Post-Menopausal Vaginal Bleeding

Menses occur during reproductive age, from age 9-12 to 48-52. Most women don't have any problems throughout their reproductive age.  However, some may have troubled times with irregular or protracted bleeding. In another scenario, some women have problems after age 50, when their menses have already stopped. In these older women, even though they are in the menopausal age, they still get occasional bleeding which is abnormal. This can happen in women aged after 60 even when on their Hajj pilgrimage. These women are unusually frightened and even though they may feel 'young once again', they do not understand the underlying grave problems and often chose to ignore it, thinking they may possibly have 'another child' in their old age. What is the cause of the bleeding in post-menopausal women? Let's find out.

RESOURCES

Background reading
Uterus-Endometrium-Cancer

Image gallery
anatomy diagrams
menstrual dysfunction
squamous atrophy of the cervix
cervix cytology - atrophy
rectocele (rectal hernia)
grade 3 cystocele (dropped bladder)
cystocele in vaginal prolapse
stress urinary incontinence
uterine prolapse
vaginal prolapse
hysterectomy
vaginal prolapse repair
female pelvic organ prolapse
vaginal rejuvenation
atrophic endometrium and lymphatics

Patient education
http://www.dronuma.com/leaflets.html

Self-assessment
http://www.studyblue.com (UI/Pelvic prolapse/Menopause)


CASE STUDY

Trigger 1: Introduction

An elderly lady named Mek Ameh went of the annual Hajj pilgrimage with Tabung Haji. She felt happy and accepted into the group of women in her tent at Mina. Though tired from the Hajj rites, she was able to obtain sufficient rest and reflected on her fortitude at being 'invited' on the Hajj. She went to the women's area to bathe and perform ablution before her zohor prayer. However, she returned to her tent, a bit worried and decided to talk to her friends in the same tent. It transpired that Mek Ameh was already a menopausal lady aged 65. She had a bleeding a few months before coming on the Hajj trip. This is her second vaginal bleeding, and the first at Mina. She was upset that she might not get to complete her Hajj rite altogether. So she and her friends approached 'Doktor Ustazah' about her postmenopausal bleeding problem at the Tabung Haji clinic in Mina.

Trigger 2: Examinations and Investigations

From her medical history, Mek Ameh first experienced bleeding when she was 12 (tamat sekolah rendah). She married at 13 and had 15 children but three of her children died young. Her last bleeding was eight years after she had her last child, now aged 23. Then she had no more periods until one occurred just prior to the Hajj months. Despite experiencing that one bleeding, she did not feel compelled to see a doctor about it but came on the Hajj trip with her friends. She has no relevant past medical and surgical history and was not on any hormonal treatment.

She was obese. Her vital signs were stable.


A blood specimen was taken for analysis by the Hematology laboratory.

Another blood specimen was taken for analysis by the Chemical Pathology laboratory.


Pelvic exam: Vulva, vagina and cervix were atrophic. Brownish stained discharge was noted. There was cystocoele and rectocoele. There was mild descent of the cervix. Uterus was 10 weeks size. A cervical smear was sent to the Pathology laboratory.

A pelvic ultrasound was arranged for her.

She was admitted for a day at the Gynae Day Ward. A hysteroscopy and diagnostic dilatation & curretage (DD&C) were ordered for her.


Trigger 3: Results

The results of her investigations were as follows:

Hb: 11.4%

Platelet count: 210 x 10**9/L]

Random Blood Sugar (RBS): 4.6 mmol/L

Cervical smear: Normal

Pelvic Ultrasound: Uterus was uniformly enlarged. Endometrium was 1.5 cm thick. Ovaries were atrophic.

Hysteroscopy and diagnostic dilatation & curretage (DD&C) returned the following diagnosis: Adenocarcinoma of the endometrium

Mek Ameh was called to the Tabung Haji clinic and counseled regarding her condition and treatment.

She successfully completed the Hajj and returned to Malaysia.

In Malaysia, she underwent total abdominal hysterectomy and bilateral salpingo-oopherectomy.

She recuperated and lived a disease-free life once again. She felt liberated.

Professors in Biochemistry

Here is a list of professors in Biochemistry whom I know since 1980.

