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The prede ned non Oncology, University Medical Center Utrecht, Utrecht, inferiority margin was an absolute di erence of 6% in vaginal recurrence. Netherlands; Radiotherapy Institute Friesland, Leeuwarden, Funding Dutch Cancer Society. About 80% of patients present1 invasion in the outer half of the myometrium, grade 3 the Netherlands Cancer 2, 3 Institute, Amsterdam, with early stage disease (International Federation of histology, and age greater than 60 years. We did not record data for the total number of patients diagnosed and who received primary treatment in the participating centres. Initial centre, brachytherapy (low-dose vs high-dose rate), and assessment included pelvic examination and endometrial patient age (<60 years vs 60 years). Preoperative assessment included chest the allocation was computer generated and not radiography and haematology and chemistry tests. Once the trial group During surgery a peritoneal cytology specimen was was assigned, the treatment and assessment of the obtained and abdominal exploration undertaken. Diagnosis, typing, and Secondary endpoints were locoregional recurrence grading of endometrial carcinoma was done by the (pelvic or vaginal, or both), distant metastases, overall regional pathologist. Commission on Radiation Units and Measurements We obtained written informed consent from all patients. For all patients, computerised treatment the protocol was approved by the Dutch Cancer Society planning was done with three-dimensional conformal or and the ethics committees of all participating centres. Centres had to complete a dummy-run procedure Randomisation and masking before activation of the trial. The dose was speci ed at 5 mm distance from the con rmed, or patients could be either reclassi ed to surface of the cylinder. Time-to-event failure type was vaginal recurrence in the case of isolated analyses were done with log-rank tests and Cox proportional vaginal recurrence. Analysis of toxicity was based on hazards regression models with date of randomisation as treatment received. A the sponsor of the study reviewed and approved the design rst failure competing risks analysis was done when the of the trial and funded data management. The sponsor had rst failure type was distant if there was distant metastasis, no role in data collection, data interpretation, data analysis, with or without simultaneous vaginal or pelvic recurrence. Moreover, rst First failure type failure analysis showed that most patients with pelvic Vaginal recurrence recurrence had simultaneous distant metastases (table 3). Shifts were mainly detected from grade 2 to grade 1 disease, and to a lesser extent from pal and associated investigators, and trial statistician had grade 2 to grade 3 disease (original vs review grade 1: full access to the data. Central review recorded 12 (3%) cases with non-endometrioid type of carcinoma (six patients in each Results group). Per-protocol analysis did not 11 patients did not receive the allocated treatment, one of change these results (data not shown), since there were whom died of cardiac arrest before the start of the rst no recurrences and only one intercurrent death in the treatment (gure 1). The rates of distant metas features of high-intermediate risk, and thus most patients tases were low and similar in both groups. Locoregional with endometrial cancer are treated with surgery alone recurrence rates in both groups were very similar to those (with radiotherapy as e ective salvage treatment for the reported in previous randomised trials in patients with occasional patient with relapse). Even with no survival that vaginal brachytherapy can be as e ectively used for bene t, radiotherapy spares these patients the psychological patients at high-intermediate risk to ensure vaginal stress of recurrence and the morbidity of intensive control.

