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Karen Hancock, MD

Department of Obstetrics and Gynecology
Mercy Suburban Hospital
Norristown, Pennsylvania

The pet should be free of obvious bacterial skin infections blood pressure medication african american buy generic vasotec 5 mg online, infections caused by superfcial dermatophytes blood pressure 9040 buy cheap vasotec 5 mg, and ectoparasitic infec tions (feas and ticks) blood pressure homeostasis purchase vasotec 5mg without prescription. All contact should be supervised throughout the visit by appropriate personnel and should be followed by hand hygiene performed by the patient and all who had contact with the pet blood pressure medication start with l order vasotec 10 mg with amex. Supervisors should be familiar with institutional policies for managing animal bites and cleaning pet urine, feces, or vomitus. For patients who are immunodefcient or for people receiving immunosuppressive therapy, the risks of exposure to the microfora of pets may outweigh the benefts of contact. These sites should have dressings that provide an effective barrier to pet contact, including licking, and be covered with clothing or gown. Concern for contamination of other body sites should be considered on a case-by-case basis. These animals are not pets, and separate policies should govern their uses and presence in the hospital according to the American Disabilities Act recommendations. Infection Control and Prevention in Ambulatory Settings Infection control and prevention is an integral part of pediatric practice in ambula tory care settings as well as in hospitals. All health care personnel should be aware of the routes of transmission and techniques to prevent transmission of infectious agents. Written policies and procedures for infection prevention and control should be developed, implemented, and reviewed at least every 2 years. Standard Precautions, as outlined for the hospitalized child (see Infection Control for Hospitalized Children, p 160) and by the Centers for Disease Control and Prevention, with a modifcation by the American 1 Academy of Pediatrics exempting the use of gloves for routine diaper changes and wip ing a child’s nose or tears, are appropriate for most patient encounters. Key principles of infection prevention and control in an outpatient setting are as follows: 1 Centers for Disease Control and Prevention. Guideline for isolation precautions: preventing transmission of infectious agents in health care settings 2007. Policies for children who are suspected of having contagious infections, such as vari cella or measles, should be implemented. Immunocompromised children and neonates should be kept away from people with potentially contagious infections. In health care settings, alcohol-based hand products are preferred for decon taminating hands routinely. Soap and water are preferred when hands are visibly dirty or contaminated with proteinaceous material, such as blood or other body fuids. Alcohol is preferred for skin preparation before immunization or routine venipuncture. Skin preparation for inci sion, suture, or collection of blood for culture requires 70% alcohol, alcohol tinctures of iodine (10%), or alcoholic chlorhexidine (>0. The use of safer medical devices designed to reduce the risk of needle sticks should be implemented. Sharps disposal containers that are impermeable and puncture resistant should be available adjacent to the areas where sharps are used (eg, areas where injections or venipunctures are performed). Sharps containers should be replaced before they become overflled and kept out of reach of young children. Policies should be established for removal and the disposal of sharps containers consistent with state and local regulations. Whenever sexual abuse is suspected, appropriate social service and law enforcement agencies must be involved to ensure the child’s or adolescent’s protection and to provide appropriate counseling. Physicians can prepare patients and families about the need for private time by educating both parents and pre adolescents about the need for confdentiality as adolescence approaches. For adolescent females who are immunosuppressed or immunocompromised, yearly Papanicolaou smears should begin with the initiation of consensual sexual intercourse or with a history of nonconsensual sexual intercourse. Sexually active adolescent females should be screened at least annually for chlamydia and gonorrhea. All adolescents should receive hepatitis B virus immunization if they were not immunized earlier in childhood. Hepatitis A vac cine should be offered to adolescent males who have sex with males (see Recommended Childhood and Adolescent Immunization Schedules, Fig 1. Patients and their partners treated for gonorrhea, Chlamydia trachomatis infection, and trichomoniasis should be advised to refrain from sexual intercourse for 1 week after completion of appropriate treatment. Retesting to detect therapeutic failure (tests of cure) for patients who receive recommended treatment regimens for Neisseria gonorrhoeae or C trachomatis infection is not recommended unless therapeutic adherence is in question or symptoms persist. Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents. Repeat testing is recommended for these infections within 3 months because of the likelihood of reinfection as a result of nontreatment of a current sexual partner and/or new infection from a new sexual partner. Therefore, tests that allow for isolation of the organism and have the highest specifcities must be used. Specimens for culture to screen for N gonorrhoeae and C trachomatis should be obtained from the rectum and vagina of girls and from the rectum and urethra of boys. Specimens for culture to screen for N gonorrhoeae also should be obtained from the pharynx, even in the absence of symptoms. Culture and nucleic acid hybridization tests require female endocervical or male urethral swab specimens. Endocervical specimens for culture are not required for prepubertal girls but are required for culture of C trachomatis and N gonorrhoeae if the female is pubertal or postmenarcheal. If vaginal discharge is present, specimens for wet mount for Trichomonas vaginalis and wet mount or Gram stain for bacterial vaginosis may be obtained as well. Completion of the hepatitis B immu nization series should be documented, or the patient should be screened for hepatitis B surface antibody. Anogenital gonorrhea in a prepubertal child indicates sexual abuse in virtually every case. All confrmed cases of gonorrhea in prepubertal children beyond the neonatal period should be reported to the local child protective services agency for investigation. In an infant or toddler in diapers, genital herpes may arise from any of these mechanisms. In a prepubertal child whose toilet-use activities are independent, the new occurrence of genital herpes should prompt a careful investigation, including a child protective services investigation, for suspected sexual abuse. In a perinatally infected infant, vaginal discharge can persist for several weeks; accordingly, intense social investigation may not be warranted. However, a new diagnosis of trichomoniasis in an older infant or child should prompt a careful investigation, including a child protective services investigation, for suspected sexual abuse. Although hepatitis B virus, scabies, and pediculosis pubis may be transmitted sexually, other modes of transmission can occur. The discovery of any of these conditions in a pre pubertal child does not warrant child protective services involvement unless the clinician fnds other information that suggests abuse. The presence of T vaginalis and bacterial vagi nosis in a pubertal and postpubertal female suggests sexual contact and should be investi gated appropriately (see Bacterial Vaginosis, p 247). Physicians are required by law to report abuse to their state child protective services agency. Most experts recommend universal screening of postpubertal patients who have been victims of sexual abuse or assault because of the possibility of a preexisting asymp tomatic infection. To preserve the “chain of custody” for information that may later constitute legal evidence, specimens for laboratory analysis obtained from sexually victim ized patients should be labeled carefully, and standard hospital procedures for transferring specimens from site to site should be followed carefully. Only tests with high specifcities should be used, and whenever possible, specimens should be obtained by health care pro fessionals with experience in the evaluation of children who have been sexually abused or assaulted. A follow-up visit approximately 2 to 6 weeks after the most recent sexual exposure may include a repeat physical examination and collection of additional speci mens. Many experts believe that prophylaxis is warranted for postpubertal female patients who seek care within 72 hours after an episode of sexual victimization because of the possibility of a preexisting asymptomatic infection, the potential risk for acquisition of new infections with the assault, and the substantial risk of pelvic infammatory disease in this age group. Postmenarcheal patients should be tested for pregnancy before antimicrobial treatment or emergency contraception is given. Prophylaxis After Sexual Victimization of Preadolescent Children Weight <100 lb (<45 kg) Weight ≥100 lb (≥45 kg) For prevention of gonorrhea 1. Consider adding prophylaxis laxis for trichomoniasis and against trichomoniasis and bacterial vaginosis (metro bacterial vaginosis (metro nidazole, 15 mg/kg per day, nidazole, 2 g, orally, in a orally, in 3 divided doses for single dose) 7 days; maximum 2 g) See text for human immunodefciency virus infection prophylaxis in children following sexual abuse or assault. Although emergency contraception is most effective if taken within 72 hours of event, data suggest it is effective up to 120 hours. The number of arrests of juveniles (younger than 18 years of age) in the United States was 2.