Prof Jolinda A. Traugh
http://biochemistry.ucr.edu/faculty/traugh/traugh.html

Prof Michael F. Dunn, Emeritus
http://biochemistry.ucr.edu/faculty/dunn/dunn.html

Prof Anthony W. Norman, Emeritus - discovered vitamin D
http://biochemistry.ucr.edu/faculty/norman/norman.html

Prof Frances A. Jurnak
http://www.faculty.uci.edu/profile.cfm?faculty_id=3271

Prof Alexander McPherson
http://www.faculty.uci.edu/profile.cfm?faculty_id=3340

Henderson-Hasselbalch Equation

The Henderson-Haselbalch (HH) equation in the most important equation in learning about acid-base homeostasis. Why is the HH equation important? It is important because it is useful. What is the HH useful for? It is useful for many things.


USES OF THE HENDERSON-HASSELBALCH EQUATION

1. It is a formula for linking the blood pH to the respiratory component (PCO2) and the renal component (HCO3-)
2. It has three terms which are interrelated and therefore inter-dependent: pH, PCO2 and HCO3-
3. Knowing the values of two components makes it easy to calculate the value of the third component
4. The plasma pH is affected by HCO3- and PCO2
5. The plasma PCO2 is affected by pH and bicarbonate
6. Plasma HCO3- is affected by pH and PCO2
7. HCO3- and PCO2 are regulated separately by different organs in the body - kidneys and lungs
8. Kidney function affects the amount of bicarbonate in blood, ie [HCO3-]
9. Lung function affects the amount of CO2 in blood, ie PCO2
10. Buffer ratio is the ratio of HCO3- to PCO2 in the HH equation; normal buffer ratio is 20:1. 
11. From buffer ratio, it also tells whether there is excess or lack of base component (ie Base Excess, B.E. is + or -); normal range is from -2 to +2; B.E. is +ve if there is excess of base. B.E. is -ve if there is a lack of base. Values exceeding the limits indicate there is excessive or severe lack of base.
12. The buffer ratio components will change in the same direction as the primary lesion in order for pH to return to normal. If the buffer ratio is 20:1, then pH is 7.4. 
13. If the buffer ratio is greater (eg 22:1), then there is excess base and the blood pH will be higher than pH 7.4. So the respiratory component will need to be increased in order for pH to decrease towards normal.
14. Similarly, if the buffer ratio is less than 20:1 (eg 18:1), then there is lack of base and the blood pH will be less than pH 7.4. So the renal component will need to be increased if pH is to increase towards normal.

Respiratory Mechanisms in Acid-Base Homeostasis

The lungs control our blood pH. The lungs form the respiratory component and affect the PCO2 of blood. Ventilatory adjustments to pH change take several minutes to control any deviation, and frequently overcompensates. Thus, respiratory mechanisms are rapid compared to renal mechanisms in correcting blood pH.


EXAMPLES OF QUESTIONS AND ANSWERS

1. Explain how the lungs are involved in regulating blood pH.

1. The lungs flush acid out of the body by exhaling carbon dioxide (CO2)
2. Within physical limits, the body can raise and lower the rate of breathing to alter the amount of CO2 that is breathed out (expired).
3. This can affect blood pH within seconds to minutes

2. How does the lung regulate blood pH?

1. The lungs excrete or retain CO2, depending on blood pH
2. Under alkaline blood pH (alkalosis), the lungs will retain CO2 by slowing down breathing rate (hypoventilation), which will retain more CO2 in blood and increase blood PCO2, which in turn will help to reduce pH towards normal
3. Under acidic blood pH (acidosis), the lungs will rapidly excrete CO2 by increasing breathing rate (hyperventilation), which will expel CO2 faster and decrease blood PCO2, thus increasing pH towards normal

3. How is it possible for patients with lung problems to regulate blood pH?

1. Assisted respiration is used in patients with lung problems, including damaged lungs or paralysed breathing muscles.
2. Assisted respiration is of two types - non invasive and invasive
3. Non invasive assisted respiration uses a respirator - a mask is applied over the mouth and the patient breathes through the mask. 
4. In babies and young children suffering from severe viral infections and where breathing is affected and laboured, a nebulizer is used to help them breathe. They only need to use the nebuliser for a few minutes until breathing becomes normal and the babies/children are not struggling to breathe.
5. In patients with paralysis of the breathing muscles (Duchenne muscular dystrophy and the like), they are often confined to wheelchairs and a breathing machine attached to the back of the wheelchair to help them breathe out (as they can breathe in but not breathe out unassisted)
6. In invasive assisted respiration, the patient lies in bed and is hooked up to a blood and lung machine and remains as such till the patient is able to breathe normally or otherwise. This is seen in patients in ICU (intensive care unit), NICU (neonatal intensive care unit) and CCU (coronary care unit).