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This contradiction may be softened by the reflection that we are not as yet able to distinguish in this field between what is rigidly fixed by biological laws and what is subject to change or shifting under the influence of accidental experience. Certain as it is that the earliest libidinal tendencies are reinforced later by regression and reaction-formation and difficult as it is to estimate the relative strength of the various confluent libidinal components, I still think that we must not overlook the fact that those first impulses have an intensity of their own which is greater than anything that comes later and may indeed be said to be incommensurable with any other force. It is to be anticipated that male analysts with feminist sympathies, and our women analysts also, will disagree with what I have said here. The opponents of those who reason thus will for their part think it quite comprehensible that members of the female sex should refuse to accept the notion that appears to gainsay their eagerly coveted equality with men. Representing the American theatre by publishing and licensing the works of new and established playwrights. Formed in 1936 by a number of prominent playwrights and theatre agents, Dramatists Play Service, Inc. Offering an extensive list of titles, including a preponderance of the most significant American plays of the past half-century, Dramatists Play Service, Inc. Older women, young women, married women, lesbians, single women, college professors, actors, corporate professionals, sex workers, African American women, Asian American women, Hispanic 1 women, Native American women, Caucasian women, Jewish women. Then, later, when my husband was pressing against me, I could feel his spiky sharpness sticking into me, my naked puffy vagina. At 72 she went into therapy, as we do in New York*, and with the help of her therapist, she went home one afternoon by herself, lit some candles, took a bath, played some music, and she got down with herself. She said it took her over an hour, because she was arthritic, but when she finally found her clitoris, she said, she cried. You can hear the pipes and things get caught there, little animals and 10 things, and it gets wet, and sometimes people have to plug up the leaks. It was like this force of passion, this river of life just flooded out of me, right through my panties, right onto the car seat of his new white Chevy Belair. Andy drove me home without saying another word and when I got out and closed his car door, I closed the whole store. He never did much for me in life, but in my dreamsit was always Burt and I, Burt and I, Burt and I.

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As with all coccidial infections treatment should be accompanied by hygiene measures designed to reduce the possibilities of reinfection. Rehydration may be needed especially in young animals and where diarrhoea is severe. Fleas Apart from imidacloprid and fpronil, there is a shortage of approved treatments for feas in ferrets. In some European countries, fpronil + S-methoprene is registered for treatment of feas and ticks in dogs and this can be used in ferrets. Mites Eradication of mites is always much more diffcult to achieve in colonies than in individual animals. For the treatment of Otodectes cynotis, selamectin (15 mg spot-on) applied once has been shown to have good effcacy. Before applying a topical treatment, ears should be cleaned with a mild antiseptic solution. For the treatment of sarcoptic mange, different macrocyclic lactones have shown effcacy: ivermectin (0. For large groups of affected ferrets, the environment can be sprayed with an enilconazole solution of 50 mg/m2 twice weekly for 4 months. Additionally, the ferret owner should use disposable gloves and thoroughly wash/disinfect clothes and shoes after every treatment and/or animal manipulation. Dogs with access to areas frequented by ferrets should be regularly treated for tapeworms to avoid infecting the ferrets with tapeworm cysts. Feed, hutches and bedding should always be kept clean and high standards of hygiene should be observed. Heartworm disease in endemic areas can be prevented by prophylactic topical administration of moxidectin (0. With the proper advice the risk of diseases and parasitic transmission between animals and humans can be minimised. I would also like to extend special thanks to Joe Rickey, who fed, watered, housed, and encouraged me throughout this entire process. The Tungiasis eLibrary, a collection of georeferenced scientific literature pertaining to the disease, was designed with the intent to serve as that profile for tungiasis. Additionally, the collected articles are displayed on a global map, developing the first ever authoritative global spatial distribution of tungiasis. The resulting collection of articles comprising the eLibrary is analyzed, and feedback from interested parties that ultimately helped inform the final application is discussed. John Snow first plotted cholera deaths as points on a map of London in 1854, public health professionals and epidemiologists have embraced the value of maps in disease management. One reason for this may be that many diseases are largely ignored due to a lack of publicity or government resources.

