#mereko aur zyada hai baat karna

[dream-to-be-frog]

honestly it was also like. god. hasn’t helene lost enough?? she saw five members of her family get cut down and literally bleed our right in front of her eyes and partially “her fault”, in a way that even though it wasn’t really her fault, she still had to cope with blaming herself for it. and yes they have all lost so much, but not quite like her. not as much all at once, in front of her eyes. not as much as her failure to save them, which is how she will think of it. and i love all the characters but helene is so interesting to me. laia is lovely but she is the main character, and that comes with some things given. elias was the love interest, so of course i would love him. helene aquilla was the fucking wild card. she was the one i never saw coming. and though i have far more in common with laia, something about the blood shrike calls to me. she was always older than her years, stronger than she realized. everyone underestimated her, and she knew this. and she still underestimated herself. the strength she is made of. keris took her living metal and she is still better. and while laia is a testament that people are survivors, helene is a testament to surviving despite loss. laia was written to survive, and to survive loss. helene was written only to survive loss. laia is the grief of thousands. helene is the grief of just one. i am lucky at least in that the survival of many is not a concern. and though i have not experienced as much loss as either, i do feel a little like i have been in mourning for so very long. and helene is also a sign to me that i can get through it. that if i can hold back the darkness, light will find its way.

ok i genuinely didn’t think avitas harper would genuinely die. like on one hand i love that sabaa committed to this war takes lives thing but also he was everything to me. what the fuck actually

[curraehospitals]

All You Need To Know About Dysmenorrhoea In Women

Today, We are going to talk about a very common problem which most of the girls, young girls, ladies who face is painful periods. Mahine ke time pe, MC ke time pe pain hona, and about endometriosis. Endometriosis is one of the reasons.

First, let me begin with what is painful periods, jisko hum log dysmenorrhoea bolte hai. Dysmenorrhoea matlab mahine ke time pe pain hona. Now, this can be either primary dysmenorrhoea or secondary dysmenorrhoea. Primary dysmenorrhoea jab hota hai to cramping hota hai, normally when there is no organic cause of pain, and it lasts… begins basically first 12 to 24 hours of period matlab jaisa hi humko mahina shuru hota hai, pahale 12 se 24 ghante tak rahata hai. Yahan koi organic cause nahi hai, matlab there is no reason for the pain to happen, okay. It’s basically because of the prostaglandins, jiske release hone pe pain hota hai. Secondary dysmenorrhoea hum usko bolte hai jab koi cause hai, koi reason hai pain ka, abhi yeh reason bohot cheezon ke wajah se ho sakta hai, where it can be endometriosis jiske bare me mai baat karungi, it can be adenomyosis, fibroids, yah agar kisine Copper T bidhaya ho, uske wajah se ho sakta hai, yah cervical stenosis, matlab jo hamara opening hai uterus ka, uska passage agar thoda sa tight ho to, to yeh reason hai.

Abhi normally, patient jo humko present karte hai, those patients present with severe pain in the abdomen, jo lower abdomen me jyada karke hota hai or when the pain radiates from the back radiating to the thighs yah agar secondary dysmenorrhoea hai to heavy menstrual flow, backache, bohot se logon ko iske dauran, menses ke dauran nausea hona yah vomiting hona yah chakkar ana, dhakan lagna, yeh sab symptoms hote hai. Abhi history jab hum lete hai, to jo primary dysmenorrhoea hai, uska history normally aise hota hai ki mereko jaise hi period ka date ane wala hai tab mujko ek 12 se 24 ghante pahale se pain shuru hota hai. Jabki secondary dysmenorrhoea jo hai unme jinko problem hai andar, unme yeh hota hai ki pain is usually continuous, pure 5 din rahana, pure 5 din rahata hai, heavy flow hona, jinme goliyon ka asar nai karna yah goli khane ke baujudh bhi pain hona yah when there is a cause like infection, to foul smell hona yah lower abdomen may bohot tez hona, urinary complaints hona, yah motion ke time pe problem hona, yeh sab symptoms secondary dysmenorrhoea me dikhte hai.