Check the batteries once a month blood pressure 8560 buy cheap vasotec online, and change the batteries at least every 6 months prehypertension pubmed buy vasotec in india. Teach family members to leave the If escape is not possible arrhythmia high blood pressure buy discount vasotec 10 mg line, stay in the room building first blood pressure er order 10 mg vasotec fast delivery, then call 9-1-1 or the designated and call 9-1-1 or the designated emergency emergency number. Include 9-1-1 or the designated emergency number, the national Poison Help hotline (1-800-222-1222), and the phone numbers of your family’s healthcare providers, as well as any other important numbers. Preventing Burns and Fires Set the water heater at a temperature of 120° F Do not wear loose clothing when cooking. If your household When you are using the stove, use the back contains children or older adults, the water temperature should be lower, between 100° F burners and turn pot and pan handles toward and 115° F. Preventing Firearm Accidents Keep firearms in the home unloaded in a Obtain the knowledge and skills you need to locked place, out of the reach of children. Safety at Work At work, participate in any workplace safety programs your employer offers. Make sure you know: Your place of employment’s emergency action plan and fire evacuation procedures. Before undertaking an activity that is unfamiliar to you, such as boating, skiing or riding a motorcycle, take lessons to learn how to perform the activity safely. Water Safety Learn to swim and obtain the knowledge and skills you need to prevent, recognize and respond to aquatic emergencies. The American Red Cross Swimming and Water Safety program teaches people to be safe in, on and around the water through water safety courses, water orientation classes for infants and toddlers, and comprehensive Learn-to-Swim courses for people of all ages and abilities. Young children, weak or inexperienced swimmers and nonswimmers should always wear a U. Coast Guard– approved life jacket when engaging in certain aquatic activities, such as boating. Stay within area that is clearly marked for diving and has no arm’s reach of the child. Pay special attention to water-depth markings and too cold, too far away from safety, too much sun “no diving” signs. Children should wear a helmet even if they are still riding along the sidewalk on training wheels. Laws on wearing bicycle helmets, including age-specific requirements, vary by state and county. For more information about helmet laws in your area, conduct an Internet search or contact state or local officials. Safety for Runners, Joggers and Walkers Plan your route carefully and exercise in well-lit, well populated areas. See Plants, rash-causing, 136, 138t, 139 also inhaler Play safety, 155–156 Mini-stroke. See also wound Slip, trip and fall prevention, 153b, 154 abdomen, 114–115 Small-volume nebulizer, 79b burns as, 103–106 Smoke alarm, 151 chest, 113–114 Snake bites, 129–131 diffuse axonal, 109 Spider bites, 131–133 head, neck and spinal, 109–111 Spill, cleaning of, 15 internal bleeding and, 95 Spinal cord injury, 109. Orthostatic intolerance, then, is an umbrella term for several conditions in which symptoms are made worse by upright posture and improve with recumbency. Neurally mediated hypotension refers to a drop in blood pressure that occurs after being upright. It occurs if too little blood circulates back to the heart when people are upright, a situation that can trigger an abnormal reflex interaction between the heart and the brain that results in a lowering of blood pressure. Postural tachycardia syndrome refers to an exaggerated increase in heart rate with standing. A healthy individual usually has a slight increase in heart rate—by about 10-15 beats per minute—within the first 10 minutes of standing. When a healthy individual stands up, gravity causes about 10-15% of his or her blood to settle in the abdomen, legs, and arms. This pooling of blood means that less blood reaches the brain, the result of which can be a feeling of lightheadedness, seeing stars, darkening of vision, or even fainting. For most of us, this lightheaded feeling is infrequent when we stand up because the leg muscles help pump blood back up to the heart, and because the body turns on a series of rapid reflex responses. To make up for the lower amount of blood returning to the heart immediately after standing, the body releases norepinephrine and epinephrine (also known as adrenaline). These substances typically cause the heart to beat a little faster and with more force (a familiar feeling after we exercise or are frightened), and norepinephrine causes the blood vessels to tighten or constrict. Most of the time, we are unaware of these reflex changes in blood flow when we stand up. The body responds by releasing more norepinephrine or epinephrine, in an attempt to cause more constriction of the blood vessels. For a variety of reasons, not all of which are well understood, the blood vessels do not seem to respond normally to these substances, and the vessels either do not constrict efficiently or they dilate. Because the heart remains able to respond to the norepinephrine and epinephrine, the heart rate often increases. Some of this is caused by a “miscommunication” between the heart and the brain, both of which usually are structurally normal. Just when the heart needs to beat faster to pump blood to the brain and prevent fainting, the brain sends out the message that the heart rate should be slowed down, and the blood vessels should dilate further. These actions take even more blood away from where it is needed in the central part of the circulation. Any time the brain is getting too little blood flow, the usual result is a lightheaded or spacey feeling. If lightheadedness is severe, individuals may have dimming of their vision, may hear sounds as though they were far away, and may have nausea or vomiting. Fainting is helpful, in that it restores a person to the flat position, removing the effect of gravity on blood pooling