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Vasopressors such as norepinephrine and vasopressin are important in regulating blood pressure and renal water retention in critically ill patients. An observational trial of vitamin C/hydrocortisone/thiamine supplementation in sepsis reported signi cant reduction in the use of vasopressors in patients receiving vitamin C [147]. Further studies are warranted to determine optimal dose and route of administration, as well as timing. Ascorbate may also preserve vascular structure and microcirculatory ow independent of antioxidant function, via maintenance of Fe2+ and Cu+-containing hydroxylase and monooxygenase enzymes. Vitamin C shows promise as a reno-protectant in kidney injury, however, whether this is via its physiological role as an enzyme co-factor, or its recognized biochemical activity as an antioxidant, or both, remains to be fully de ned. Chronic kidney disease after acute kidney injury: A systematic review and meta-analysis. Novel pharmacological approaches to the treatment of renal ischemia-reperfusion injury: A comprehensive review. Molecular mechanisms and novel therapeutic approaches to rhabdomyolysis-induced acute kidney injury. Oxidative stress is increased in critically ill patients with acute renal failure. The elephant in uremia: Oxidant stress as a unifying concept of cardiovascular disease in uremia. Association between mitochondrial dysfunction and severity and outcome of septic shock. Lipid oxidation in human low-density lipoprotein induced by metmyoglobin/H2O2: Involvement of alpha-tocopheroxyl and phosphatidylcholine alkoxyl radicals. The redox activity of hemoglobins: From physiologic functions to pathologic mechanisms. A causative role for redox cycling of myoglobin and its inhibition by alkalinization in the pathogenesis and treatment of rhabdomyolysis-induced renal failure. Nephrotoxicity from chemotherapeutic agents: Clinical manifestations, pathobiology, and prevention/therapy. In vivo imaging of oxidative stress in ischemia-reperfusion renal injury using electron paramagnetic resonance. In vivo multiphoton imaging of mitochondrial structure and function during acute kidney injury. Plasma biomarkers of oxidant stress and development of organ failure in severe sepsis. Postoperative acute kidney injury is associated with hemoglobinemia and an enhanced oxidative stress response. Mitochondrial dysfunction and oxidative stress in patients with chronic kidney disease. How do nutritional antioxidants really work: Nucleophilic tone and para-hormesis versus free radical scavenging in vivo. Evidence suggesting a role for hydroxyl radical in glycerol-induced acute renal failure. Hemoglobin and myoglobin-induced acute renal failure in rats: Role of iron in nephrotoxicity. Combined mannitol and deferoxamine therapy for myohemoglobinuric renal injury and oxidant tubular stress. Evidence for cytochrome p-450 as a source of catalytic iron in myoglobinuric acute renal failure. Role of cytochrome p-450 as a source of catalytic iron in cisplatin-induced nephrotoxicity. Inhibition of cytochrome p450 2e1 and activation of transcription factor nrf2 are renoprotective in myoglobinuric acute kidney injury. Differential effect of ischaemia-reperfusion injury on anti-oxidant enzyme activity in the rat kidney. Deterioration of ischemia/reperfusion induced acute renal failure in sod1-de cient mice.

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Everything grows much bigger and finer in Asia, and the nature of the land is tamer, while the character of the inhabitants is milder and less passionate. The reason for this is the equable blending of the climate, for it lies in the midst of the sunrise facing the dawn. Luxuriance and ease of cultivation are to be found most often when there are no violent extremes, but when a temperate climate prevails. All parts of Asia are not alike, but that which is centrally placed between the hot and the cold parts is the most fertile and well wooded; it has the best weather and the best water, both rain water and water from springs. It is not too much burnt up by the heat nor desiccated by parching drought; it is neither racked by cold nor drenched by frequent rains from the south or by snow. Crops are likely to be large, both those which are from seed and those which the earth produces of her own accord. But as the fruits of the latter are eaten by man, they have cultivated them by transplanting. The cattle raised there are most likely to do well, being most prolific and best at rearing their young. Such a land resembles the spring time in its character and the mildness of the climate. The small variations of climate to which the Asiatics are subject, extremes both of heat and cold being avoided, account for their mental flabbiness and cowardice as well. They are less warlike than Europeans and tamer of spirit, for they are not subject to those physical changes and the mental stimulation which sharpen tempers and induce recklessness and hot-headedness. Such things appear to me to be the cause of the feebleness of the Asiatic race, but a contributory cause lies in their customs; for the greater part is under monarchical rule. When men do not govern themselves and are not their own masters they do not worry so much about warlike exercises as about not appearing warlike, for they do not run the same risks. The subjects of a monarchy are compelled to fight and to suffer and die for their masters, far from their wives, their children and friends. Deeds of prowess and valour redound to the advantage and advancement of their masters, while their own reward is danger and death. A good proof of this is that the most warlike men in Asia, whether Greeks or barbarians, are those who are not subject races but rule themselves and labour on their own behalf. Running risks only for themselves, they reap for themselves the rewards of bravery or the penalties of cowardice. You will also find that the Asiatics differ greatly among themselves, some being better At this point some paragraphs have been lost, and the order of what remains is uncertain. This follows from the variations of climate to which they are subject, as I explained before. I will now discuss the area to the east-north-east as far as Lake MaeotiS, * for this is the boundary between Europe and Asia. Where the weather shows the greatest and the most frequent variations, there the land is wildest and most uneven. But where there is not much difference in the weather throughout the year, the ground will be all very level. Climates differ and cause differences in character; the greater the variations in climate, so much the greater will be differences in character. I will leave out the minor distinctions of the various races and confine myself to the major differences in character and custom which obtain among them.