Renal Mechanisms in Acid-Base Homeostasis

The renal mechanisms for correcting blood pH are very important. However, renal adjustments to pH change take from several hours to days to complete. Thus, we cannot expect someone with a respiratory problem to rapidly recover within an hour or two. Usually, they will be hospitalised (warded) for a few hours or days, depending on the nature of their problems, before we can hope to see some changes in our patients, and before we get to see changes to improve their blood pH values. It often takes several hours or even days if the renal component is to effect change to the altered blood pH.


GENERAL QUESTIONS

1. How does the kidney regulate blood pH?

1. The kidneys reabsorb or excrete bicarbonate, depending on blood pH.
2. Under alkaline blood pH (alkalosis), the kidneys excrete excess blood bicarbonate
3. Under acidic blood pH (acidosis), the kidneys reabsorb secreted bicarbonate, which then re-enters blood

2. What are the renal mechanisms that come into play to correct blood pH?

1. Secreting or absorbing hydrogen ions or bicarbonate
2. Controlling excretion of acids and bases
3. Generating additional buffers
4. The kidneys excrete some acids in the urine. 
5. The kidneys also produce and regulate the retention of bicarbonate. Bicarbonate will increase the blood's pH. Changes in bicarbonate concentration occur more slowly than changes in CO2, taking hours or days

SPECIFIC QUESTIONS

1. What are the renal responses to acidosis?

1. Secretion of hydrogen ions (H+)
2. Activity of buffers in renal tubular fluid - refer to text elsewhere for mechanisms
3. Removal of carbon dioxide (CO2)
4. Reabsorption of sodium bicarbonate (NaHCO3)

2. What are the renal responses to alkalosis?

1. Rate of hydrogen ion (H+) secretion at kidneys declines
2. Tubule cells do not reclaim bicarbonates in tubular fluid
3. Collecting system transports bicarbonate (HCO3-) out into tubular fluid while releasing strong acid (hydrochloric acid, HCl) into peritubular fluid

Buffers, Need for Buffering, and Buffering Mechanisms

I. BUFFERS

1. Buffers are chemical substance systems found in blood and urine
2. Buffers are found in two compartments - ECF (extracellular fluid) and ICF (intracellular fluid)
3. ECF is plasma and blood. ICF is interstitial fluid (in between cells) and intracellular fluid (inside cells)
4. ECF buffers are carbonic acid-bicarbonate buffer system (maximal, most effective) and protein buffer systems. The phosphate buffer system is very minimal.
5. ICF buffers are phosphate buffer system, ammonia buffer system, and protein buffer systems

A. BLOOD BUFFERS

1. Blood is ECF
2. Bloof buffers are carbonic acid-bicarbonate buffer system and protein buffer systems
3. Phosphate buffer system buffers best as pH 7.4 but there is very little (limited amount) phosphate in blood to do this. So the phosphate buffer system plays a very minimal role in buffering blood pH even though it is the best buffer for the body.
4. Carbonic acid-bicarbonate buffer system plays a major role in buffering blood pH as there is plenty of it in blood, even though it buffers best at pH 6.1.
5. Proteins in blood plasma also buffer blood pH to a large extent since there is a lot of proteins in blood (60g-70g/L) but proteins are compartmentalised and due to their sizes, cannot easily or freely traverse cell membranes are well as bicarbonate can. Therefore, buffering is limited as well as compartmentalised.

1. CARBONIC ACID-BICARBONATE BUFFER SYSTEM

1. Carbonic acid-bicarbonate buffer system is most important in ECF
2. Carbonic acid-bicarbonate buffer system is volatile - carbon dioxide is expired or inhaled
3. In tissues, 93% CO2 enters rbc's. From this, 23% binds to Hb as carboxyHb while 70% forms carbonic acid which instantly dissociates to free bicarbonate and proton; proton binds to Hb to form protonated Hb (H.Hb) while potassium dissociates from Hb; bicarbonate then enters blood while chloride enters rbc's ("chloride shift"); chloride then associates with potassium in rbc's 
4. Approximately 70% of carbon dioxide is carried in the blood as bicarbonate
5. In the lungs, the reverse occurs in rbc's: bicarbonate enters rbc's while chloride exits rbc's ("chloride shift"); proton dissociates from H.Hb and combines with bicarbonate while potassium dissociate from chloride and recombines with Hb to form K.Hb; carbonic acid that is formed dissociates to CO2 and water; CO2 diffuses out of rbc's and is expired via alveoli in the lungs