in the limbs, and allowing more blood to return to the heart. Following the episodes of lightheadedness 2 or fainting, most people feel tired for several hours (sometimes more than a day) and their thinking can be somewhat foggy. This fatigue after exertion or sustained activity can also last 24-72 hours, and can interfere with many daily activities. The mental confusion takes the form of difficulty concentrating, staying on task, paying attention, remembering, or finding the right words. This may occur because the blood vessels of the limbs dilate rather than constrict in response to mental tasks, allowing more blood to pool. The reflex 3 response that results in lowered blood pressure simply occurs at an earlier point in some individuals. Each person’s susceptibility is affected by a number of factors, including genetics, diet, psychological make-up, and the presence of other medical disorders including infection, inflammation, or allergy. Many hospitals and academic centers throughout the world perform tilt table testing. It allows careful measurement of the heart rate and blood pressure responses to the head-up position, usually at a 70-degree angle, in an almost standing position. The usual reason for performing a tilt table test in the past had been for the evaluation of recurrent fainting. However, during the tilt table test they must remain still, and they cannot call upon these natural defenses. Increased fatigue and malaise often occur for a few days after the test is performed, although our experience has suggested that these symptoms can be minimized if the individual is treated with intravenous saline solutions immediately after completion of the tilt test. Other environmental factors may also play a role, but more research is needed before we will know what actually causes either condition. Salt helps us retain fluid in the blood vessels, and helps maintain a healthy blood pressure. Salt has received bad press in the last couple of decades because a high salt diet in some individuals with high or high-normal blood pressure can lead to further increases in blood pressure, and thereby contribute to heart disease and stroke. An adult’s systolic blood pressure [the top number] is considered low if it is below 100, and it is considered elevated if it is above 140. An adult’s diastolic blood pressure [the bottom number] is considered high if it is over 90. In experimental work earlier this century, severe short-term salt depletion led to fatigue and mental dulling in the adult research participants. Because patients have a different mix of underlying contributors to their orthostatic intolerance, therapy has to be tailored to the individual, and usually requires persistence and a willingness to try multiple methods. The approach we use has been based on the available evidence from formal studies and from our experiences treating large numbers of individuals. Step 1 focuses on non-pharmacologic treatments, Step 2 involves use of a single medication, and Step 3 involves rational and judicious use of more than one medication.

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Iontophoresis is thought to decrease inflammation zofran arrhythmia order vasotec with a visa, decrease pain arterial hypertension treatment vasotec 10 mg on-line, decrease muscle spasm blood pressure medication vision changes order vasotec 10mg amex, decrease swelling and edema pulse pressure measurement purchase vasotec with american express, reduce calcium deposits in the body and manage scar tissue. Iontophoresis is administered in a physical therapy clinic or the patient wears a small battery-operated patch for 24 hours. American Chronic Pain Association Copyright 2018 39 Paraffin (wax) A paraffin treatment uses warm oil-based wax most commonly used on the hands, elbows and feet to provide deep heat therapy. The affected body part is dipped into the paraffin and then removed to allow the paraffin to harden. Paraffin provides the benefits of heat including increased blood flow, increased muscle flexibility and decreasing joint stiffness. Home units are available although one should always use paraffin wax heater which has automatic heat controller to maintain appropriate temperatures. Infrared Light Therapy Infrared Light therapy delivers light energy safely through the skin. Light at longer wavelengths are no longer visible to the human eye and are called infrared. Infrared Light therapy is thought to increase blood circulation, stimulate healing and reduce inflammation. Spinal Traction & Spinal Decompression Spine Traction simply means providing a pulling force that provides a stretch to the spine. Traction is thought to decrease the intradiscal pressure to promote retraction of the herniated disc which would decrease the pressure on the adjacent nerve. However, muscles surrounding this area can contract as the body attempts to protect itself against the stretch, eliminating the benefit. Spinal decompression claims to use computer controlled force to achieve gradual and calculated increases in traction forces and angles to the spine that creates a vacuum action within the disc. The computerized decompression table continuously monitors spinal resistance and adjusts forces accordingly. The goal of treatment is to create a negative intradiscal pressure to promote repositioning of the herniated disc material and to cause an influx of healing nutrients and other substances into thedisc. Spinal Traction and Spinal Decompression have not been proven effective in treatment of pain. There is moderate evidence that home-based patient-controlled traction may be a noninvasive conservative option, if used along with other evidence-based conservative care. Kinesiotape is made up of cotton fibers with polymer elastic strands and is lightweight with heat-sensitive acrylic adhesive. Clinicians that use the tape believe that it can improve blood and lymph flow, provide soft tissue and muscle support, allow for beneficial muscle activation and provide joint protection. Kinesiotape can be American Chronic