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Ideally, all women should receive the results of their test, whether negative or positive. At the very least, women whose test result is positive or abnormal Annex 4444 must be informed of the result and of what follow-up is needed. Follow-up should be in line with national protocols or based on the Flowchart screening recommendations found in Annex 4. Health care managers and providers can develop other locally appropriate approaches to reach women with abnormal screening tests. Health facilities need to make every effort to nd women with abnormal results if they do not return for scheduled appointments. If women need to return later for their results, a system must be in place to ensure that those with abnormal results are noti ed and that women who are hard to Annex 7777 locate are traced. New York, Cervical Health Implementation Project, South Africa, University of Cape Town, University of the Witwatersrand, EngenderHealth, 2004. This means that she should understand what is to take place, including the potential risks and complications of both proceeding and not proceeding, and has given permission for the procedure. It should be made clear to the woman that there will be no punitive action if she refuses the procedure. You may adapt these to individual situations to help explain procedures in terms the patient and her family understand. Ensure privacy and explain that con dentiality is always respected in your facility. Ask her if she would like to have family members present or if she would like to discuss the decision with family members at home. Give all the necessary information on the test, procedure or treatment you are recommending and any available alternatives. Use the explanations for patients included in this Guide, adapted to your facility and the individual situation, to help explain procedures such as cryotherapy, surgery, and radiotherapy. Ask the woman to empty her bladder (urinate) and have her undress from the waist down. Be particularly sensitive to her sense of modesty about uncovering normally clothed areas, or if the examination is perceived to be invasive.

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Temozolomide-induced desquamative skin rash in a patient with metastatic mela noma. Successful treatment of palmo-plantar erythrodysesthesia possibly due to temozolomide with dexamethasone. Hypersensitivity reactions to epipodophyllotoxins in children with acute lym phoblastic leukaemia. Used in the treatment of ovarian, breast cancer and bladder tumors (intravesical instillation). Combined thiotepa and mitomycin C instillation therapy for low-grade superfi cial bladder tumor. Topotecan as a continuous infusion over 14 days in recurrent ovarian cancer patients. S Diagnostic methods One case of positive leukocyte migration test to vincristine. Vincristine-induced fever in a child with rhabdomyosarcoma: cellular hyper sensitivity to vincristine demonstrated by leukocyte migration test. Hand-foot syndrome associated with short infusions of combination che motherapy with gemcitabine and vinorelbine. Incidence and syndrome of acute shortness of breath following vinca alka loids in patients receiving mitomycin. Fatal acute respiratory failure following vinblastine and mitomycin administration for breast cancer. Acute bronchospasm after vinca alkaloids in patients previously treated with mitomycin. Maculopapular rash, occuring within the first weeks of treatment, often transitory, rarely a cause of discontinuation of treatment; pityriasis-rosea like rash, toxic erythema, exfoliative dermatitis, purpuric rash. S Diagnostic methods Skin tests (anaphylactic or cutaneous reactions) Intradermal: 0. Skin biopsy: vasculitis with leukocyte infiltration in patients with cutaneous lesions. Accumulation of bradykinin which stimulates the release of tachykinins including substance P and neurokinin A. Substance P is important in neurogenic inflammation and has a functio nal relationship via C fibers with mast cells in various tissues, including lung and skin. Bradykinin is known to activate afferent sensory C fibers via type J receptors which cause coughing. Conversely, bradykinin could increase the formation of prostaglandins and leukotrienes. In addition, a decrease in bradykinin degradation increases the synthesis of bradykinin and/or related kinins. Potential role of vasomotor effects of fibrinogen in bradykinin-induced angioedema. Acute adverse reactions associated with angiotensin-converting enzyme inhibi tors: genetic factors and therapeutic implications. Angioedema associated with angiotensin-converting enzyme inhi bitor use: outcome after switching to a different treatment. Life-threatening orolingual angioedema during thrombolysis in acute ischemic stroke.