Abhi iska diagnosis hum kaise karte hai, pahali cheez to jab aap doctor ke pass jaoge to aapko ek sonography karne ka salah diya jayenga, just to rule out ki koi cause hai andar yah examination pe. Mainly, when the patient comes, hum examine karte hai. Abhi agar young girl hai, unmarried hai, not sexually active hai to hum unme internal examination nahi kar sakte but agar sexually active hai yah jinke hue hai, shadi hui hai, unme hum internal examination karke bhi humko pata chal jata hai. Uske baad sonography advise ki jati hai. Agar koi other reason hai jaise Copper T hua yah koi urinary infection hua to urine test honga, apka ek Pap smear honga. Yeh sab karke hum ek reason find out karte hai. Abhi is reason ke… on the basis of this investigation, hum treatment decide karte hai. Agar primary dysmenorrhoea hai yane sonography ka report normal hai, koi bhi pathology nahi hai, un cases me a mild painkiller or an antispasmodic should be more than enough, matlab jaisa jaisa age badenga larki ka yah jaise unki shaadi hongi, bacche honge, passage open honga to woh apne aap se yeh jo spasm ke wajah se jo pain hota hai, primary dysmenorrhoea me, woh release ho jata hai. Magar agar secondary dysmenorrhoea hai, jaise koi cause hai jaise endometriosis hai yah fibroid hai yah agar adenomyosis hai, to uske hisaab se fir treatment decide hota hai.

So now, I am going to discuss about endometriosis to begin with. Endometriosis basically kya hai? It is endometriotic tissue outside the uterus, matlab jo hamara menses ke time pe jo normally shed hota hai endometrium, woh uterus ke alawa kisi aur jagah pe uska maujudh hona. To abhi ye, humlog isko divide karte hai, into pelvic endometriosis yah extrapelvic endometriosis. Pelvis matlab jahan hamara uterus hai, to endometriosis aga tubes me hai, fallopian tubes me hai yah ovaries me hai yah uterus me hai, adenomyosis hai yah fir uterus ke side ki jo jagah hai, peritoneum jisko bolte hai wahan hai, usko yah bladder ke idhar hai, udhar usko pelvic endometriosis bolte hai. Abhi jo extrapelvic matlab endometriosis ka hona, yeh bahar ke taraf bhi ho sakta matlab uterus ke alawa bhi, to woh bohot se logon me bowel, that is intestines me uske components paye jate hai yah phir bladder me, matlab urinary jo hamara bag hai, wahan paya ja sakta hai, yah phir rectum me jahan se motion  hamara nikalta hai, wahan se ho sakta hai. Bohot se logon ko agar koi scar hai matlab agar pahale ki normal delivery hai to episiotomy jo lagta, piche takah lagta udhar kabhi kabhi endometriosis paya jata hai, yah caesarean ka jo scar hai uspe ho sakta hai. In rare cases, it is also seen in the lungs, matlab lungs ke yahan paya ja sakta hai, to uske basis pe symptoms hote hai, jaise endometriosis ke main symptom kya hai, ki painful periods hona that is the most common symptom, patient go mahine ke time pe yah period ke time pe continuous pain rahana, agar pain bohot severe hai to we suspect deep infiltration, matlab bohot andar tak dhasa hua endometriosis hum suspect karte hai. Dusra complain hai, agar married hai to dyspareunia. Dyspareunia ka matlab kya, ki intercourse karte samay yah sex karte samay bohot pain hona. Now, this can be a component of endometriosis again, where the endometriosis is in depth in the subperitoneal tissue, means andar dhasa hua, in the vagina ke jagah pe, to that causes dyspareunia, yah phir chronic pelvic pain matlab mahina nahi hote hue bhi ek dull aching pain rahana, hamesha ek lower abdomen me ek pain sa rahana, this is chronic pelvic pain.

The last but not the least is subfertility. Bohot se logon ko kuch symptom nahi hota hai but they have complaints of subfertility, matlab conceive hone me problem hona. Conception me problem hona, endometriosis ke wajah se ho sakta hai because endometriosis does not allow pregnancy to happen, so yeh aur ek bohot important reason hai. Yeh kyo hota hai, endometriosis kyo hota hai? This is a very common doubt which we have ki uterus ke bahar endometriotic tissue ko kyo jana chahiye. Abhi uske bohot theories hai, bohot reasons hai. The more specific ones are ki ek to hai ki backflow, jaise kabhi kabhi MC, menses ke time pe agar bleeding jo hai woh uterus ke, cervix ke, vagina ke jagah se nah ate hue uska backflow hona, matlab tubes ke taraf se abdomen me uska jana, that is one of the reasons which is seen. Second reason is it is an oestrogen dependent disease, matlab jin aurton me oestrogen ka hormone ho hai, wo agar bohot matra me paya jata hai to unke yeh hone ke chances zyada and third one is genetic. Agan appke mummy ko hai yah apke family me woh run karta hai to bhi uska hona is very natural to have that.