Pain Association Copyright 2018 40 applied in a variety of patterns on different body parts. Despite the fact that the brightly colored Kinesiotape has been widely seen on Olympic and professional athletes, the scientific evidence for its use remains low. Kinesiotape may have a small beneficial role in improving strength, range of motion and fluid circulation in certain injured individuals, but multiple systematic reviews have found insufficient evidence to support the use of Kinesiotape for those following injury or those with chronic musculoskeletal pain. Non-Elastic or Corrective Taping, often called McConnell Taping technique named after physical therapist Jenny McConnell who developed it, is characterized by tape with a combination of minimal elasticity and a high adhesive. Due to the highly adhesive backing of the tape (usually called Leukotape), a protective tape (usually called cover roll tape) is applied on the skin first. This type of taping technique is much more rigid and is used for structural support or alignment. McConnell taping is most frequently used for taping of the knee however the research is inconclusive for its benefit. Spinal manipulation is a historically recognized therapeutic intervention that has been employed in various cultures for thousands of years. Chiropractors prefer the term "adjustment" whereas physical therapists apply the word "mobilization. Manipulation and mobilization are two types of manual (hands-on) therapies that include a wide array of different techniques and schools of thought. In general, mobilization involves assisted low force, low velocity movement often directed to one or more compromised vertebral segments and typically uses long lever arms to deliver the force. The effects of spinal manipulation include relief of acute and chronic back pain, improved spinal motion, and affecting the nervous system mostly at the local spinal level. Overall, studies have shown that spinal manipulation can provide relief from acute and chronic low back and neck pain. In 2007 Guidelines, the American College of Physicians and the American Pain Society include spinal manipulation as one of several treatment options for practitioners to American Chronic Pain Association Copyright 2018 41 consider using when pain does not improve with self-care. Electrical Stimulation Devices (external) Electrotherapy represents the therapeutic use of electricity and is another modality that can be used in the treatment of pain. Transcutaneous electrotherapy is the most common form of electrotherapy in which electrical stimulation is applied to the surface of the skin. Interferential current is proposed to produce less impedance in the tissue, and the intensity provided is supposed to be more comfortable. Because there is minimal skin resistance with the interferential current therapy, a maximum amount of energy goes deeper into the tissue. This crisscrossing is postulated to be more effective because it serves to confuse the nerve endings, preventing the treated area from adjusting to the current. All cells produce electromagnetic fields and every organ in the body produces its own signature bioelectromagnetic field. As low frequency pulsed electromagnetic current passes through the body, it stimulates the electrical and chemical processes in the tissues. Treatment times are typically 10-30 minutes and multiple areas can be treated at one time. Diathermy uses high-frequency electric current to produce heat deep inside a targeted tissue. Instead, the waves generated by the machine allow the body to generate heat from within the targeted tissue. Shortwave diathermy uses high-frequency electromagnetic energy, microwave diathermy uses microwaves and ultrasound diathermy uses sound waves. Treatment can also make connective tissue more flexible, minimize inflammation and reduce the incidence of edema, or fluid retention. Dry Needling Dry needling is a technique that uses a “dry” needle (meaning one that doesn’t release any medication). Trigger points can be tender to the touch and touching a trigger point may cause pain to other parts ofthe body. Dry needling is used to release the trigger points to relieve pain and tension or improve motion. Dry needling is also thought to normalize abnormal motor end plates (the sites that transmit nerve impulses to muscles). Dry needling can produce minor bleeding and some soreness but is a safe procedure when performed by a trained professional. Dry needling is not the same thing as acupuncture, a practice based on traditional Chinese medicine and performed by acupuncturists. Trigger Point Injections Trigger point injections are given to individuals with a myofascial pain syndrome, a regional painful muscle condition. These injections may provide short-term benefit only but are curative for some individuals. A trigger point is a discrete focal tenderness located in a palpable taut band of skeletal muscle, which produces a local twitch in response to stimulus to the band. Myofascial pain syndrome is a regional painful muscle condition with a direct relationship between a specific trigger point and its associated pain region. These injections may occasionally be necessary to maintain function in those with myofascial problems when myofascial trigger points are present on examination. Intra-Articular Steroid Injections Invasive therapeutic interventions for osteoarthritis include steroid injections into the joint. Intra articular steroids are effective for short-term (one to three weeks) pain relief but do not seem to improve function or provide pain relief for longer time periods. The number of steroid injections should be limited secondary to associated side effects including fat necrosis, loss of skin pigmentation, skin atrophy, avascular necrosis of the femoral head, Cushing’s disease, and in some cases, acceleration of joint degeneration. Following a steroid injection, the treated joint should be rested (limit its use) for a minimum of 24 hours in order to prolong and to improve effects on function and pain control.