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The paper focuses on the e ects of morbidity (ill-health) and thus chooses to use an in nitely lived agent framework. There are multiple balanced growth paths where the endogenous prevalence of the disease determines whether human capital is accumulated or not, i. The paper also shows that an exogenous demographic transition could lead to a take-o from poverty trap to a positive growth. This a ects the the size and allocation of savings amongst the di erent types of capital which will be missed in models that treat as exogenous. So consumption, physical and human capital all grow at the same rate g = (1 u), given by 3 1 equation (A. Due to the Inada condition in Assumption 1, health expenditure is strictly positive. By intermediate value theorem, there exists a q > 0 such that G(q) = 0, that is, there exists an endemic-disease case. When infectious diseases are eradicated, there is no health expenditure and thus no need for the health subsidy. When infectious diseases are endemic, the e ective health capital q, is determined by the equation G (q) = 0. Compared with G(q) = 0 in Proposition 1, the di erence lies in the rst term in the net marginal bene t, which is distorted by the relative marginal value of physical capital investment and health expenditure, due to the subsidy. The subside is chosen such that q, determined by equation G (q) = 0 is the same as q, c determined by equation G(q) + b + = 0. From G (q) = 0, we have (q) + b + d = (1 + q) 1 0 (q)(1 L(q)) (q) + b + d = (1 + q) (q) (b+)+ b+d 1+q b + = (1 + q). The government of Ethiopia continues to develop critical strategies that potentially lead to Universal Health Coverage. Consequently, interventions were selected and prioritized based on the essential health needs of the population. I believe any health policy, strategy, and program designing require the full participation of every citizen. It is my full confidence that we will prevail in meeting the Essential Health Service Package by the unwavering commitment of our government, ownership of the health programs by the community, enthusiastic service by health workers, and entrusted support of our development partners. A technical working group, composed of 30 senior experts on various health system dimensions was established. Seven prioritisation criteria were selected, mostly based on the review of the national health policy, the review of relevant strategic documents of the health sector and several rounds of consultations with global and local experts, public representatives and a professional association. Interventions chosen to address the major causes of death and disease are detailed for the key health service sub-components falling under each major component. Strengthen the logistics and supply chain management system to ensure access to essential medicines and equipment 7. Improve data utilisation for decision-making at all levels of the health system 8. Background In 1993, the health policy of Ethiopia was formulated with an emphasis on increasing access to a basic package of quality primary health care services to all segments of the population. The commitment and efforts of the government in designing innovative and evidence-based high-impact interventions have significantly improved the health outcomes. However, the selection of high-impact interventions has never been an easy task and demands systematic priority setting. Priority setting in health is critical for governments that seek to promote equitable access to essential packages of health services. These services encompass the delivery of a comprehensive range of health services appropriate to the primary level of care. Demographic and socioeconomic situation Ethiopia has a total population of about 109 million (as of 2018) [5]. About 80% of the population lives in rural areas and is mainly dependent on subsistence agriculture [6]. The population of Ethiopia is characterised by a rapid population growth and a young age structure.