2. PROTEIN BUFFER SYSTEMS

1. Protein buffer systems are found in both ECF and ICF
2. Protein buffer systems are: hemoglobin buffer system (in rbc's), amino acid buffers (all proteins), and plasma protein buffers. Plasma proteins are mainly albumin, transferin, antibodies, haptoglobin, etc. Plasma proteins are present as salt-weak acid systems and act as buffers in blood. The plasma protein buffering effect is minor compared to the bicarbonate system or hemoglobin system. The plasma protein buffering capacity is approximately one-sixth that of Hb
3. Protein buffer systems help to regulate pH in ECF and ICF
4. Protein buffer systems interact extensively with other buffer systems
5. The most powerful, plentiful buffer system in the body is the proteins of plasma and cells

B. URINARY BUFFERS

1. The body secretes hydrogen ions into the lumen of renal tubules
2. These secreted hydrogen ions either combine with phosphate of ammonia and are then excreted out of the body in urine. 
3. In acidosis, more hydrogen ions are excreted in urine in order to increase blood pH towards normal. Bicarbonate is reabsorbed and also regenerated.
4. In alkalosis, hydrogen ions are recaptured and returned to blood in order to reduce blood pH toward normal

1. PHOSPHATE BUFFER SYSTEM

1. Phosphate buffer system buffers pH of ICF and urine
2. There is minimal buffering by phosphate buffer system in blood. The phosphate buffers in the blood are inorganic phosphates
3. Phosphate buffer system is the main buffer in renal system
4. Intracellular buffers are both inorganic and organic phosphates
5. ICF phosphate buffer system consists of the anion monophosphate H2PO4- (a weak acid) and the anion biphosphate HPO42- (a base)

2. AMMONIA BUFFER SYSTEM

1. Tubular deamination of amino acids creates ammonia (NH3)
2. Ammonia freely diffuses into the renal tubule 
3. In the renal tubule, ammonia combines with proton to form ammonium (NH4+)
4. Ammonia is impermeable to the renal cell membrane and is not reabsorbed by the renal tubular cells but excreted
5. Hyperammonianemia is toxic to the brain and occurs in newborns with kidney problems.

II. NEED FOR BUFFERING

1. The body needs to keep its body fluids within a narrow range of pH as large fluctuations in pH are not compatible with life.
2. Extreme pH values are not compatible with life
3. Death occurs at extreme pH values: when pH < 6.80; when pH > 7.80
4. Life is only possible between a narrow pH range, between pH 6.80-pH 7.80 ... ie only 1 pH unit
5. Almost all the chemical reactions in our body are catalysed by enzymes. Enzyme activity is dependent on pH, between pH 6.80 and pH 7.80 (ie, physiological pH). Only a few enzymes are active at extreme pH.

III. BUFFERING MECHANISMS

1. Chemical buffers are immediate responders to any change in pH of body fluids
2. Chemical buffers form the first line of defense against added hydrogen ions (acid load; most common) or against added hydroxyl ions (less commonly).
3. In blood: When hydrogen ions are added, they combine with bicarbonate and form carbonic acid.
4. In urine: Secreted hydrogen ions combine with ammonia to form ammonium. Secreted hydrogen ions also combine with diphosphate to form monophospate.

Primary Acid-Base Disorders

There are four primary acid-base disorders:

1. Respiratory Acidosis
    Eg: COPD (chronic obstructive pulmonary disorder), emphysema, chronic bronchitis
    Tx: Assisted respiration

2. Respiratory Alkalosis
    Eg: Mountain climbing, hysteria, panic attack
    Tx: Breathe into a paper bag

3. Metabolic Acidosis
    Eg: Starvation, diabetic ketoacidosis (DKA), toxins
    Ix: High Anion Gap (high AG) - see MUDPILES, GOLDMARK & KURT; Osmolal Gap (OG) +- High AG

4. Metabolic Alkalosis
    Eg: Diarrhoea, prolonged vomiting
    Ix: "Alkaline tide" - a postprandial phenomenon up to 2 hours

Acid-Base Short-Answer Questions (SAQ)

Prolonged starvation - metabolic acidosis

Hysteria (hyperventilation) - respiratory alkalosis

Prolonged vomiting - metabolic alkalosis or mixed with metabolic acidosis

Emphysema (destruction of alveoli) / COPD (chronic obstructive pulmonary disease) / chronic bronchitis - respiratory acidosis