If menstrual headaches are a reaction to cyclic changes in circulating levels of the sex steroids arrhythmia beta blocker effective vasotec 5 mg, it makes sense to avoid cyclicity and maintain a relatively steady state with daily administration of exogenous hormones blood pressure quiz nursing buy vasotec 5 mg with mastercard. Another option is to use an estrogen transdermal application during the menstrual time period arrhythmia definition buy vasotec in united states online. The elimination of cyclicity can be applied to postmenopausal women who experience exacerbation or onset of headaches on a sequential hormone regimen blood pressure juicing buy discount vasotec 5mg on line. The maintenance of daily, relatively constant hormone levels with the daily, continuous program of combined estrogen-progestin has been effective in our experience. The run-of-the-mill headache is treated with mild analgesics such as aspirin, acetaminophen, or the nonsteroidal anti-inflammatory agents. A problem of severe headaches on oral contraception requires an immediate response. On the other hand, the headache can be due to stress or some other reversible condition. We would argue that automatic discontinuation of oral contraception is not necessary with the low-dose preparations. It would be better to evaluate the patient and find out if the patient can continue her contraceptive protection, by discovering an explanation for the headaches. Case-control studies with the old higher dose oral contraceptives indicated that migraine headaches were linked to a risk of stroke. True severe vascular headaches (migraine with aura) represent a contraindication for the use of combined oral contraceptives and their appearance is an indication to discontinue oral contraception. The symptom complex that deserves serious consideration includes headaches that last a long time; dizziness, nausea, or vomiting with headaches; scotomata or blurred vision; episodes of blindness; unilateral, unremitting headaches; and headaches that continue despite medication. Concern over headaches with oral contraception should be limited to the use of combined oral contraceptives. Therefore, the sustained release progestin-only methods are also free of headache concern. Catamenial Seizures 100 Catamenial epilepsy in ancient times was attributed to the moon, giving rise to the word, “lunatic. In addition, seizure frequency increases at the time of the midcycle peak in estrogen and during anovulatory cycles. In animal experiments, estrogen increases seizure activity, and progesterone is antiepileptic. Progestational hormones are known to have a sedative effect on the central nervous system. This pharmacologic effect combined with the observations indicating increased seizure activity at times when circulating levels of progesterone are low indicated that treatment with a progestin would have a beneficial impact on 105 seizures. Treatment with orally administered progesterone during the luteal phase has been reported to decrease seizure activity. Antiepileptic drugs enhance hepatic metabolic activity, and, therefore, doses must be relatively high. Oral medroxyprogesterone acetate is relatively ineffective, probably because it is difficult to achieve high blood levels. Intramuscular injections of depot-medroxyprogesterone acetate can improve seizure control. In a case report of an 8-year-old girl, 104 150 mg administered every 2 weeks abolished seizure activity. Intravenous progesterone (producing luteal phase levels) can produce a significant decrease in 107 spike frequency. In women with a seizure pattern consistently linked to menses, elimination of cyclic hormonal changes can bring impressive relief. Premenstrual Asthma 108, 109 and 110 Approximately 30–40% of women with asthma have an increase in symptoms associated with menstruation. Even asthmatics not aware of a link to 111, 112 menstruation demonstrate a menstrual worsening of pulmonary function. The mechanism is not known, but obvious effects of menstrual hormonal changes have been suggested, such as prostaglandin release, changes in the immune system, or a direct impact of declining estrogen and progesterone on bronchial smooth 112 muscle. The administration of estrogen (estradiol 2 mg orally daily) improves symptoms and measurements of pulmonary function. In another