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Induction of drug tolerance procedures vary cautiously administer a drug to a patient who is unlikely to be with individual drugs, and they are intended for agents that allergic to it when there is no intention to alter the immune induce IgE-mediated reactions and, in some cases, for ana response. Patients who tolerate a example, in penicillin induction of drug tolerance, the initial graded challenge are considered to not be allergic to the drug dose is typically approximately 1/10, 000 of the full therapeu and are not at increased risk for future reactions compared tic dose. The use of prophylactic medi previous dose and are administered at 15 to 30-minute in cations to prevent systemic reactions in these procedures is tervals until therapeutic levels are achieved. These protocols require the supervision of a health the procedure varies, depending on the drug and route of care professional with previous experience performing these administration, but, in most cases, can be accomplished procedures. Induction of drug tolerance should be the choice of whether to introduce a clinically indicated performed in an appropriate setting, supervised by physicians drug via graded challenge or via induction of drug tolerance familiar with the procedure, with continual monitoring of the mainly depends on the likelihood that the patient is allergic at patient and readiness to treat reactions, including anaphy the time of the procedure. Induction of drug tolerance protocols and/or diagnostic test results, are unlikely to be allergic to a are available for a variety of drugs, including virtually all drug may undergo graded challenge. For example, if penicil classes of antibiotics, insulin, chemotherapeutic agents, and lin skin testing is unavailable and a patient with a history of biological agents, such as humanized monoclonal antibod a mild pruritic rash during penicillin treatment 30 years ago ies. Patients who have a imately a third of patients who undergo penicillin induction relatively higher likelihood of being allergic to a drug should of drug tolerance experience allergic reactions, which are undergo an induction of drug tolerance procedure. For exam generally mild and occur predominantly after the procedure, ple, if penicillin skin testing is unavailable and a patient with during treatment with penicillin. Example of Intravenous Cephalosporin IgE Induction of Tolerance (eg, Desensitization) Protocol. These are typically performed over hours to days with an initial dose in the milligram range. Vancomycin Induction of Drug Tolerance Procedure344a ceptions, such as when benefit of treatment of a life-threat Concentration Infusion Vancomycin Time, Cumulative of vancomycin, rate, infusion rate, min dose, mg mg/mL mL/min mg/min Table 6. Representative Paclitaxel Immunologic IgE Induction of Drug Tolerance (eg, Desensitization) Protocol. Six-Hour Trimethoprim-Sulfamethoxazole Induction of aspirin is required for patients to remain in a tolerant state. After aspirin desensitization, loss of tolerance desensitization protocols and continue to experience flares of generally returns in 2 to 4 days after discontinuation of their cutaneous condition with exposure to aspirin or cross continuous aspirin therapy. Ten-Day Trimethoprim-Sulfamethoxazole Induction of Drug Tolerance Procedure680a gram amounts. The protocol differs from both IgE and Day Dosage, mg Concentration/tablet Amount non-IgE induction of drug tolerance. It involves a metabolic shift, reduction in urinary leukotriene E4, internalization of 1 0. Continued daily administration of 325 to 650 mg of available as 40/200/5 mL (8/40 mg/mL). After patient completely stabilized, provoking dose can be Document informed consent and advise patient it may take repeated (assuming another 3 hours of observation time), several days to complete (most will take 2 days). Dosing interval may be extended to 3 hours based on individual patient characteristics. Medications for treatment of aspirin-induced reactions Reactions will likely occur with early doses, usually 81mg. Nasal Antihistamine, topical decongestant After patient completely stabilized (but not less than 3 hours Laryngeal Racemic epinephrine nebulization after the last dose), the provoking dose can be repeated. No confirmatory challenge studies could a this recommended protocol is intended to be more practical, using be performed to determine whether the previous reactions doses based on commercially available 81 mg aspirin products and a were causally or coincidentally associated with aspirin. There are no data on safety and efficacy of this reason, it is uncertain whether these patients were truly this protocol. An example of a rapid aspirin challenge desensitization protocol is provided in Table 13. Allopurinol (High-Risk Patients) Induction of Drug Patients With Coronary Artery Disease Requiring Aspirin366 Tolerance Procedurea Timea Aspirin dose, mg Daily dose Concentration/tablet Amount Days 0 0. Summary Statement 69: Some induction of drug tolerance procedures have been described that appear to be successful induce a severe reaction.

