer that involves the brain can cause headaches and
stroke-like signs and symptoms, such as weakness on one side of your body.

Unusual immune system reactions to cancer. In some cases the body's immune system may
react to the presence of cancer by attacking healthy cells. Called paraneoplastic syndromes,
these very rare reactions can lead to a variety of signs and symptoms, such as difficulty walking
and seizures.

Cancer that spreads. As cancer advances, it may spread (metastasize) to other parts of the
body. Where cancer spreads depends on the type of cancer.
Cancer that returns. Cancer survivors have a risk of cancer recurrence. Some cancers are more
likely to recur than others.

Prevention
Stop smoking. If you smoke, quit. If you don't smoke, don't start. Smoking is linked to several
types of cancer — not just lung cancer. Stopping now will reduce your risk of cancer in the
future.

Avoid excessive sun exposure.

Eat a healthy diet. Choose a diet rich in fruits and vegetables. Select whole grains and lean
proteins. Limit your intake of processed meats.

Exercise most days of the week. Regular exercise is linked to a lower risk of cancer. Aim for at
least 30 minutes of exercise most days of the week or longer.

Maintain a healthy weight. Being overweight or obese may increase your risk of cancer. Work
to achieve and maintain a healthy weight through a combination of a healthy diet and regular
exercise.

Drink alcohol in moderation, if you choose to drink. If you choose to drink alcohol, do so in
moderation. For healthy adults, that means up to one drink a day for women and up to two
drinks a day for men.

Schedule cancer screening exams. Talk to your doctor about what types of cancer screening
exams are best for you based on your risk factors.

Ask your doctor about immunizations. Certain viruses increase your risk of cancer.
Immunizations may help prevent those viruses, including hepatitis B, which increases the risk of
liver cancer, and human papillomavirus (HPV), which increases the risk of cervical cancer and
other cancers. Ask your doctor whether immunization against these viruses is appropriate for
you.

Screening and early diagnoses of reproductive cancer

Early detection of cancer greatly increases the chances for successful treatment. Early
diagnosis focuses on detecting symptomatic patients as early as possible, while screening
consists of testing healthy individuals to identify those having cancers before any symptoms
appear.

Iimproved accessibility and affordability of diagnosis and treatment services, and improved
referral from first to secondary and tertiary levels of care.
 Screening

Screening refers to the use of simple tests across a healthy population to identify those
individuals who have a disease, but do not yet have symptoms. Examples include breast cancer
screening using mammography or clinical breast exam, and cervical cancer screening using pap
smears, human papillomavirus test or visual inspection with acetic acid

•The PSA test is a blood test used primarily to screen for prostate cancer.

•A Pap smear, also alled a Pap test, is a procedure to test for cervical cancer in women. A Pap
smear involves collecting cells from your cervix — the lower, narrow end of your uterus that's
at the top of your vagina.

•VIA is a visual examination of the uterine cervix after application of 3-5% acetic acid.

Unit 8: Gender concept and gender based violence

WHAT IS GENDER-BASED VIOLENCE
Gender-based violence (GBV) is violence committed against a person because of
his or her sex or gender. It is forcing another person to do something against his
or her will through violence, coercion, threats, deception, cultural expectations,
or economic means. Although the majority of survivors of GBV are girls and
women, boys and men can also be targeted through GBV.

Forms of gender-based violence

There are several forms that gender-based violence can take:

Sexual violence is any act, attempted or threatened, that is sexual in nature and
carried out without the consent of the victim. Sexual violence includes rape,
sexual abuse and harassment, exploitation, and forced prostitution. It can happen
within marriages, especially when there is a lack of consent for sexual activity by
one of the spouses. Any sexual activity with a child (any person who has not yet
completed 18 years of age) constitutes sexual violence. It has devastating effects
on the development of the child involved, as well as on his or her physical and
mental health.
Physical violence such as beating, punching, maiming and killing (with or without
weapons) is often combined with non-violent forms of GBV, including emotional
and psychological violence.

Emotional or psychological violence is non-sexual, verbal abuse that is insulting

and degrading to the survivor. This can include isolating a person from his or her
friends and family, and restricting the person’s freedom of movement

Socio-economic violence, which excludes a person from participating in society.

This includes the denial of access of the person to health services, education and
work, and the denial of his or her civil, social, economic, cultural and political
rights.

Domestic violence is any physical, sexual, psychological, verbal and economic

violence between one person and another within the family. It may be committed
by family members and/or people considered as family members, whether or not
they live in the same household.

Harmful practices include female circumcision, honour killings, polygamous

marriages (marriages to more than one person), marriage of a child (any person
who has not yet completed 18 years of age) and forced marriage (any marriage
imposed against the will of a person or through being left with no other choice
than marriage).

Gender mainstreaming is an approach to policy-making that takes into

account both women's and men's interests and concerns. The concept of gender
mainstreaming was first introduced at the 1985 Nairobi World Conference on
Women. It was established as a strategy in international gender equality policy
through the Beijing Platform for Action, adopted at the 1995 Fourth United
Nations World Conference on Women in Beijing, and subsequently adopted as a
tool to promote gender equality at all levels. In 1998, the Council of Europe
defined gender mainstreaming as:

Gender mainstreaming means integrating a gender equality perspective at all

stages and levels of policies, programmes and projects. Women and men have
different needs and living conditions and circumstances, including unequal access
to and control over power, resources, human rights and institutions, including the
justice system. The situations of women and men also differ according to country,
region, age, ethnic or social origin, or other factors. The aim of gender
mainstreaming is to take into account these differences when designing,
implementing and evaluating policies, programmes and projects, so that they
benefit both women and men and do not increase inequality but enhance gender
equality. Gender mainstreaming aims to solve –sometimes hidden- gender
inequalities. It is therefore a tool for achieving gender equality.