report, the 113 administration of intramuscular progesterone ameliorated premenstrual asthma. Catamenial Pneumothorax 114 Very rarely, recurrent pneumothoraces, often due to pulmonary endometriosis, occur at the time of menses. Effective medical treatment requires the long-term 115 suppression of menstruation. Golub S, Periods, from Menarche to Menopause, Sage Publications, Newbury Park, California, 1992. Patterns of menstrual disturbances in the community: results of the Zurich Cohort Study, Eur Arch Psychiatry Clin Neurosci 243:23, 1993. Sommer B, the effect of menstruation on cognitive and perceptual-motor behavior: a review, Psychosom Med 35:515, 1973. Dalton K, the Premenstrual Syndrome and Progesterone Therapy, 2nd edition, Yearbook Medical Publishers, Inc. Tulenheimo A, Laatikainen T, Salminen K, Plasma b-endorphin immunoreactivity in premenstrual tension, Br J Obstet Gynaecol 94:26, 1987. Collins A, Cerin A, Coleman G, Landgren B-M, Essential fatty acids in the treatment of premenstrual syndrome, Obstet Gynecol 81:93, 1993. Puolakka J, Makarainen L, Viinikka L, Ylikorkola O, Biochemical and clinical effects of treating the premenstrual syndrome with prostaglandin synthesis precursors, J Reprod Med 30:149, 1985. Andersch B, Hahn L, Progesterone treatment of premenstrual tension — a double blind study, J Psychosom Res 29:489, 1985. Steiner M, Steinberg S, Stewart D, Carter D, Berger C, Reid R, Grover D, Streiner D, for the Canadian Fluoxetine/Premenstrual Dysphoria Collaborative Study Group, Fluoxetine in the treatment of premenstrual dysphoria, New Engl J Med 332:1529, 1995. Halbreich U, Endicott J, Methodological issues in studies of premenstrual changes, Psychoneuroendocrinology 10:15, 1985. Thys-Jacobs S, Starkey P, Bernstein D, Tian J, and the Premenstrual Syndrome Study Group, Calcium carbonate and the premenstrual syndrome: effects on premenstrual and menstrual symptoms, Am J Obstet Gynecol 179:444, 1998. Andersch B, Milsom I, An epidemiologic study of young women with dysmenorrhea, Am J Obstet Gynecol 144:655, 1982. Vicdan K, Kukner S, Dabakoglu T, Ergin T, Keles G, Gokmen O, Demographic and epidemiologic features of female adolescents in Turkey, J Adolesc Health 18:54, 1996. Parazzini F, Tozzi L, Mezzopane R, Luchini L, Marchini M, Fedele L, Cigarette smoking, alcohol consumption, and risk of primary dysmenorrhea, Epidemiology 5:469, 1994. Charlton A, While D, Smoking and menstrual problems in 16-year-olds, J Roy Soc Med 89:193, 1996. Sundell G, Milsom I, Andersch B, Factors influencing the prevalence and severity of dysmenorrhea in young women, Br J Obstet Gynaecol 97:588, 1990. Fioroni L, Martignoni E, Facchinetti F, Changes of neuroendocrine axes in patients with menstrual migraine, Cephalagia 15:297, 1995. Facchinetti F, Bonellie G, Kangasniemi P, Fascual J, Shuaib A, the efficacy and safety of subcutaneous sumatriptan in the acute treatment of menstrual migraine, Obstet Gynecol 86:911, 1995. Attempted prophylaxis by continuous estradiol administration, Neurology 25:245, 1975. Backstrom T, Epileptic seizures in women related to plasma estrogen and progesterone during the menstrual cycle, Acta Neurol Scand 54:321, 1976. Backstrom T, Zetterlund B, Blom S, Romano M, Effects of intravenous progesterone infusions on the epileptic discharge frequency in women with partial epilepsy, Acta Neurol Scand 69:240, 1984. It can be confidently managed without surgical intervention by therapeutic regimens founded on sound physiologic principles. Our formulation is based on knowledge of how the postovulatory menstrual function is naturally controlled, and uses pharmacologic application of sex steroids to reverse the abnormal tissue factors that lead to the excessive and prolonged flow typical of anovulatory cycles. In each instance, the manner in which the endometrium deviates from the norm is characterized, and specific sex steroid therapy is recommended to counter the difficulties each situation presents. This mode of clinical management has been in regular use for many years, and failure to control vaginal bleeding with this therapy, despite appropriate application and utilization, excludes the diagnosis of dysfunctional uterine bleeding. If this occurs, attention is directed to a pathologic entity within the reproductive tract as the cause of abnormal bleeding.