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Thus, depressed mood should not be attributed automatically to the menopause transition (Hunter & Rendall, 2007) and many longitudinal studies have found that the transition is not associated with increased rates of depression in healthy women (Avis & McKinley, 1991). However, the evidence for these associations is often contradictory and the mechanisms are unclear. Nevertheless, there are some symptoms that can reliably be attributed to menopause. These include hot flushes and night sweats (vasomotor symptoms) and vaginal dryness. Mood change, sleep disturbances, urinary incontinence, cognitive changes, somatic complaints, sexual dysfunction and reduced quality of life may be secondary to other symptoms or related to other causes. It is these more common symptoms that will be the focus of the discussion about prevalence rates and mechanisms. Prevalence rates of the most common symptoms associated with menopause the list of symptoms that have been attributed to menopause is large and includes (in no particular order) vasomotor symptoms, insomnia, vaginal atrophy, dizziness, palpitations, breathing difficulties, flatulence, panic attacks, headaches, joint and muscular pain, restless legs, tiredness, breast tenderness, anxiety and depression, wanting to be alone, loss of libido, bladder incontinence and poor memory. In fact, some questionnaires that measure menopause symptoms list as many as 32 items (Bowles, 1986; Greene, 1998; Hilditch et al. For sexual discomfort symptoms, a minority (4%) of women were classified as having a very severe profile. Sixty-five per cent were identified as having low severity for all symptoms except joint ache, 13% were identified as high severity for all symptoms except hot flushes (which were moderate), 12% had high severity for hot flushes, joint ache and waking at night and 10% were identified as high severity for poor concentration and joint ache. This suggests that the causal link is 12 complex and that whilst changes in the hypothalamic-ovarian-pituitary axis may be responsible for some symptoms, stress levels and lifestyle may also play a role. Changes to hormone concentrations, in particular to estrogen and estradiol, are thought to be responsible for the vasomotor symptoms and vaginal dryness often reported by women. Prevalence rates for symptoms vary but it is estimated that 70 to 80% of women experience vasomotor symptoms (Bruce & Rymer, 2009; Dennerstein, Dudley, Hopper, Guthrie, & Burger, 2000; Nelson, 2008) though the majority do not perceive them to be problematic. A substantial minority of up to 20% of women report that they are severe (Blumel et al. If 70% of them are experiencing symptoms and follow a similar profile pattern to that reported by Mishra and Kuh, then more than 47, 000 women would report severe psychological symptoms, a similar number would report severe somatic symptoms, more than 850, 000 women would be experiencing severe or very severe vasomotor symptoms, and 189, 000 women would have severe sexual discomfort. It is not statistically accurate to extrapolate the data in this way but it indicates that, although only a minority report problematic symptoms, this may translate into a relatively large cohort of women who suffer from severe or very severe disruptions to their daily lives. A review of 51 studies by Nelson (2008) demonstrated the variability of symptom reporting (see Fig. These data from different populations indicate that mood changes, urinary complaints and sleep disturbance can occur at all reproductive stages but the most common menopause-related complaints, vasomotor symptoms and vaginal dryness, increase during the menopause transition and postmenopause, though both may be reported by women before the onset of perimenopause. This is supported by Kronenberg, (1990) who found that the age range for reporting hot flushes was 29-58 years with 50% of women reporting when their menstrual cycles were still regular. The median duration for experiencing hot flushes is 4 years (Politi, Schleinitz, & Col, 2008) but a small percentage experience them to the end of their lives (Kronenberg 1990). Women with this profile had 13 a peak in symptoms at 1 to 4 years postmenopause but more than a decade later these women were reporting at least one vasomotor symptom. Notes: Rates of vasomotor symptoms, vaginal dryness and sleep disturbances are higher for women in menopausal transition and postmenopause than for women in reproductive stages It is evident that symptom reporting among women going through the menopause is elevated and that symptoms can continue for some years, though it may be difficult to distinguish symptoms relating to menopause from those relating to aging in general. When menopause is considered within a lifespan perspective, there is a progressive loss of function across many domains, including motor functions (Papalia, 2007, p.

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