Coma - respiratory acidosis

Hibernation - normal

Aspirin poisoning - metabolic acidosis

Toxic alcohols - metabolic acidosis

Shock - respiratory acidosis

Acute panic attack - respiratory alkalosis

Solfeggio Frequencies and Fibonacci Numbers

Ascient Solfeggio Frequencies

There are six Solfeggio frequencies:

396 Hz
417 Hz
528 Hz, yellow - to initate DNA repair mechanisms and transformation
639 Hz
741 Hz
852 Hz, purple

Each frequency has a purpose or function and related colour. The 852 Hz is a soft purple velvety colour. These frequencies and sound patterns are used to energize the soul. They are particularly useful as miracles where no medical cure exists. These frequencies are the same rates at which things happen in the body.

When these sound tones vibrate in harmony we feel good and are cured. How shall we mix these tones so that they are harmonious and useful or curative? Apart of music (sound tones), we can also see the sound effects in vibrating sand and also water. Is vibrating water useful?


Fibonacci Numbers

0  1  1  2  3  5  8  13  21  34  55  89  144

The Fibonacci number sequence is a pattern upon which most things in nature follow or conform to. It is evident in growth of seashells such as the Nautilus, arrangement of sunflower seeds, design of dragonfly wings, etc.

When we blow a Nautilus shell or horn, what do we hear? Why is it that when we hold a large seashell or a conch tightly against our ear, we hear the sea as if we were by the sea?!


The Miracle of 528 Hz Solfeggio and Fibonacci numbers
http://www.youtube.com/watch?NR=1&v=9oSePXRbW9o&feature=endscreen

Golden Ratio for Beauty

The golden ratio is 1.618. It is in the universe, nature, buildings, and our bodies. Everything is superbly designed and conforms to this ratio.

Golden ratio or Phi
http://www.youtube.com/watch?v=0hvD5kLqjuw

Hugo Chavez

The Venezuelan President Commander Hugo Chavez ruled for 14 years (1999-2013). He (then 56) suffered from a pelvic cancer, a tumour (query prostatic cancer) and had surgeries in Havana, Cuba, including for pelvic abscess on 10 June 2011. He developed lung infection, had kidney failure and was on dialysis, had respiratory deficiency and died on Tuesday afternoon, 5 March 2013 in Cuba, aged 58.

His two-year battle with cancer ended and Venezuela now grieves. He leaves behind a wife Marisabel and two daughters Rosa Virginia Chavez and Maria Gabriela Chavez.

His body lies in state at the Military Academy in Caracas. His remains will be embalmed (just like other leftists Lenin, Mao Tze Tung and Ho Chi Minh) and displayed at the Museum of the Revolution.

External links
http://www.telegraph.co.uk/news/worldnews/southamerica/venezuela/Hugo-Chavez-dead
http://www.telegraph.co.uk/news/worldnews/southamerica/venezuela/Hugo-Chavezs-embalmed

Lung Diseases

There are a few lung diseases which will be mentioned in lectures on Acid-Base Homeostasis. These are:

1. Chronic obstructive pulmonary disease (COPD)/emphysema/chronic bronchitis
2. Lung cancer
3. Asthma

Lung Disease external links

NIH Index

Lung cancer external links

Lung cancer symptoms (YouTube video)

Lung cancer treatment using CyberKnife (YouTube video)

COPD external links

COPD U of Maryland

COPD NIH (video)

Asthma external links

Asthma (YouTube video)

Asthma NIH

Asthma NHLBI

Habbatus sauda

Black seeds (Habbatus sauda, Nigella sativa) have long been used in traditional and tribal medicine since time immemorial. The Greeks, Egyptians, Turkish, Indians, Arabs and almost all communities have used it and continue to use it. Why? Why is the usage of black seeds widespread and worldwide?

Black seeds contain a host of medicinally potent active ingredients. They are the only known type of edible seeds that have many medical benefits, some of which we know and other uses and benefits have still to be discovered or uncovered.

Blacks seeds is a cure for all except death itself. It is prescribed in Prophetic Medicine. It is mentioned in all divine texts, including the Quran.

Kings, queens, and those who knew of its benefits all consumed its oil. The Pharaohs and Cleopatra consumed it. The Pharaohs never suffered any disease.

Research on the medicinal benefits of black seeds are on-going in areas of pancreatic cancer.

Black seed oil is sold as softgel capsules and are available at Jaafar Rawas store in Kota Bharu, Kelantan,

http://nigellasativa.org/