Abhi, how do we differentiate it? Yah why does it call subfertility? Endometriosis me main hota hai ovulation bara bar se nahi hona yah anovulatory cycles hona yah jo quality of the eggs hai jab release hota uska accha na hona, fibrosis hona, because endometriosis ke wajah se kya hota hai ki hamare tubes jo hai, fallopian tubes, woh kharab ho jate hai, unki function kum ho jata hai, plus bohot sara scarring yah fibrosis hota hai. Peritoneum me agar hai to pura chipak jata hai under ka, jo tubes hai, ovaries hai, yah phir cyst hona. Bohot young girls ate hai with big cyst, big endometriotic cyst, to cyst agar bohot zyada hai, yah aap logon ne bohot commonly suna honga, chocolate cyst. Chocolate cyst is nothing but an endometriotic cyst, to yeh sab hone ke wajah se hamara jo under ka virgin peritoneum hai woh kharab ho jata hai, uske karan fertility meh problems hote hai.

Abhi jo extrapelvic endometriosis hai, jo jaise maine bataya ki alag jagah pe hona, agar bowel involvement hai jaise intestines ke yahan pe hona. So, patients will present with severe pain in the abdomen yah phir bar bar motion ke time pe takleef hona, constipation hona, excessive vomiting during your periods, yah phir pulmonary agar hum log pagadte hai to, to periods ke time pe saans lene me dikat hona, yah hemothorax hona, yeh bohot severe form me dikhta hai. Scar endometriosis aisa hai, where during periods ke time pe hi aapko episiotomy ka jo scar hai, jo normal delivery ka scar hai, udhar pain hona yah udar se bleeding hona yah caesarean ka jo scar hai woh scar sirf period ke time pe dukhna, yeh sab scar endometriosis ke features hai.

Abhi hum isko kaise diagnose karte hai, first of all, is a history jaise maine bataya. Yeh sab history janne pe hum ek conclusion meh ate hai ke there is a possibility of endometriosis, and examination. Examination pe jab period ke time pe when the patient comes, we examine their vulva, vagina, cervix, agar koi component dikh raha hai to, external examination pe. Uske alawa scar endometriosis hai to phir scar tissue pe endometriotic yeh hona, woh dikhna, humko pata chalta yah cyclical bleeding hona, yah cyclical pain in the abdomen, matlab sirf period ke time pe umbilicus ke yahan pe pain hona. Yeh sab features dikhte hai.

Abhi iska diagnosis hum kaise karte hai – pahali cheez hai, sonography as I said, aap doctor ke pass jayenge, doctor aapko ek sonography likh ke de denge. Sonography pe normally jo humko dikhta hai, is the endometriotic cyst, matlab ovaries ke idhar cyst hona. Abhi ek complex cyst hota hai, jo uska size upar depend hai. Agar less than 3 centimetre hai yah chota sa cyst hai to usko normally hum log medical line of management se treat karte hai, jisme hormonal therapy involved hai. Magar agar size bohot bada hai jaise more than 4 to 5 centimetres ke upar hai, to uska operation hi treatment hai because bohot bada cyst does not normally respond to a medical line of treatment aur uska usse bhi zyada bade hone chances bohot zyada hai.

Second is a CA-125, yeh ek prakar blood test hai jo hum normally endometriosis patients meh recommend karte hai because CA-125 helps us to differentiate with the other tumour markers, matlab koi aur prakar ka tumour to nahi hai, yeh dekhne ka humko pata chalta hai. Abhi iske hisaab se last but not the least is a laparoscopy. Laparoscopy is the gold standard to diagnose as well as treat endometriosis. Laparoscopy iske liye bhi better mana jata hai because laparoscopy meh hamara stay kum hai hospital meh, mobility better hai matlab operation ke baad yah procedure ke baad aap immediately mobile hote hai. Post-operative, less chances of adhesions, adhesions ka matlab operation ke baad jab hum cyst nikalte yah uska ka jo fluid bahar nikalta hai uske wajah se bhi bohot sara undar organs chipak sakte hai jo hum laparoscopy se avoid kar sakte hai. And as well as cost, if you compare the cost with the hormonal line of treatment, which is a long course of treatment for endometriosis, that it also less.

Laparotomy matlab cut karke operation unn patients may hum log recommend karte bohot severe endometriosis hai, matlab it is on the… hum log staging karte hai, laparoscopy ke hisaab se we can even stage the endometriosis. Staging ke hisaab se humko pata chalta hai ki kitna involvement hai endometriosis ka andar, jaise agar uterus involved hai, sirf uterus hai aur tubes, ovaries involved hai ki bahar ka intestines involved hai yah bladder that is the urinary bag involved hai, to uske hisaab se hum staging karte hai, kitna spread hua hai endometriosis. Laparotomy unn patients meh karte hai jahan bohot severe form me humko dikhayi de raha hai, jin me operation jaise laparoscopy not advisable, koi other medical condition ke wajah se, to unn patients meh hum laparotomy karte hai yah jinme fertility is not an issue, matlab unke bacche ho juke hai, unme hum log open surgery karte hai. Laparoscopy ka aur ek advantage yeh hai ki hum log isme jo operation karte hai woh normally reproductive age group, matlab jo hamare paas pregnancy ke liye ate hai unme laparoscopy zyada recommended karte hai because fertility rates are much better after laparoscopy, plus the treatment matlab hum log jo postoperatively medical line of treatment dete hai uspe bhi patients respond much better after laparoscopy, to in cases meh laparoscopy is the gold standard.