Guiding principles for all actions

Organizations that agree to adhere to a set of guiding principles aimed at ensuring
staff are committed to integrating GBV into their work and are adequately skilled
to do so; and aimed at ensuring their programmes are gender sensitive,
collaborative and participatory.

Organizations should:
 Integrate and mainstream GBV interventions into all programmes and all
sectors.
 Establish and maintain carefully coordinated multi-sectoral and inter-
organizational interventions for GBV prevention and response.

 Extend the fullest cooperation and assistance between organizations and

institutions in preventing and responding to GBV. This includes sharing situation
analyses and assessment information to avoid duplication and to maximize a
shared understanding of situations.
 Engage the community fully in understanding and promoting gender equality
and gender power relations that protect and respect the rights of women and
girls.
 Ensure equal and active participation by women and men, girls and boys in
assessing, planning, implementing, monitoring, and evaluating programmes
through the systematic use of participatory methods.
 Ensure accountability at all levels to local communities and among all
humanitarian actors working in any sector.
 Ensure all staff understand and adhere to ethical and safety recommendations
for researching, documenting and monitoring sexual violence in emergencies
 Ensure all staff, contractors and volunteers involved in prevention of and
response to GBV understand and sign a code of conduct on Protection from
Sexual Exploitation and Abuse/Sexual Harassment or similar document setting out
the same standards of conduct.
Guiding principles for working with individual survivors
Guiding principles are a set of inter-related norms which are considered best
practice. The institutions/organizations that convene to be part of this multi-
sectoral mechanism to address GBV agree to adhere, without exception, to the
following set of principles that represent the foundation for their
interventions/assistance, referral, attitudes, and behaviours in addressing GBV:
•Safety and Security: Ensure the safety of the survivor, child and family at all
times. Remember that s/he may be frightened, and needs assurance that s/he is
safe. In all types of cases, ensure that s/he is not placed at risk of further harm by
the assailant. If necessary, undertake a safety assessment and ask for assistance
from security, police, elders, community leaders or others who can provide
security. Maintain awareness of safety and security of people who are helping the
survivor, such as family, friends, counsellors, health care workers, etc.
•Confidentiality: Respect the confidentiality of the survivor, child and their family
at all times. If the survivor gives his/her informed consent, share only relevant
information with others for the purpose of helping the survivor, such as referring
for services. All written information about survivors must be maintained in secure,
locked files. If any reports or statistics are to be made public, only the actors who
report data each month will have the authority to release such information,
guided by the ISP. All identifying personal information (name, address, etc.) will
be withheld in the reporting, compilation and sharing of data. Encourage other
community members and humanitarian actors to respect the confidentiality of
the survivor and not gossip about a case which may increase the stigma of the
survivor and discourage other survivors from seeking help in future. When
relating to children make sure they understand that you have to share the
information with their caretakers or other appointed legal guardian to ensure the
safety and security of the child.
•Informed Consent: All actors must receive informed consent from the survivor,
or legal guardian if working with a minor, prior to any response service or sharing
of information. If the survivor cannot read and write an informed consent
statement will be read up to the survivor and a verbal consent will be obtained.
The survivor should have the option to provide limited consent where they can
choose which information is released and which is kept confidential. The objective
of informed consent is that the survivor understands what s/he is consenting and
agreeing to. Children must be consulted and given all the information needed to
make an informed decision using child-friendly techniques that encourage them
to express themselves. Their ability to provide consent on the use of the
information and the credibility of the information will depend on their age,
maturity and ability to express themselves freely.
•Respect: Offer information about available support services and respect the
choice of the survivor concerning which services s/he wishes to access. Maintain a
non-judgmental manner; do not judge the person or her/his behaviour or
decision. Be patient; do not press for more information if s/he is not ready to
speak about it. Ensure that children are participating in the decision making
process of services they can access, and are involved in all decision making
processes regarding referral and access to services.
•Non-Discrimination and Impartiality: Ensure non-discrimination and impartiality
in all interactions with survivors and in all service provision. All actors should
provide services without discrimination based on age, sex, religion, clan, ethnicity,
wealth, language, nationality, status, political opinion, culture, etc. All actors must
be impartial.
•Do No Harm: When documenting, reporting, monitoring or providing a service to
a survivor, ensure that risks are not greater than the benefits to the survivor.

•Information: All survivors and those at risk have the right to accurate
information on what services are available, how to reach or access the services,
the potential risks and consequences of accepting additional services and not
accepting additional services. Make sure information is given to children in a
manner they understand and is child friendly. Information should be honest and
complete.
•Best Interest of the Child: In all cases concerning a child, the best interest of the
child should be the primary consideration. Apply all the listed guiding principles to
children, including their right to participate in decisions that will affect them. A
child should be listened to and believed in, and their concerns should be taken
seriously. If a decision is taken on behalf of the child, the best interests of the
child shall be the overriding guide and the appropriate procedures should be
followed. Best interest determination guidelines can also be consulted

•Privacy and Survivor’s Comfort: Ensure privacy before starting interviews with
survivors, this includes children. Avoid requiring him/her to repeat the story in
multiple interviews. Only ask survivors relevant questions. Be empathetic. Do not
show any disrespect for the individual or her/his culture or family or situation.
Where possible conduct interviews and examinations by staff of the same sex as
survivor unless there is no other staff available. Survivor’s comfort must always be
taken into consideration, and interview settings must reflect that.