Now, after the patient has undergone a laparoscopy, bohot bada cyst hai usko nikala gaya hai, uske baad taki recurrence nah ho, see recurrence, yeh endometriosis me ho sakta hai because hamara menses to band nahi hota hai, to recurrence bhi ho sakta hai, usko prevent karne ke liye hum medical line of treatment bhi rakhte hai. Medical line of treatment abhi kiss hisaab se karenge? First of all, hum pahale low-dose oral contraceptive pills deke dekhte hai, we give them low-dose pills first, matlab hormonal cyclical pills jo hote hai woh leke dekhte hai. Kyo dete hai? Because endometriosis has been shown to have oestrogen dependent, to oestrogen ko hum thoda control karenge yah hormones ko control karenge. We put them on a low-dose pill and we see how they respond. If the pain is less, if the bleeding is less, then yes, she is responding to the medical line of treatment. Yeh bhi nahi hota, then we go one-one step ahead, then we go one step ahead with progesterones. Abhi progesterones meh kya karte hai ki yeh oestrogen to oppose karte hai, to progesterones meh we either give injectable progesterone like medroxyprogesterone acetate, intramuscular injections. Yah phir hum log agar samhjo family complete hai yah bacche ho juke hai to hum ek loop bhi bidha sakte hai jo hormonal loop hai jisse bleeding, pain, aur continuous release of progesterone andar rahata hai, to usse bhi pain kum hota hai. Yah phir anti- progesterone, jiske wajah se, jaise Mifepristone hai, uska ek low dose hum continuous rakhte hai taki endometriosis bade nahi. Previously, pahale ke zamane meh Danazol use kiya jata tha magar filhal Danazol hum bohot kum use karte hai because Danazol ka side effect bohot zyada hai.

Recently, in severe endometriosis, what we have seen is GnRH, that is gonadotropin hormone which is an agonist which we use, jo injectable form meh monthly diya jata hai. Yeh dose meh dene se endometriosis jo hai uska recurrence nahi hota hai aur uska jo andar jo adhesions hai woh bhi kum ho jate hai. Now, the only side effects with this GnRH Agonist are that it causes severe menopausal symptoms, isko hum log pseudo menopause bolte hai, matlab aapko injection dene ke baad ek menopause ke jaisa picture create ho jata hai, jahan hormones nahi hai hamare body meh. To yeh hum recommend karte hai only in severe endometriosis, jahan peh fertility is not an issue, matlab hum log bacche ke bare me planning nahi kar rahe hai, family complete hai, but sirf pain is a criteria, unn cases me hum yeh patients ko recommend karte hai.

So, overall, if you see endometriosis, it’s basically a chronic treatment, chronic disease, yeh puri tarah se hum cure kar sakte hai magar iska recurrence bhi utna hi severe ho sakta hai, if it is not treated properly. To agar chota sa cyst hai, it is better to start with the improvement. If there is a cyst which is causing you pain, at least remove the focus, laparoscopy say hum usko at least nikalte hai, uska major component jo hai, nikalte hai. Agar scar endometriosis hai to jo scar tissue hai usme se endometriosis ko excise karke nikalte taki yeh bade nahi yah pain kum ho jaye. So this is… we depend upon the patient’s reproductive age. Abhi patient agar fertility ke liye aya hai, pain is not an issue, to uss hisaab se hum usko medications dete hai. Once the endometriosis is cured of, then we suggest the line of treatment, jaise agar natural conception hua yah if agar bohot age is a criteria, phir IVF, IUI, iske hisaab hum log medical line of treatment decide karte hai.

So, overall, endometriosis is a dreaded disease. Sirf pain hona is not endometriosis. Jaise maine bataya, agar primary dysmenorrhoea hai aur sirf pain hai periods pe, baki aapke investigations normal hai to koi chinta ki baat nahi hai, it will just respond to the medical line of treatment. Magar yes, agar endometriosis ata hai yah koi other organic cause ata hai to uska treatment time pe lena bohot zaruri hai.